Innovations in the Care of the Elderly

Bernard Isaacs, Helen Evers, Bernard Isaacs, Helen Evers

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000577990
• Edition: 1
• Topic: Medicine
• Subtopic: Geriatrics

Originally published in 1984 and concentrating on the West Midlands area of the UK, this book describes the innovations that were made and all that was involved in bringing about changes in care provision for elderly people. The areas covered include hospital-based geriatric and psychogeriatric services, changes in the public housing sector, the development of a domiciliary physiotherapy service and community nursing teams for the terminally ill. These new attitudes and practical treatment changes succeeded in radically altering the climate of care and were the result of small innovatory groups of care-providers.

Chapter One The Nature of Innovation

Bernard Isaacs

An innovation has three components: a good idea, making it work, and demonstrating that it works.

Good ideas are the products of inspiration, translation or emulation.

Inspiration is an idea that has never been thought of before; translation is one taken from a quite different field; and emulation is copying what has already been done.

Few are gifted with absolute originality and most of these are astronomers or composers. The ability to translate good ideas from other times, places and fields of activity is a rare gift, requiring the vision of seeing what is similar in different states and what is different in similar states. Emulation is the Higher Plagiarism, necessitating the nice mixture of humility and pride which is inherent in the phrase ‘If they can do it’ (a concession to their pre-eminence) ‘then so can we’(a re-statement of our own pre-eminence) .

Innovation is disruptive. It necessitates changes in the way in which people work and think. It is not enough for the innovator himself to see the Vision of the Brave New World which his Idea will open up. He has to capture the minds of those others who will, as a result of his innovation, be required to do a different job in a different way; to subject cherished ideas to re-examination; to see new vistas not at all as rosy as those of the Great Innovator.

Innovations usually cost money. When the innovations described in this volume were introduced cost did not dominate quite so obtrusively as it does as this introduction is being written, a time when infant innovations are strangled in their cradles at the first whimper of more money having to be spent.

Innovation is in the public eye. Advantages must be made plain to those who receive, deliver and pay for them. Rhetoric convinces some; but in every scene there are hard-nosed men and women demanding hard facts and hard brass. The most inspired schemes have their disadvantages, not all for-seeable. The case must be worked out in much detail before the innovation starts its journey through the bureaucratic birth canal. It must fulfil its promises and early be shown to do so.

The Care of the Elderly

Innovation grows best in Spring, when the soil is bare and the climate is changing. Services for old people in the past were bare enough, based as they were on parsimonious paternalism. Old people were given what was best for them and they were given it on the cheap. In today’s warmer climate it is easy to express the idea of replacing paternalism by respect for human dignity and individuality. The innovator with imagination and experience of progress in other fields like the care of children soon sees how to apply these principles to his area of concern. Parsimony is not so easy to replace. The innovator must either put something there that was not there before, which is expensive; or remove something that was there before, which is disruptive. Of the innovations to be described here some actually demonstrated that they saved money. Some, described in chapters four, ten and eleven, managed to establish themselves without costing money. Others, such as those described in chapters twelve and fourteen, succeeded in finding new sources of money.

The care of the elderly in the past involved out-door relief, or cash handouts; in-door relief or institutionalisation; and a third element which Dorothy Wedderburn called ‘The Myth of All Old People’; and which I refer to as the metamorphosis principle. This states that after a certain age and below a certain income the infinite variety of human nature clots into a formless mass; adult men and women metamorphose into ‘old people’ or ‘the elderly’ or ‘senior citizens’; with attributes and needs which are characterised by the years which they have attained rather than the years that they have spent in attaining them. This fatuous view of old people is no longer held by enlightened people (circular definition of ‘enlightened’) but even enlightened people use unenlightened words, like doctors who attribute symptoms of illness to ‘your age’; or do unenlightened things, like architects who build homes with beautiful views of trees and flowers when the occupants might prefer beautiful views of streets and people.

Innovators seek to replace paternalism by participation, homogeneity by individuality; and parsimony by public expenditure. They provide services which meet the needs of clients; rather than seeking amongst the clients for needs which the service can provide.

From Paternalism to Participation

The paternalistic attitude to old people stems from perception of them as physically dependent, mentally obsolete, and objects to be nice to. Many old people will accept this description of themselves and obligingly complete a negative feedback loop. The innovator breaks this by perceiving that dependence is but a diminution of independence; obsolescence a product of disuse; and niceness a superior form of distancing. He learns what old people want, not by distributing questionnaires, another form of distancing, but by rubbing up against them in blunt proximity, with eyes and ears open. On learning that they do not all want the same thing and most just want to be left alone the innovator proposes the delicious but dangerous change of letting old people off the leash. He then changes his task from setting limits to the liberty of the ageing human spirit to setting limits to the damage that can result from unbridled freedom. Examples of such innovations in this book are the use of high rise flats for sheltered housing with minimum disturbance of the residents, (Chapter Six);the maintenance of the mentally ill elderly at home with the help of a Day Centre (Chapter Twelve);and the sharing of the care of the severely impaired between hospital and home (Chapter Eleven).

From Homogeneity to Individuality

The difficulty of changing from an ‘all old people’ to an ‘individual’ approach is that no care provider believes that he is not already practising an individual approach. The agenda of social support begins with safety. With the limitation of ‘safety first’ a carer may genuinely believe that the care offered provides individual choice. But that may be no more than a choice between pudding and prunes as part of an undesired lunch at a table shared with strangers. Carers encourage individual choice, so long as the individual makes the right choice. The innovator wants to give old people freedom to make the wrong choice. The old person who should ‘ideally’ be in an Old People’s Home may choose not to be. The person who should be clean, well fed and safe is allowed to be dirty, scraggy and at risk. The innovator provides services to meet either choice. His task is to convince the convinced that they are not convinced,to explain that the banal principle of individuality has some startling implications. Many of the innovations described in this book accept these implications, and contain the definition of ‘acceptable risk’ as the price to be paid for individual freedom of choice.

The reason that such an obvious lesson as ‘old people are individuals’ has to be rehearsed again and again is that it is simpler and cheaper to treat them as Biomass. If their needs are all the same they can be batch processed on a production line by few poorly trained and poorly paid staff with standardised equipment. As soon as the principle of ‘individual choice’ comes in, so too does data acquisition, programme planning, record keeping, decision making, consumer choice multi disciplinary case conference, and a host of labour-intensive education-intensive high-cost activities with dubious outcomes and rampant professionalisation. Many of the most successful ‘innovations’ in the care of the elderly are essays in the removal of the chains with which a previous generation of beneficent innovators shackled the struggling individuality of old people. Examples of these in this volume include the description of an enlightened home help service (see Chapter Five) and the socialisation of aphasic stroke victims (see Chapter Eight).

From Parsimony to Public Expenditure

It seems a long time since the notion prevailed of caring for old people at the lowest possible charge to the public purse; but today’s emphasis on cost effectiveness brings the idea back in modern guise. The wily innovator exploits the difference in outlook between economists and accountants. Economists talk about ‘opportunity costs’ and ‘marginal costs’ which some members of public bodies may not fully understand. Innovators should be able to produce evidence that their innovations will make ‘notional savings’, which should at least be sufficient to fund a ‘pilot project’. Committee members are usually willing to support ‘pilot projects’; because they are seen to demonstrate the forward looking encouragement given to those with new ideas, while at the same time reflecting a proper spirit of prudence in the care of the public purse. The innovator well knows that once a project is started and seen to be apparently doing good, any attempt to disband it will raise political outcries. By the time the accountant announces that the ‘notional savings’ are costing real money it is too late to stop. The ‘notional savings’ in any case were only savings when compared with a more expensive service which was not being given away anyway.

Those who have their houses painted and decorated know that a better job costs more, and it is naive to pretend that the same is not true of caring for old people. It is not a matter of where the service is given but of how many people of what degree of training are paid to give it. To replace nothing with something, or a little with a bit more costs money. There remains an obligation on the innovator to see that the money is well spent.

The doctrine of ‘cost-effectiveness’ states that the objective is defined in advance; the extent to which it is attained is measured; and the costs of attaining it are calculated. The ‘givens’ are that the objective is worthy; that it could not be attained by the expenditure of less money; or that spending the same money in a different way could not achieve other more appropriate objectives.

It would be surprising if innovators gave more than a cursory nod in the direction of these ideas. The concepts pose questions which cannot be objectively answered (although there are those who pretend to be able to answer them); because they leave out of account the enthusiasm, conviction and dedication which makes innovations work; and because measurement of effectiveness evaluates a ‘movie’ by examining a ‘still’. The innovative service does not stay the same for long enough for a true picture to be taken of what it is doing. Innovations change as new ideas become modified, routinised, and no longer innovative. Comparison of the new with the old is contaminated by the effect of novelty. If the innovation is no good it is dropped; if it appears to be good it is replicated; and subsequently comparisons have to be with areas which have not had the initiative to modify their own service, so the comparison is questionable.

Many of the innovations described in this book have been funded from new sources of money. Few have been formally evaluated. Some like the Stroke Scheme (Chapter Eight) are replications of evaluated services from other parts of the country. Few services anywhere have been replicated because of the findings of a cost-effectiveness study; and few have failed to be replicated because of the absence of a cost-effectiveness study. This may be deplored but not ignored. It seems to say something about the nature of change in public service. It may represent a gap in credibility, between scientific and evaluative research; or a difference in pace between political and scientific imperatives; or the elusiveness of the object to be measured. The spread of innovation in a politically visible field, such as the care of the elderly, seems more suited to the activities of the publicist than of the scientist. The innovator needs communication skills in so far as these are based on objective data such as the number of clients dealt with by a service or the unit cost. Crisp and clear presentation is at least as useful as extensive documentation. But also required is a flair for the telling anecdote, the evocative photograph, the microphone and the camera. The change from public parsimony to public profligacy must gain public popularity.

Conclusion

The themes of this essay are extensively illustrated in the descriptions of practical achievements by practical people moving two steps ahead of public opinion to provide new services in new ways. These ways are sufficiently novel to be called ‘in novatory’, but not so startling as to be called ‘revolutionary’. All the innovations have been preserved to become part of the service to the public. Many have been replicated by the innovator or by another authority. All are being monitored and modified with growing experience. They are altering the level of expectation of old people of the services which they can receive; and they are altering the perceptions of old people which are held by those who seek to serve them. They illustrate the vision and perseverance involved in creating innovations in the care of the elderly.

Chapter Two Promoting Innovation - A District Medical Officer’s View

R. Griffiths

It is difficult to generalise about innovation because it involves a departure from what has gone before. Despite this it is helpful to classify the processes involved because it may facilitate new thinking.

The broadest taxonomy we could use in the health service context might be innovations for their own sake and innovations for the patients’ sake. Some innovation for its own sake is probably essential, because it is difficult to accept that the world has reached a state of perfection which we must not change. However, this is damaging if it is carried too far. It is regrettably true that in medicine many new features of clinical practice or medical equipment are introduced for the professional satisfaction of the doctors concerned, even though they can be shown to have marginal or even harmful impact on patient care. The review of expensive medical techniques by the Council for Science and Society (1983) documents a number of instances of this sort of innovation. It is important that most health care professionals should be able to recognise this kind of change for what it is and make sure that it does no more than fulfil its legitimate role of maintaining professional interest without harming patients. The rest of this chapter will therefore be concerned with innovation for the patients’ sake and how we may seek it, recognise it and foster it.

Innovation for the patients’ sake must by definition be problem-oriented and must have gone through a number of recognisable stages: recognition of the problem; inspiration and hypothesis formation; experimentation and evaluation; and finally, implementation.

Recognition of the Problem

This stage of the innovative process is usually given inadequate attention. Very often problems are not clearly defined until an inspiration has come along which may solve part of it, and then the problem is defined in order to suit the solution and often in order to justify investment in the solution which has become attractive in its own right. It is a surprisingly difficult thing for any group of staff to sit down and define what their current problems are; but any effective team should include within its normal routine a periodic assessment of its problems; whether they are clinical, administrative or personal.

When assessing a problem it is necessary to have a mental checklist which is very helpful in defining the kind of inspiration that is required, and which will provide a background to evaluation at a later stage. Most important, we should have a notion of how common the problem is, in formal terms what are the incidence and the prevalence? To put it another way, how often does this problem crop up and how long does it go on for once it has cropped up? This method can be applied to administrative problems just as easily as it can be to clinical ones. We can ask ourselves how often does the chest X-ray show an abnormality just as easily as we can ask ourselves how often do we fail to have the correct X-rays in outpatients? In either case we need to know whether the changes in the X-ray, whether they are changes in clinical appearance or losses to the system, are permanent or episodic, and we might need to know the proportion of patients to whom these changes apply. Some estimate of the incidence and prevalence is usually essential in deciding the priority of attack on a problem and in assessing the cost of any solution.

Another feature of our mental checklist is the size of the problem and the size of the change that is necessary to effect a solution. To continue the same example, do the patients show major changes in their lung function or merely minor discrepancies from normal; or on an administrative front do we lose all of the patients’ X-rays or just some of them? Similarly, we can pose the characteristics of a useful solution in quantitative termas. Would a 50 per cent improvement in lung function make ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• List of tables and figures
• Acknowledgements
• Introduction
• Chapter One: The Nature of Innovation
• Chapter Two: Promoting Innovation - A District Medical Officer’s View
• Chapter Three: How Local Government Funds Innovations in Social Services
• Chapter Four: Early Intervention in a General Practice
• Chapter Five: Extended Role of the Home Help Service
• Chapter Six: High-Rise Sheltered Housing
• Chapter Seven: Domiciliary Physiotherapy for the Elderly in South Birmingham
• Chapter Eight: The Volunteer Stroke Scheme
• Chapter Nine: A Continence Advisory Service
• Chapter Ten: Making a Geriatric Department Effective
• Chapter Eleven: Hollymoor Psychogeriatric Service
• Chapter Twelve: A Day Centre for the Elderly Mentally Infirm
• Chapter Thirteen: Residential Home for the Elderly Mentally Infirm
• Chapter Fourteen: Domiciliary Care of the Terminally Ill
• Chapter Fifteen: Education in Care of the Elderly
• Chapter Sixteen: The Societal Context of Innovation in Care of the Elderly
• List of Contributors
• Index