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Here’s the emergence of a new “social case”
Abandoned in hospital, more than 100 elderly people are living at St Luke’s until they are given accommodation . Karl Schembri reports about the people referred to as “social cases”
Crouched on an old couch with a rusty iron frame, Mrs C, 82, stares vaguely in silence, all day long. At the other end of the hall, the window opens to the beautiful sea and the Floriana fortifications, but that’s not what she’s seeing.
In front of her another old patient in bed, Mrs C has been here for three weeks after her son found her at home lying on the floor after she fell.
“He got so worried,” she says, almost with a sense of guilt.
It was not the first time, but since she’s been living on her own such accidents have been worrying her children.
She is suffering of arthritis, and at times the pain can make it unbearable for her to stand, but she is otherwise able to walk and carry on with everyday chores.
“I was washing and cooking and taking care of my house until I fell the last time,” she says. “I even used to go out with friends.”
But since she has been hospitalised, she has become wary of her movements, extremely worried that something may happen to her while she is out.
“I’m a bit concerned that something might happen to me,” she says vaguely, though she also adds in a determined tone that she can still walk out of the ward.
Nurses in this ward know Mrs C is destined to remain here until either her son finds an alternative or a vacancy arises in one of the government-run homes for the elderly.
Talking to Mrs C, it is clear there are not enough services to guarantee her return to independent living in the community. She is scared that something serious might happen to her, although she would still like to remain active in one way or another.
“We recognise social cases immediately,” the nursing officer tells me. “Every year, we keep getting more and more of these cases occupying hospital beds, increasing the waiting list and aggravating our overcrowding problem here.”
Like Mrs C, there are 102 people living at St Luke’s and identified as social cases.
They are normally admitted with a vague diagnosis, with either nobody to pick them up after they are ready for discharge or their relatives unable to look after them.
Some consultants, who have the last say on who is ultimately admitted as an in-patient at St Luke’s, write “relatives cannot cope anymore” in the diagnosis sheet upon their admission, signalling immediately that rather than medical cases, these are people at the edge of the social safety net.
“Social cases are the only people who are not at fault,” Health Minister Louis Deguara says, “because if nobody can take care of them, they’re at the end of the safety net, and that’s why we can’t just kick them out of hospital. At the end of the day if you end up with a patient at the door without a name, surname, address, nothing… they just leave him there… what can we do then? The patient is the least one to blame, and they are the most vulnerable. We can’t refuse anyone at that point.”
The beds they occupy are mostly those found in medical wards, being the major cause of widespread overcrowding in great part of the hospital wards where patients end up living in corridors because of the stretched bed capacities.
“The life of a social case at St Luke’s is pathetic,” one of the nurses says. “They end up totally inactive, they don’t even watch television but just sit staring waiting for the time to pass, occupying beds that should be used by medical cases, at times for periods up to a year or more.”
According to the 2005 annual Social Cases Report for St Luke’s submitted last February, there was a total of 275 social cases last year residing in the various hospital wards. The hospital’s database shows that 76 of them, or 28 per cent, died during their long stay there, while 74 were transferred to Saint Vincent de Paule residence for the elderly. Another 32, or 12 per cent, ended up returning to their home, seven people were transferred to other homes for the elderly and three in other government hospitals – namely Zammit Clapp or Boffa Hospital. By the end of 2005, 83 were still living at St Luke’s as social cases.
The same social cases report admits that “the utilisation of hospital beds to accommodate social cases is not set in any form of hospital policy”.
The annual bed days used by social cases last year amounted to 34,185 bed days in wards, setting an annual average rate of bed occupancy at 16.8 per cent. This means that the total bed days used by social cases rose by 5,457 bed days over the previous year, an increase of 2 per cent.
Women are most vulnerable; they outnumber men and stay longer. While the annual average length of stay for women was 146 days, for men it was 75 days – a difference of 71 days indicating a disconcerting gender difference. The highest number of social cases last year was registered from the Southern Harbour region, with localities starting from Valletta, followed by Paola, Zejtun and Sliema, Qormi, and Rabat.
The report states in no uncertain terms that a solution has to be found immediately if the authorities want to be taken seriously about the overcrowding problem at St Luke’s.
“It is evident when compiling this report that the social case situation at hospital cannot be ignored or surpassed and must be on the agenda for discussion in the current year if one is serious on finding a solution to the bed availability at St Luke’s Hospital,” the report concludes.
Outlining the priorities that have to be tackled, the report adds that “the publication of monthly, half yearly and annual statistics on social cases over the last two years is simply not enough!”
As an immediate step, the health minister will be opening what he is calling a “step down facility” at Mount Carmel Hospital, which will be housing 34 of the social cases at St Luke’s.
“We had to decide whether to open new units or else use the hospitals we already have,” the minister said. “We looked at different options, one of them Mount Carmel, which up to some time ago housed around 700 people, now we have 400; so there is the physical space for 300 people. It will be a separate unit that has nothing to do with the mental hospital, so here again we’ll have a different entrance. It would be crazy if we throw away a bed capacity for 300 people just like that. So we’ll be opening a completely refurbished unit with 34 beds, of the same level as San Vincenz.”
Experts estimate that 100 extra beds will be needed every year over the next decade, meaning that the problem is bound to get worse.
“We’re building a new block at San Vincenz that will house 108 social cases, and we will have another 150 beds in a new home in Mellieha, so our immediate needs for the next two years are catered for,” the minister says.
The Minister for Family and Social Solidarity, Dolores Cristina, says extended life expectancy is putting forward new challenges for the country.
“The plus side is that we are also more health conscious and therefore, the quality of a person’s daily life is so much better than it used to be,” Cristina said. “This also implies that more persons are capable of caring for themselves for a longer stretch; this is our ultimate aim, in fact. That of encouraging independent living and making provisions for persons who choose to remain in the community and to postpone the need for residential care. Community based services need to be beefed up and strengthened so as to arrive at a wider target audience. Ultimately, the more persons are active in the community, the healthier the community is.”
In the long term, the health minister promises a holistic coordination at the still under construction Mater Dei hospital.
“One of the posts we will be creating is that of a bed manager,” Deguara said. “We will also have an admission ward, where one will be admitted immediately for further tests, as opposed to what happens today at St Luke’s where you have people awaiting tests and others waiting for the ward round to be discharged. So if the ward round happens twice a week you’ll end up occupying the bed for three days until the next ward round, for no reason whatsoever.
“What will happen at the admission ward is that once a patient is suspected to be a social case, he will be assessed by a gerontologist or a social worker, so once you put your foot inside the hospital your discharge starts being prepared. Let’s say you have a patient who had a foot amputation who is ready to return home after recovery. At that point he tells you he lives in a three-storey building. Is that the right time to sort out his problem? Of course not. The system should work in a way that once you’re admitted for an amputation, the social worker visits your home and starts planning your reintegration, and if there’s a need for a lift or a chair or whatever he applies for them from day one, because he knows that ultimately you’re going to return back home. Every patient has to be managed by a team of people and rehabilitation has got to start as soon as he is admitted.”
All that would be nice on paper, and nurses say this already exists in theory. In reality, Mrs C is still staring vaguely, doing nothing, waiting for her son to arrive.