Sometimes, on Sundays, I visit Richard, a friend who’s 95 and lives alone. The idea originally was that I’d be doing Richard a favour, but the truth is he cheers me up far more than I do him.
I visit because I like him, but as the weeks go by, I’m afraid I’ve also developed a grim curiosity about what it’s like to be in your nineties. Meals-on-wheels, crumbling knees, hernias, cannulas, the way a day dissolves into unintended naps… ‘Can’t we talk about something more cheerful?’ says Richard, as we sit knee to knee. But I’m obsessed, like a tourist taking notes on some awful country they must one day go to.
The notion I struggle most with is that Richard, though partially sighted and mostly immobile, is one of the very luckiest of old people. He’s made it to nearly 100 in decent nick: not blown up, run over or demented. He’s looked after, not in some woebegone home but in his own flat, and isn’t that the great ideal? Expert after expert, government after government, stresses the vital importance of keeping the elderly in their houses. It spares hospitals, saves money and more importantly it allows them — us — some dignity in our dotage, so they say.
So they say… but feeling dignified depends on being treated with dignity. And of all the terrible, riveting details about nonagenarian life, it’s Richard’s experience of care, courtesy of the NHS, that scares me most. Richard is looked after by district nurses, whom I’d always imagined to be old-school paragons: pleasant, dependable and skilled. ‘Well, they did used to be like that a decade ago,’ says Richard. Not any more. The longer I visit Richard the more I worry that there’s been a collapse in the quality of the nursing that goes on unseen in people’s homes. Given there are more than 370,000 over-65s cared for in some way at home right now, this should trouble Mrs May far more than how care is paid for.
Richard is not a problem patient but he does have dressings that need changing — sometimes more often than officially scheduled because they unpeel and fall off. Richard’s wound is an awful, messy affair and it can’t be left uncovered for long, but when he calls the district nurse hotline to ask for help, the reply is always the same: ‘You’re not due a change.’ When he insists that the dressing has fallen off, the nurses make their displeasure clear. Some have hung up on him, others simply say: ‘I’m not coming.’ When, after repeated calls, they do agree to come, it’s usually in the dead of night.
Last time he needed help, Richard began calling at midday. Fifteen uncomfortable hours later, at three in the morning, the door of his flat was flung open and a nurse marched in and started stripping him without a word. Richard wasn’t so fazed by the time of day — though spare a thought for the many thousands of more bewildered old folk subjected to dawn raids — but, he said, didn’t I think it was odd that she didn’t knock?
Letting people age with dignity — what a lovely idea. Imagine all the away days and workshops on this subject attended by the management class of the NHS.
What has happened to the dear, dependable district nurses? The best and clearest explanation comes courtesy of the King’s Fund, which conducted a study on district nursing last year. I had, before reading it, been full of vim and outrage on Richard’s behalf. Afterwards I felt only despair.
The intended aim of the study was to find out whether nurses and their patients agree about what makes good care. They do, it turns out, which is the one bright point in the dismal twilight. Proficiency and hygiene all come a distant second to ‘treating the whole person’ and ‘continuity of care’. The desperate longing of most housebound old people is simply to be treated with respect by a familiar face.
The second half of the King’s Fund study is devoted to its inadvertent finding. In the course of their research the authors discovered, quite by surprise, that district nurses are leaving the job in droves. District nursing has what NHS managers call a ‘recruitment and retention problem’, which these days is NHS code for a catastrophe. As with paramedics and junior doctors, so with those stalwart district nurses.
Between September 2000 and September 2014 the number of staff recorded as working in district nursing posts halved, and hard as senior staff try, numbers are still falling at the same rate. One manager quoted in the report says: ‘We only have a full team for about two or three months in a year before nurses leave again.’
Why are they leaving? Here’s the real heart of the tragedy: it’s not because they don’t care for our elderly any more, but because they care too much. The nurses interviewed for the King’s Fund report feel utterly overrun. We are all living longer and longer, as Matthew Parris says. There are 5.4 million of us over 75 now, set to rise to ten million by 2040. And as we creak on to the receding grave, so our health problems become more complex. It’s not enough for nurses to plump pillows and check blood pressure; homes are like hospitals these days. Overloaded, struggling with the severely ill, nurses are forced to be brusque and to rush, though they know their fragile charges depend on a chat.
It’s because they can’t do the job they love properly that they leave. And then begins the usual vicious circle which is eating away at the heart of the NHS. Because good staff leave, the rest feel more stressed and more pressured, so they leave too. Agency staff fill the gaps, but too often they can do the job specifically because they don’t really care.
The whole NHS is suffering, as Max Pemberton pointed out a week ago. Hospital staff are just as overrun as district nurses, but the difference is that care in hospitals is scrutinised. Care in people’s own homes is not, and the elderly are the least likely to complain. Richard doesn’t want to. He doesn’t want to make a fuss. And who would listen anyway?
This article was originally published in The Spectator on 27 May 2017