Who Decides? Protecting Our Parents

LINE RINGS

'Ambulance service. Is the patient breathing?'

'Hello. Is the patient breathing?'

'Are you having trouble breathing?'

'That's OK. Don't worry, don't worry.'

'We know where you are. We know where we're coming to.'

Kathleen and Leonard Price live in Birmingham

in the house they've owned for 50 years.

They want to stay there.

LINE RINGS

'Ambulance Service. Is the patient breathing?'

Kathleen is permanently bed-bound.

She receives social services' maximum home care package.

But in the past three months,

she's called 999 over 150 times asking for help.

LINE RINGS

'Ambulance Service. Is the patient breathing?'

We had an e-mail yesterday, regarding Mr and Mrs Price.

The elderly care system

aims to keep us in our own homes for as long as possible.

But as our population ages rapidly,

the NHS and social services are struggling

to work together to keep us there.

I don't want to go into a care home.

I've got my home here.

Doctors and social workers have to balance stretched budgets

against our needs and desires.

It's a dilemma. I want them to be at home, together.

But it's been explained to her

that if it doesn't work at home it will be long-term care.

I think at some point you're going to have to make the decision,

with our help, that it's not possible any more

and maybe we look at an alternative.

We want to remain together.

As we get older, who should make the decision

that we can no longer be cared for in our own home?

Well, we had a good life, really, didn't we?

Yes.

Happy days, though.

-All memories.

-Yeah.

Memories.

'Ambulance Service. Can I help you?'

'Yes, we've got a female who's 80 years old who's unconscious.'

'OK, and a name at all?'

'Er, yes. She's called Kathleen Price.'

Kathleen has been brought to Birmingham's Heartlands Hospital

with a suspected kidney infection.

OK, she'll be going into...

I'll put her into bay one, actually.

It's her fourth emergency admission in 18 months.

Kathleen Price has been down in A&E for quite a few hours now.

Probably looking at about seven or eight hours.

She's not able to come up because we've got no bed space for her.

So she's got to sit it down in A&E.

A&E's quite full regularly in wintertime.

There's a lot of pneumonias coming through,

falls - it's a lot to do with the elderly, actually.

Kathleen is stabilised, and after a nine-hour wait,

she's moved to a bed on a renal ward for treatment.

All right, I'll keep you in the loop...

Birmingham Social Services' older adults team has been managing

the Prices' case for over 18 months.

They are a devoted couple who have been married, I think,

about 60 years.

They live for each other.

It's a very symbiotic relationship, they live for each other.

But he's not in good health himself, which has slowed him down.

He's not sleeping in his bed now - he sort of sleeps downstairs.

The Council pays for two carers to visit Leonard twice a day.

With Kathleen in hospital, his case-worker Sam Iliffe

is also checking up on him.

Hiya, are you all right?

Leonard and Kathleen have two sons - one estranged,

and another who visits whenever he can, but lives over 120 miles away.

Leonard, you know why I've come today, don't you?

Remember I rang you yesterday?

-Yeah.

-I've just come today to check you're OK and see if you're coping

while Kathleen's in hospital.

-Yes, I'm all right.

-You look very smart.

-I've only just got up.

-You've just got up?

-Yeah, I sleep here.

-You're still sleeping downstairs?

-Yeah.

-Even though Kathleen's not here?

-No. I've got used to it now.

-And you're coping OK at the moment?

-Yes.

-OK.

-Feels a bit strange being on your own.

I know.

No-one to talk to?

-Yeah. Nobody to row on, like.

-No-one to row on!

-At least you can watch what you want on the TV.

-That's it.

You've got the control over the remote control.

Yeah. I like a good cowboy film, you know.

A Western, like. I don't mean these silly things.

But, um, she likes a love story.

-Aah! The romantic stuff.

-Romantic!

You not romantic?

HE LAUGHS

She keeps slipping down that bed.

I used to have to keep pulling her up.

You'll end up hurting yourself lifting her.

Yeah, well, I've been doing it, though.

You shouldn't. You'll hurt yourself.

We'll have to see what she's like when she comes home.

Yes. She's hoping to be home next week.

That's good.

Hoping.

She's been a good wife.

LINE RINGS

Hello, Kay, my name is Louise Graham, I'm a social worker

here at Heartlands Hospital...

While Kathleen recovers from her kidney infection,

responsibility for planning her care

when she leaves Heartlands is handed to the hospital social work team.

I'm just trying to clarify what was happening in the community

prior to her admission, you see.

Do you know how many times she's called them?

57...?

57,000...?

Like most local authorities,

Birmingham doesn't pay for 24-hour care at home.

And Kathleen doesn't have enough savings

to fund her own care privately.

-Hello, are you Mrs Price?

-Yes.

Hi. I'm Louise Graham.

Social services' maximum care package

provides four visits a day by two carers.

But this doesn't appear to be meeting her needs.

Obviously there's been meetings in the community

and I know they've spoken to you before...

-Yes, and I'd rather be at home.

-..and that you want to go home.

-Yes.

-I don't want you to worry that I'm pushing for anything else,

I just want to make sure that that's what you want

and that you understand that how things were

before you came into hospital

when you were calling, say, the emergency services,

it can't really continue.

But we need to make sure that, going forward,

that you have the right support

and that we can reduce those calls to the emergency services.

How long will it be before I can go home?

At the moment, I'm not sure, because I think we may need

to get the community social work team involved

with the planning of your discharge, you see,

to make sure we have everything in place.

I thought she was very coherent.

I do believe she has got capacity to make the decision about going home.

Obviously she's aware of the calls,

but it's about, is she aware of the implication it has on others?

That probably is questionable.

And I know Mrs Price wants to go home soon,

but I don't think it's going to be as soon as she would like.

Kathleen is now well enough to leave hospital,

but she can't go home until she has the right level of care in place.

She's occupying a bed that costs the NHS £310 a day,

and so for each day she remains on the ward,

social services are liable for a £100 fine from the Hospital Trust.

It's in their hands now.

Yes. But I'd still like to go home.

That sounds ungrateful, don't it?

There's no place like home.

No.

I don't like leaving him.

We're always together, you know.

Married, and before that we was courting.

He was in the forces, mind you.

He didn't get married in uniform because he was already out,

but he wore his de-mob suit, we called it.

Yes.

Yeah. Yes.

Very nice.

Seems a long time ago now.

He's missing me more, I think. But he's coping.

But he wouldn't strike out on his own, no.

I don't bully him.

He just, he takes the easy way out really, you know.

Like most men!

Yes.

Any questions you have for me?

Professor George Tadros is a consultant psychiatrist

for the local mental health trust.

So in December she called 999 80 times,

and 80-plus times in February.

While social services are trying to put in place a care package

that will work for Kathleen,

the hospital team wants to test her memory

and her understanding of her needs at home.

The law assumes that all of us above the age of 16 have mental capacity.

So we can make decisions for ourselves.

And the law specifies if we have mental capacity,

we can make whatever decisions we want -

even if those decisions are seen to be ridiculous or wrong,

as we do sometimes.

The difficulty in health care, especially with dementia,

when the patient can't make those decisions,

if the patient doesn't have capacity,

that doesn't mean we take their lives away from them -

no, that means we have to make decisions

based on their best interest.

Kathleen's doctors and social workers

tested her mental capacity on two separate occasions

before she came into hospital - with conflicting results.

-How are you doing today?

-Very well, thank you.

Very good.

Do you think the care package will work in the future for you?

I'm sure it will. As soon as you get on your feet

-then you soon get going, don't you?

-Right, and you hope you'll be back

on your feet and then things will...?

Yes. Take it steady, you know. Take it steady.

I have been looking into your records

and it looks like you have been calling 999.

-No, not necessarily.

-Not necessarily, OK.

-No.

-Right.

So, what are the situations

when you would feel it is appropriate to call 999?

I don't remember that I have called it that many times.

No, all right, OK. And how's your memory?

-Very good.

-What day is it today?

Erm...you've got me.

Well, it's difficult when you are in hospital to keep track of days.

But do you know what month is it?

It's April.

Kathleen, can I ask you to try to remember three objects for me?

All right? I'm testing your memory now.

Lemon, key, flag.

Can you repeat them?

Lemon, key, slag.

-Flag.

-Slug.

No, flag, you know the flag?

-Oh, flag!

-Yes!

Lemon, key, flag.

Very good, OK. Keep them in your mind.

Can you tell me the days of the week backwards, beginning from Sunday?

Sunday, Saturday, Friday, Thursday,

Wednesday, Tuesday...Monday.

Very good. Do you remember the three objects you repeated after me?

Er...

-It's gone.

-That's all right. That's all right.

-I'm not doing very well, am I?

-No, I think you're doing very well.

I know your memory is not brilliant, but that's OK.

Do you have any questions for me?

Not really, apart from when am I going home?

We're not ready for care homes and things like that.

You're not ready for that?

-No.

-Do you think in the future you might consider that?

Well, you don't know, do you?

No. We'll certainly help you to go back to your home.

Yes. Well, I hope so.

-We'll do that.

-Yes.

-All right.

Kathleen, good to see you.

Lovely to meet you. Take care, bye-bye.

I think in Kathleen's case, there is a genuine memory impairment,

but also I think she underestimates her needs.

She has been calling 999 very frequently,

but as she was telling me,

she can't remember that she called them that often at all.

She can express herself,

but she fails to comprehend what is going on around her.

Kathleen lacks capacity.

We will communicate that to the social services work team here

and in the community,

because the difficulty with elderly care, as you have seen -

many people involved,

and we need to keep them together working on the same plan.

I understand where the medics are all coming from,

the cost involved and manpower

and she keeps ringing the ambulance service and it's inappropriate.

It's horrendous. Who knows?

One of these days that ambulance that she's called, I might need it.

But every time I speak to her about it she says

she knows it's wrong and she shouldn't do it.

There's the assessment that you asked for.

Senior social worker Anna Wilkie is Louise's manager.

Seems to be lacking capacity.

Social services has concerns about Professor Tadros's assessment.

Denies that she has been calling 999...

The decision that Kathleen lacks capacity means that in future

she may not be allowed to choose where she lives.

It's life-changing.

We're making a decision that could change this person's life,

and you have to weigh up everything

and you have to keep going back and asking these questions.

Because otherwise, if you get it wrong it might mean them

having to be separated and you cannot undertake it lightly.

You can't.

Hello, Mrs Price.

OK, then. So you know we're trying to arrange for you to go home

with your package of care.

Yes. OK.

I know there were issues when you went home with you calling

services at times when you needed to be lifted up the bed, or...

I'm not trying to make you feel bad.

I don't want you getting upset about this.

-No, I won't.

-I just need to know that you understand

it's not a good thing to do.

No, I thought it was settled, that point.

You know, about calling in to 999.

-So, you know it's not a good idea?

-Well, obviously.

So, what we were thinking,

we've tried to come up with some extra support.

So, what my manager has agreed to do,

the person who holds the funding,

she's agreed to give you an extra call...

-Yes.

-..and hopefully it'll solve the problem

and you won't need to be calling the ambulance service.

-Yes.

-So, do you think that's a good plan?

-I think so. It's like an extra call.

-Yeah.

As I say, I would never call 999 unnecessarily.

Great. We'll get you out of here as soon as we can.

She fully understands that ringing the ambulance service

to be lifted up the bed is not what you should do.

But her need, to her, is very real and very apparent as well.

She's been quite rational.

-OFF CAMERA:

-So, do you think that she has capacity?

I do.

She fully understood that it wasn't what she should be doing.

As the question over her mental capacity remains unresolved,

Kathleen can still make decisions about her own care.

After five weeks in hospital, she will be allowed to return home,

with an extra care visit in place - and two more for husband Leonard.

Social services hope it will stop her calling 999 for help.

So, do think we should phone him?

You know, is he prepared for his wife to come home?

I will go and ring him now.

It's the day of Kathleen's discharge

and the community social work team is planning for her return home.

LINE RINGS

It's answer machine, I'll ring back in a sec.

LINE RINGS

Still answer machine.

LINE RINGS

-I don't know where he is.

-All right, OK...

Is Leonard there, please?

One of Leonard's carers picks up the phone.

He's gone out?

He's not in the house at all?

Is he not in the garage?

Back door's locked. He's nowhere in the garden at all?

And all upstairs is totally clear?

OK, do you want me to give you my number

so you can give me a ring if you find him?

OK, thanks. OK, thanks.

Bye.

-So how long has he been missing now?

-Well...

We've been ringing since half past ten.

Nearly an hour. So has the carer been in today?

-There is a carer there now.

-PHONE RINGS

Hello.

He's gone to hospital. Which hospital is he in?

Half six this morning. OK. Bye.

He went his hospital this morning about half six.

-Well, how can she be discharged?

-Kath can't go home then, can she?

-No.

Hello, is that ward three? Hello, ward three. My name is Kaye Duhig,

senior practitioner, Hodge Hill.

You've got Kathleen Price with you, haven't you, at the moment?

I know she was due for discharge today -

her husband has been admitted now.

Well, I want to make sure that this patient is not discharged.

Leonard has been brought into Heartlands with a twisted bowel.

I was expecting to go home, but fortunately or unfortunately,

my husband has had to come back in

and so there was nobody there to receive me.

I am glad that I have stayed here.

I don't think I would be capable for the time being.

It was very frustrating to find out that after all our hard work

that the area social worker had rung ward three

and had cancelled the discharge of Mrs Price

because Mr Price had come into hospital.

Well, you know, as far as the hospital is concerned,

that doesn't matter.

I know it sounds very hard and very callous,

but it doesn't matter.

She shouldn't be on an acute hospital ward,

not when everything is in place for her to go home.

-Kathleen.

-Yes.

We have spoken to the social worker and you are going home today.

I am going home today?

Yes, yes. There will be a carer at home at six o'clock.

I see. OK?

But Len is staying in?

-Leonard, yes - just for overnight monitoring, OK?

-All right.

Yes, thank you.

The decision that Kathleen can return home safely

has been taken by the social workers' managers

and the Hospital Trust.

I have had a call from the hospital

and the ward want to discharge her home.

I said, "Well, he's not going to be there."

You know, she's been in hospital coming up to five weeks.

She is going to be lonely, isolated.

She'll be on the phone to the ambulance

because she will feel, you know, there is nobody there.

So it's starting the problem again.

You do see the Trust's side of it.

I understand both sides and you feel like piggy in the middle.

And part of me wanted to be able to say,

"Oh, no, she can stay here until he goes home."

Because that would be lovely in an ideal world -

but that's not the real world,

because we have got no beds for people who are really ill.

I didn't think they would let me.

There'll be a carer there for six o'clock.

There is a reason for everything.

-All the best. Look after yourself.

-Thank you.

No problem.

Sad though it is, there are hundreds of people in the community

who have nobody else living with them,

who are bed-bound and who rely on carers going in,

and that's the only contact they have, day in, day out.

The carers should have been here.

And we don't know what the carers do.

Is that where you're going - into your bed?

-Sorry?

-Is that where you wanted to go, into your bed?

I ain't fussy. Whichever is easiest.

Do you sit here, sometimes? We can put you there all right.

-All right, Kath?

-Yeah.

-Have you got her?

-Yeah.

Have I got her?

-You better have!

-THEY LAUGH

Are you ready, Kath? Same as we done in the ambulance, ready?

One, two, three...

-Ta.

-Comfy?

-Yeah.

-Is that all right?

We want to leave you so you feel comfortable and safe.

-You should have gone straight into bed, really.

-Oh...

Oh, God.

-Are you comfortable like that, Kath?

-Not really.

Not really, no.

I am a nuisance.

No, it's not your fault, Kath.

If the carers had been here there wouldn't be any problem

because they can hoist her straight onto the bed.

So we can just do what we can.

-Hello.

-Help yourself!

Hello, Kath. Long time no see!

Hello, welcome home, how are you, Kath?

Not too bad.

It's good to see you home, anyway, Kath.

I'll go and get the stuff for the bed.

Glad to be home?

Oh, yes. Mind you, the house looks as though a bomb has hit it.

You'll be all right, Kath.

When you settle back in you'll be all right.

Right. So, Kath, we'll be in later on, then, all right?

We shouldn't be much later than nine o'clock.

Don't leave me too long.

No, we'll be here by about nine-ish. So we'll see you a bit later.

See you later. All right, Kath?

-See you in a bit, Kath.

-You're OK. Mind how you go.

Bye, Kath. See you later.

Put that kitchen light on.

When Len was admitted, I thought they wouldn't let me out

but they did, so...

But I was sad because I expected him to be here, you know.

But it's just one of them things.

Are you listening, Len? Can you hear me?

I don't want to shout loud.

After his overnight stay in hospital, Leonard is back home too.

I was glad he was home safe and sound.

We've had a few tiffs.

SHE CHUCKLES

But he was going with another girl at the time.

And I met him at a dance...

..and...

..he took me home.

And it went from there, didn't it, Len?

HE MUTTERS

What's that, Len?

Oh, yeah.

HE CHUCKLES

Must be 60 years.

It's got to be - I was 20 and I am 80 now.

THEY CHUCKLE

As I say, I always worked evenings.

I never left the children.

Mostly factory work.

My God, they worked you to death.

But it was a job.

We never had a lot to squander.

No. There was no such thing as old people's homes.

It was a last resort, you know.

I don't think I would like to give my home up

to go into a care home,

but you don't know what's around the corner, do you, you know?

LINE RINGS

'Ambulance Service, is the patient breathing?'

It's a month since Kathleen left hospital

with her new package of care.

'Don't worry, we're going to get the right help for you.'

The Prices have called 999 40 more times.

My understanding is that she was OK at night.

She's been ringing all hours of the day.

The police have been out to the house,

the ambulance have still been out to her.

It just seems that the package, at the moment,

is just not working whatsoever.

The carers are saying that Leonard looked really poorly.

But Kath's saying she wants 24-hour care.

Well, she can have 24-hour care in a care home...

-But not in her home.

-..not at home, no.

Hello, I am Liza Armstrong, I'm your new social worker.

How are you getting on with the carers?

They're all right.

They're good girls? They're looking after you?

They are good girls. Yes.

But one of the other things that I receive, you know,

the feedback, is also that the ambulance came, didn't they?

Can you remember why did you call them?

Because I needed help.

-Right.

-And your carers could do a lot more, and they would do a lot more

if they had the time and was paid properly.

How else could we help you?

They should pay them more, give them more time.

They're allowed - how many minutes is it? I can't run on minutes.

They do care. But they haven't got the time.

That's what I'm trying to say.

If we could get more carers, would you physically pay for them?

I can't afford to pay.

I might be lying here now, but I've paid into the system.

What we are here to talk about

is whether you really do understand how much care you really need.

You can't have the carers 24 hours in your home,

unless you can pay for it.

I know that you do need care

and I do think you would get a lot more, better care in a nursing home.

-I know you're not going to agree with that.

-Well, I'm not going, no way.

-Forget it.

-I know that.

Please don't. Yeah?

Unless it's really an emergency,

really something happens, something wrong.

Yes?

You have to wait for the carer to come.

I don't want to go into a care home.

I've got my home here.

I'm very disappointed.

Not in being old - in the treatment.

You know, as if you're a kid,

as if you're asking for help unnecessarily.

I wouldn't do that.

I didn't realise that it was so costly dialling the 999,

so what do I do from there?

They are using a large amount of the health resource.

I haven't had that conversation about resource.

I worry that if I do with patients,

if I'm honest,

if I raise that discussion

that this is how much it costs,

that people will think I'm making decisions on the basis of cost.

In a sense, it would feel as if we're saying you're not deserving.

Sit down.

The cost of the 999 calls, and Kathleen and Leonard's

hospital admissions, is charged to the local health budget.

Under the new NHS funding structure, this is run by Dr Chitnis,

who has been the Price's GP for 20 years.

I would feel very uncomfortable

that we were making the most important decisions

solely because of money.

But actually, what do we do as a society,

when their ultimate wish to stay at home is just not affordable?

That's a very uncomfortable place,

to be saying it is money that's going to drive the decisions

around this couple's care.

I'm sad to say it might end up at that place,

and we're going to have to make some very difficult choices.

Hello? It's Dr Chitnis.

Oh, hello...

Dr Chitnis and community psychiatrist Dr Dhariwal

are here to review the Price's case.

-How are you?

-Still here.

-You're still here, OK?

-Yeah.

-How's your chest feeling?

-Not too bad.

'Ultimately, I would love to keep this couple at home.'

But her situation of being bed-bound with the pressure

sores on her feet, the incontinence,

the, at times, being in a pad that is damp

because it takes time for a carer to get there

and Mr Price can't change her.

'Living in that distress all the time seems a very poor quality of life.'

-You finished your tablet course, have you?

-I think so.

'What is it we need to do?

'What is it that would make their lives better?'

We know we aren't meeting their need at least four or five times

a day, because she picks up the phone and phones 999.

We're going to try and keep you at home as much as possible.

-I'm not going away.

-Well, we'll see what we can do, OK?

It's my home and I'll be treated here.

Absolutely. I understand that. I understand that.

And if you can't do it, don't bother.

Yeah. Well, we're not going to let you...

You know, not going to abandon you, either.

-No.

-That's important.

-Please yourself.

-Yeah?

OK. Dr Dhariwal's here, do you remember him?

-Yes, I do indeed.

-He's the nice one.

Kath...

Dr Avi Dhariwal has been assessing

Kathleen's mental health for three months.

So, how have the last few days been for you?

Not too bad. Not too bad.

Have you felt the need to give the ambulance services a call?

I call them to get the carers.

Yeah. Have you called them in the last few hours?

-In the last day or so?

-I can't remember.

There have been a number of calls.

Well, I won't call them again.

I know, you said that to me last time, Kath.

-I think you were upset that...

-I was upset.

Let's move away from the ambulance calls.

Can I ask you some silly questions

to see how your memory is today, Kath?

I did this before with you. Can I do that again?

You can do what you like.

All right, all right.

I'll try not to sort of upset you too much.

But can you tell me what day it is today?

-Sorry?

-What day is it today?

Saturday.

OK. Can you tell me which month we're in?

I don't know.

And do you get some help here at home?

Some carers come here?

They do, they're very good. There's not a lot they can do.

They do their best.

But they're not here when you really need 'em.

If it's too much I won't call them again.

Who? The...

Call who?

The carers.

They come anyway. You don't have to call them, do you?

They just come, don't they?

I don't know.

Kath, you're a bit more upset today than you were when I last saw you.

Yeah, I should think so, as well.

What is it that's been unsettling you a little bit?

I'm feel as if I'm being made a nuisance and I'm not a nuisance.

-Right, OK.

-If I need help, I need help.

-Sure.

I can't explain it.

Is there anything else you want to say to me, Kath,

or anything else you want to ask?

No. Just don't blame me.

-I can't help being poorly.

-No.

'I don't think she has capacity.'

Her decision-making is impaired now.

We just have to see if we can get as much help as we can in between times,

so that we can try and look after you here.

We'll have to see what we can do. Yeah?

We're keen to look after you here. It's your house.

Okey-dokey. Well, it's lovely to see you.

All right.

-Bye-bye. It's lovely to see you.

-Bye, Kath.

-Take care.

I suspect we're going to see a further decline

to a point where them being able to safely manage in this environment

-is tested.

-Yeah.

-And that's going to be incredibly difficult for her.

If we carry on on that trajectory,

at what point do we have to make a best-interest decision

on what we do here in the home?

Or, similarly, whether we have to take the very difficult decision

about whether we move her?

It is a possibility that even if the Prices feel

that they do not want to leave their home

that they have lived in for decades,

if their care needs can't be met at home,

then it is our duty to ensure that they are safe,

and if that means moving from home then we would have to do that.

But it is good practice to have everyone on board with that,

including the Prices, but that may not necessarily happen.

In the last few days, she's come into hospital with pneumonia.

Looking at her today, she's not quite as sharp.

I think she has clearly been a little bit unwell.

We'll just compare that to her previous X-ray.

Kathleen is being treated by Dr Peter Wallis,

Heartlands' lead elderly care consultant.

It is a challenge. As couples age, their needs can grow apart.

Obviously, in Kathleen's situation,

she is becoming physically unwell now

and her needs and those of her husband do overlap to some extent,

but they have very different care needs.

So sometimes it is quite difficult to balance the needs

of both patients and to get a care plan that can support both of them.

LINE RINGS

'Ambulance service. Is the patient breathing?'

What's wrong with you today?

It's your heart?

Pardon?

Are you having any pain in your heart?

Leonard Price is back with us, the 83-year-old gentleman.

He has come in, had a fall, post his chest pain.

He has been in now three days.

He is actually medically fit for discharge,

we're just waiting for the social working team,

and that's it really with him.

I can't hear you, Len.

I look...?

Everybody tells me that.

Do what?

No.

It is no good me coming out now with you not there.

Have you been worried about me?

He is having the time of his life!

He does love me, really.

SHE COUGHS

'This case is not straightforward.

'The dilemma here is we have a huge health system

'and so many professional people involved -

'social care, health care.'

And with Mr and Mrs Price, my worry is that they may be falling

through all these different systems around them.

After six months of disagreement,

social services now accepts the doctors' view that Kathleen

has lost the mental capacity to make decisions about her care.

It's a difficult situation, this,

from her perspective and obviously the team's,

because clearly, as we know,

she has lost the capacity now for the fine detail of discharge planning,

and so, as a team, with her husband, we need to act in her best interests.

Good afternoon, Leonard. I'm Louise, a social worker here at Heartlands.

I'm here to support you and your wife.

'We could make a decision that would mean that Kathleen and Leonard

'would never see their home again.

'That's a massive thing to do.'

You know, we are so often the decision-makers, and it's hard.

It is hard.

Right, um.

We have met today to talk about

Leonard and Kathleen's future care together.

Len, although Kathleen is considerably better

in comparison to when she came into hospital

when she had pneumonia, she is not as well as she used to be

a few months ago, and she does now need quite a bit more care.

In particular, she requires oxygen most of the time

to help her breathe comfortably, all right?

I am going to ask Dr Dhariwal and Professor Tadros

to tell us a little bit about Kathleen's mental welfare,

because she has not been quite as sharp,

and at times, has been a little delirious on the ward,

particularly when she first came into hospital.

Since February time 2013, I think there has been a gradual decline,

probably more pronounced with Kath than Leonard.

And Kath will consistently say she wants to go home,

she wants to go home,

but I don't believe she understands

the risks of returning home.

Leonard, I think you have done a very good job

to look after Kathleen and keep her going.

When I looked at Kathleen, I agree with Dr Dhariwal and Dr Wallis,

I don't think she truly understands the consequences of her needs.

She's got a brain and she has always had a very good brain,

but her judgment is not as good as it used to be.

Because Kathleen is not able to understand

the amount of help that she needs,

we've got to try and act in her best interest,

and if I may, I'd like to ask our social work colleagues

for their thoughts on that.

Sometimes, people just manage better in their own home,

but obviously if it's not working, yes, we do have to step in,

and I do acknowledge that.

I'm not saying that all the points raised today are not valid,

because I do think they're valid,

but I'm constantly thinking about what Kathleen would want.

She is saying she wants to go home.

I think at some point, you are going to have to make the decision,

with our help, that it's not possible any more,

and maybe we look at an alternative, which is...

No, we are not talking about putting her away,

we are talking about you both being somewhere else

rather than at home, where the care is there 24 hours a day.

She has the care staff there if she needs them and you remain together.

Leonard, what is important for you?

Just going home,

or actually you and Kathleen remaining together

for the rest of your days?

I agree with you.

You need to be together. You're a good team together.

What Professor Tadros is trying to suggest

is that by keeping you both together

somewhere where you can both receive the help that you need,

you are more likely to be able to stay together,

rather than one or other of you coming backwards and forwards

to hospital, you see.

We have been talking around various options

that might suit you and Kathleen.

One of the options may be to purchase some private nursing care,

particularly overnight with two carers to look after Kathleen,

to enable her to be kept at home, but...

Yes. But there is a cost to that,

and we will look to see how much can be borne by the statutory services

and health services,

and whether there is any cost that might fall to you on that.

The second option is to see whether we can go into a care home setting

to see whether it is something that suits you both,

because that is another option that keeps you both together

and gives you both the care that you need - all right?

-Morning, Mrs Price. Hello.

-Your hands are cold.

-Yes, it is not a very nice day today, I am afraid.

-No.

Um, Kathleen, Dr Brown and I wanted to come and talk with you

about the plans we're making to help you

-and your husband Leonard leave hospital.

-That's right.

Now, because of your health problems

it's difficult for you to really plan in detail

everything that's needed for your leaving hospital.

-I know.

-I know you are keen to get involved

and we want to keep you involved and keep you informed,

but you are not quite as confident about making plans

and holding all the information in your mind as you were before.

-I can't do it. I admit it.

-Yes.

Because of that, Kathleen,

it is important that those who have your best interests at heart,

and that is obviously Leonard,

and I would hope that you think that the doctors and nurses

and social workers are trying to work with you and help you,

it's important that together we all do the right thing

for you and Leonard.

-Yes. I will soon let you know.

-OK. I am sure you will, yes.

And what we said we would try to do

is that we would try to allow

-you and Leonard to be safely at home together.

-Yes.

But it's only fair for me to point out

that is going to be a tall order,

because you do need a lot more help now than you did before.

-Yes.

-Now, the second thing that I wanted you to understand was that,

if is not possible for us to safely look after you and Leonard at home,

the next best thing that we came to the conclusion was

that we needed to find somewhere where you could have all the help

that you need that kept you and Leonard together.

Please, don't let me keep away from my home.

We will do our best to make that our first option...

-I beg you.

-..to try to get you home.

-I beg you.

-No, I do understand.

If we can't do it then we will have to pay.

-I am not giving my home up.

-No.

But you must let us guide you, because at the moment

you are not really well enough either physically or...

You are not quite able to think through all the implications.

I can do. I know what's what.

I know you don't always get what you wish for,

unless you start paying, and I don't think it is fair

that we got to start paying for private care.

I don't, honestly.

I mean that. I would rather take me chances, and suffer.

Don't worry about paying and money,

we will talk to your social workers about that

and see what arrangements we can come up with, all right?

And we will come back and talk with you again.

As long as you don't expect me to foot the bill, cos I am not.

I would rather lie and die here.

-All right.

-Thank you.

-Well, thanks for talking with me, Kathleen.

-You are welcome.

-Bye for now.

-Thank you.

Our role as clinicians is to try to do what is best for

Kathleen and Leonard,

but we will come up against what resources are available.

And it is something that's going to be an increasing issue

because we know that society is ageing -

there is a steady increase in the numbers of people

with frailty who need a considerable amount of care,

and that is going to be expensive.

-KATHLEEN:

-Being at home, that's the most important thing.

-KATHLEEN:

-The system is all wrong.

The left hand don't know what the right hand is doing.

That's the impression I get.

I never slept last night, Gladys,

because I knew what was going to happen.

It's hard being a carer. It has an impact on everyone's life.

There's nothing else, nothing else we can do for you. Nothing.

What judgments do we make about people older than us?

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