For the want of a nail

Lisa oval

I’m at that age where my contemporaries are gradually losing their ageing parents. Plus doing all they can to help the ones who are left to cope with the indignities of living longer than our society seems to be set up for.

We are all born. And we all die. And people haven’t suddenly started to live longer. It’s been happening for years. And yet we seem to have devised our health care system as though none if this were the case.

As if there really were such a thing as saving lives.

There isn’t. All health care folk can do is help to prolong a person’s life, hopefully until that person feels they have lived a full one. And in doing so, take account of their needs and wishes. About how they want to live and also how they want to die. In the NHS we aren’t always very good at the first. And we are often very bad at the second.

There’s something very odd about the NHS. It’s called the National Health Service. And yet the majority of NHS time, attention and money is spent on hospitals. So much so that services that used to be called community health services were recently re-named ” Out of Hospital Care”. This may not seem important.  But it really is. And this is why.

Many years ago when I was a student nurse, I spent three months at what was then called a geriatric hospital. I remember an elderly lady who had suffered a stroke. Her face was turned literally and metaphorically to the wall. When I left the ward for my next placement, it was assumed she would soon die. Then a few weeks later, I had the opportunity to accompany the Health Visitor for the Elderly on her rounds. And in a tiny Cambridgeshire cottage, who should hobble to the door, all smiles, to let us in and offer to make us a cup of tea while her cat snoozed on the sunny window sill, than that lady?  And I suddenly realised that people live in homes not hospitals, and that being in hospital for even a day longer than is necessary diminishes people. My lady managed to escape. But these days, not many are so lucky.

If you wanted to devise a system that made sure that most elderly people die in their least preferred but also the most expensive possible place, i.e. hospital, it would be our NHS and the services that supposedly support it.

Local authorities have been starved of cash. And now hardly anyone except the most profoundly disabled gets any help at home with what is called social care, but includes essentials like eating, drinking, going to the toilet and having a wash. Organising private home care is in many instances a nightmare and a lottery. Simple adaptations to stop old people from falling down at home such as stair rails, bath handles and toilet grab rails are impossible to come by unless you have the money to pay for them and someone who will arrange for the work to be done. Such jobs may seem simple. But they can overwhelm an older person.

And yet as Atul Gawande says in his book Being Mortal, preventing falls is the top priority if you want to stop old people from being admitted to hospital. And where do they most often fall? On the stairs, getting out of the bath and getting on or off the loo.

Atul Gawande also writes about the importance of nutrition in old age, the positive benefits of minimal medication, and how vital it is to ensure good care of the feet. All of these help prevent falling. But here in the UK, NHS chiropody is a thing of the past for anyone who is “just” old. I don’t know of any older person who has had useful, regular advice and support about eating well. And many older people are on multiple medications which cause dizziness, which then leads to falling.

And when the almost inevitable happens and the older person “has a fall”, in most parts of this country there is still only one response, which is for two highly trained people to take them in a high-tech ambulance to the place where lives are saved, the hospital. And they will wait in A and E because it’s very busy there and their condition isn’t currently life-threatening. And they will deteriorate rapidly and possibly either get sent home, with an increased risk of readmission, or simply be admitted, in most cases never to go home again. Neither are great outcomes.

(I don’t know what the legal age is when one stops actively falling over and starts “having falls”. But I hope someone is campaigning for this term to be banned. Because it is passive and suggests that bad things just happen to older people. Which they don’t have to.)

In some A and Es, specialists in elderly care are at last being employed. We either need these people to be on duty 24/7 or we need everyone who works in A and E to become a specialist in elderly care because assessing and treating very old people is the majority of their work.

And we need to do all that we can to prevent as many as possible such visits in the first place.

As Benjamin Franklin said, for the want of a nail….

I love spending time with my mother and her friends and the parents of my friends. These people lived through WW2 and their parents through WW1. They have known hardship and loss. When they were growing up, anyone over 60 was old. They remember what things were like before the NHS. They are kind, funny and stoic in the face of much grimness. We owe it to them, and to the ones coming afterwards, including you and me, to reset the NHS dials so that it is possible to live well and to die well. And for everything to be focussed on helping older people to stay at home, or somewhere lovely that feels like home. In the end this will cost much less. And be so much better for everyone.

My elderly lady would probably not have survived another stroke. But how much nicer for her to die in her own bed, with the cat asleep on the end of it, than in a lonely hospital ward.

Now, can someone tell me who is in charge of Out of Hospital Care please? I’d like to help organise a renaming ceremony.




  1. A thoughtful, wise post as ever, Lisa. The ‘had a fall’ phrase makes my toes curl too, but incidents of falling can often be reduced by improving someone’s balance. Our local villages have got together to run a community gym in a
    community hall with rented equipment from the local authority. It costs £3.50 a session and has no joining fee. The fully qualified trainer gives everyone an individual programme just as in a ‘conventional’ gym and pays close attention. But, here, you’ll see people gently working out while attached to an oxygen bottle, or someone else managing to increase movement after a stroke. My husband lost most of his hand in a motorcycle accident and the increase in strength and, perhaps more importantly, his self esteem, is astonishing. The folk who come are mostly over 50, no lycra, no mirrors! Diabetes has been eliminated, beer bellies gone, balance improved and falls greatly reduced. One member says it’s done away with his three-year depression. The three GPs have seen a measurable improvement in local health, and are keen on ‘prescribing’ a stint at the gym. It’s a little miracle! I know it isn’t a miracle really, and exercise can only do so much, but little gyms like this as an outreach of the NHS, would be a help in so many ways.


  2. Hi Lisa,Great article and I so agree with you.I retired as a nurse for the elderly at a GP surgery two years ago and I was one of very few in the country.They haven’t replaced me.There are some very good falls teams across the country but they only go after an event.My job involved falls prevention amongst other things.The Ots and physics had plenty of referrals from me.The piece which was written into the GP contract that everyone of 75 should have a yearly check up had been abolished.This is such a pity as there is so much very simple preventative work that can be done.Its something I feel quite passionate about having seen how much it helps!


  3. Last night my husband couldn’t get a reply from his Mum who’s 94 and has had 3 falls in the last few months. Panic ensued getting hold of sheltered accommodation helpline etc. No reply to their intercom and neighbour found her ‘deeply’ asleep in her chair and confused when aroused. We live 2 hours away. Thank goodness for a brilliant Community first responder there yet again within minutes and finally another A&E trip and hospital admission. Probably another stroke.

    Much to the family’s dismay mum in law can only get morning care paid for. Evening care she would have to pay for which she says she can’t afford Quote ‘I wouldn’t have enough money to buy a new washing machine if it broke’. We have to rely on an evening call every night to check on her and lovely neighbours. Although the neighbour willingly went to check how would she have been if mum in law was dead.

    Yes the hospital has been great. Intensive physiotherapy and then more at home. But to early discharge once meant a quick readmission. The hospital is noisy 24 hours a day. Usually the ward has at least one confused disruptive patient and it’s boring for my mum who has lost most of her sight. Not nice.

    Basically she either needs to be in a home which for a previously active and ‘still got her marbles’ old lady would seem like a living death. Quality not quantity of life is maybe the answer. Meanwhile the family are at a loss to know what to do. We would all contribute to extra care for her but actually she wants to maintain a little bit of independence – without realising the strain this puts on all of us.

    All the other 3 parents remained at home up to the end. Dad died slowly over a week at home supported by compassionate district nurses who knew him well and grieved with us. He was 88. Mum died in her sleep in her own bed aged 91. Independent until the end. Dad in law (90) died in hospital – he always dreaded being admitted as he always thought he would never come out. All 3 died alone.

    I dread getting old


  4. Some paramedic practitioners can treat someone at home without taking them to hospital & then liaise with family/GP/carers a fantastic idea but there seems to be just 1 covering 3 counties! A missed opportunity surely.


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