Andrew Elder: Older folk sentenced to death by our uncaring attitudes

Despite the increasingly frantic calls for help from care workers and families and the proximity of a large acute hospital yards across the street, 18 residents died of heat exposure and dehydration in the following few days.

As the story broke, a local senator gave his reaction. “Look at the population. You’re dealing with the ninety somethings. Some of these deaths would naturally occur, storm or no storm. Eventually, everyone who was in that nursing home will die.”

Faced with a media backlash he quickly reorganised his thinking.

“I apologise if my comments yesterday did not properly convey the deep respect I have for elder members of our communities. No family member should have to fear that their loved one is suffering in a nursing home. I look forward to working with my colleagues to ensure the legislature takes the appropriate steps to safeguard our seniors from the horrific and inexcusable situation that occurred in Hollywood.”

The storm of Covid-19 has left its own trail of harm across Scotland. Deaths were particularly frequent in our care homes. Some factors contributing to these deaths cannot be changed – the older age, frailty and multiple co-morbidities of many residents makes them implicitly more susceptible.

In addition, the care needed to support personal activities of daily living, such as dressing, washing and toileting, cannot be provided without close, frequent and often prolonged contact with caregivers. Dementia brings additional challenges in infection control. But some things, with hindsight, could have been better. For example, rapid access to personal protective equipment (PPE) and prioritised testing, for residents and carers alike, may have helped reduce deaths.

But, just as the absence of a back up generator was not the sole cause of residents’ deaths at Hollywood Hills, neither was suboptimal PPE or testing in our care homes.

The problems are deeper, chronic, systemic and, despite many other differences in US and UK cultures, common to both. A highly skilled and dedicated – but poorly supported and remunerated – care workforce, given much responsibility but precious little respect.

A split between the provider of so called “social” care and the provider of health services. Hollywood Hills’ residents were eligible for free medical care, but could not access it at their time of crisis. It is suggested that some of our care home residents, all eligible for NHS care, may have had a similar experience.

But a deeper problem may underlie. Although we may not like to think it, our attitudes towards the old, and particularly the frail and dependent old, may be at the heart of the problem.

Negative attitudes about the old are common, pervasive and not confined to the minds of politicians. They are more often unspoken than openly voiced.

Pearl Buck, the first American woman to win the Nobel prize for literature, put it thus: “Our society must make it right and possible for old people not to fear the young or be deserted by them, for the test of a civilisation is the way that it cares for its helpless members.” That was in 1954.

Four-years after Hurricane Irma passed through Florida, back-up generators are now mandatory, Hollywood Hills is closed, but the general landscape of nursing home care is unchanged.

A specific problem has been addressed, but the systemic issues persist. Pledges made at a time of tragedy have not remedied the deeper problems.

Our older population is rapidly expanding. For the foreseeable future, many older people will develop dementia or physical limitations that require support and care, be that in their own home or a care home. Covid 19 has cast a sharp light on our shortcomings in that support and care. We can undoubtedly improve, but only if our attitudes change.

Professor Andrew Elder is President of the Royal College of Physicians of Edinburgh, and a consultant NHS geriatrician.