Personal View: Caring for the elderly: a cautionary tale
Authors: Pearl Hettiaratchy
Journal: BMJ (2003)

That a society should be judged by the degree of protection it offers its most vulnerable members is a truism scarcely worth repeating. Despite government efforts, special inquiries, a Royal Commission, and rafts of good intentions, the problem of long term care for elderly people remains. Elderly people deserve more: any of us may have to face personally the problems we collectively fail to solve. Frail elderly people could be excused for imagining that our society offers them little beyond goodwill, sympathy, and the hope that they will stay out of sight.

Nearly 10 years ago several elderly patients were discharged from Park Prewett Hospital in Basingstoke to a private nursing home, as part of a phased running down in the pursuit of “care in the community,” brought forward hastily because the home was expanding.


Confusion surrounded the decision to move the patients


Three weeks later three of them were dead. One was 95 years old, extremely frail, with end stage organic brain disease, several physical problems, and severe behavioural difficulties. Confusion over responsibilities led to his having no GP cover until the day before his death. Confusion, in fact, surrounded both the decision to move the patients—taken at a private health authority meeting—and its implementation. The harm that ensued was unintended but avoidable.

As the patients' psychogeriatrician I assessed their fitness for discharge. Departmental guidance was quite explicit: no patient may be discharged without the authority of the doctor holding responsibility, and that responsibility may be delegated only by the doctor; patients should not be discharged until the doctors have agreed and management is satisfied that everything reasonably practicable has been done to organise the patient's care in the community.

At Park Prewett I found myself an unwilling observer—certain that discharge was wholly inappropriate but finessed by authorities seeking a quick solution. Knowing my clinical decision, they obtained an opinion from another consultant who shared my reservations but felt that discharge was inevitable. And they gave undue weight to the views of a ward sister who had known the patients for only six months.

Sir William Reid, the then parliamentary and health service ombudsman, said that the health authority's decision “should serve as a grim warning to any... authority... planning the discharge of patients from hospital to long term care.” A parliamentary committee punctuated its report with striking phrases: “improper haste,” “willingness to cut corners,” “blatant disregard for departmental guidance,” “brazen attempt to ignore expert advice.”

The secretary of state for health said that there had been critical breakdowns in the delivery of care. The health authority's chairman resigned, and there was much extravagant language. Any future proposal to handle frightened and vulnerable patients in this way would surely be condemned.

A decade later: progress or backsliding? It is now more widely accepted that long term care for the elderly is a social good. Scotland has shown the way. But the questionable decisions continue.

The media regularly highlight individual cases—harrowing examples of avoidable failure. In just four months earlier this year the ombudsman identified



A patient with Alzheimer's disease who, after a fall that broke her hip, became incontinent, immobile, and unable to feed herself and lost all means of communication—her consultant recommended full continuing care funded by the NHS, but the health authority's team elsewhere in the county decided she was ineligible, and the family had to pay


Another patient with Alzheimer's disease who, though needing specialist care and full assistance with all personal tasks, was refused NHS funding on superseded criteria (the eligibility assessment forms had not been updated)


A person who had had a stroke and was totally dependent on carers for personal care and safety who was inappropriately assessed with forms that were based on outdated criteria.






Isolated cases? Possibly—and perhaps diminishing in number as new criteria are applied. But every case of this kind is a personal tragedy. Eligibility criteria must be clear, up to date, consistent, and compassionate; and they must address the realities of life faced by elderly ill people.

The NHS ideals demand a mindset that asks how best to meet a patient's needs, how to make available the necessary resources, and how to implement decisions sensitively. It should never ask what the minimum is that can be got away with or how responsibility can be shuffled off on to someone else.

The quality of life of vulnerable elderly people need not be as poor as we have allowed it to become. Lack of resources, poor staffing, and the inconvenient demands of performance measures that are based on numbers are ritual excuses. I don't need reminding how expensive the necessary care is. Is it price we are interested in, or value?