The best unexpected conversation I have had was with a geriatrician I was working with a few years ago. She had the view that no older person she looked after was a single unit. She said that occasionally they have a gaggle around them keeping them going - daughters, neighbours, paid carers, but generally they came in pairs (i.e. couples - usually married, or sometimes in close companionship), each holding the other up.
She felt that the best physicians - or any member of the clinical team - knew to treat the unit, to ask as much about the quiet, accompanying support, as the person with their needs and hopes in the chair or on the trolley.
I shared the experience of my own grandparents: my Nana refusing to recognise the limitations imposed by her numerous conditions, or noticing the impact her constant admissions and crises had on my Granddad, silently toiling away, always remembering the walking sticks, the cushions or checking the daily AM/PM pill boxes.
While she was in hospital again for complications of dementia, he quietly slipped away at home, succumbing to a quiet condition, never diagnosed, never complained about. Suddenly the unit was cracked open and an inevitable, sadly typically brief, care home stay and expensive stint in a hospital 'place of safety' resulted. We talked about missed opportunities and why the system may have failed to support them.
This was a classic story into which Tammy - the geriatrician - had huge insight. She saw the potential of better care, more effective support and more control in the hands of patients - by treating that couple, by designing solutions and approaches to therapy that helped sure-up that unit. It may take longer, and certainly isn't how the NHS is set up, with its single-referral and deficit-based approach to diagnosing needs and thresholds for treatment. It is more than just supporting carers; it is understanding the essential co-dependency of health and wellbeing between couples later in life.
As I have learned from this and other conversations, as we panic for hours with bleeps and bed states to clear wards and make space for admissions from A&E - it's who is at home, who can keep an eye and what is in the fridge that often prevents that admission, or that discharge, or an unfortunate readmission - contributing to poorer and poorer outcomes.
As Tammy and I worked together to design a commissioning plan for older people across health and social care - still going today and now linked to a Vanguard - we always had that unit - two little figures - at the centre of our schematics and diagrams. We remembered that we must aim to design systems that could accommodate those who toddle along, two-by-two, for as long as possible.
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