In my opinion Frailty – and the ‘P’ word

By Felix Alvarez

One word. One shape-shifting word at the centre of what we don’t much want to see.

Yet there’s something vital and unshakeable in us that calls us to respond to vulnerability. Perhaps because we know it will be us one day. Perhaps because we agree with John Donne: no [wo]man is an island.

In my time, many first-born children bore a special responsibility. Not the primogeniture of kings, but of little helpers as much to struggling working mums and dads, as to younger brothers and sisters. And the image of early-rising parents late and broken to an exhausted bed every night remains in our hearts. How could we not remember their sacrifices and struggles in bringing us up? We must; if we value ourselves at all, that is. Especially in the later, difficult years.

Vulnerability (physical, mental and economic) is a creeping concern for our society with, on the one hand, citizens living longer as a result of diet, education, care and medical advances, and on the other demanding more of the right to live just and equal lives even through periods of challenging economic difficulties.

It’s impossible to ignore the pressures on people when heading a movement for their human and civil rights such as Equality Rights Group/Action on Poverty.

Equally impossibly it cannot be anything other than a core concern for any government; and, at a time of announced ministerial retirement and change prior to elections, it is only right I take a moment to acknowledge the challenging work that Minister Sacramento has been addressing across the years. Whoever takes over from her had better come equipped with the seriousness and dedication she brought.

It is my sincere hope and trust that the focus on the physically mentally, and socially vulnerable in our society will be accompanied by that for the economically disadvantaged; and all of them occupy a central concern for whichever minister or government with social rights responsibilities emerges from our forthcoming General Election next month. Also, that Gibraltar finally delivers on full UN Convention rights for the disabled.

Similarly, we need to pay attention to the fact that in the latest annual Police statistics on hate crime and hate speech, race-based offences topped the list. A worrying and unacceptably silent and under- reported fact about us. But time we looked it straight in the eye! There’s no room for racism on our shores.

It’s always painful to witness the many problems people face, though. And architecting lively social dialogue is useful, but rarely acknowledged with political grace.

It’s hurtful to know with a good measure of certitude, for example, that these days 70% of people regularly needing a daily meal from free kitchens are Gibraltarians. The figures have been growing significantly since sit-down meals were replaced by take-away packs during Covid. It’s not difficult to understand why this change in the numbers has come about, the answer is obvious once we engage with what the embarrassment of disadvantage means in a tiny community such as ours: most people feel discomfort at being seen depending on charity (social security in Gibraltar is pitifully meagre), so we naturally like to protect our self-esteem and dignity. This decent human instinct belies the disbelief of those who labour under the repeated impression that hardship (we prefer to avoid the ‘P’ word; an avoidance that reveals volumes of failure to understand, even among the best-intentioned) is merely characteristic of those who are less than honest with the rest of us. Scammers and scroungers, no less. And yet the raw, honest need exists; it’s there and will show its face when the coast is clear, fearful of self-appointed judges, of what others may say! How cruelly wrong we can so often be; saints paying for sinners.

Vulnerability, however, has another face: frailty.

The UK is set to start an initiative which will see around 10,000 patients attended to in what are being called ‘virtual wards.’ It’s a work-around the problems of insufficient staff and resources versus an increasingly ageing population. People with serious illnesses that require close monitoring, for example, will be able to take their own readings and send them on electronically. On a regular basis, virtual contact will mean more frequent attention rather than accumulating waiting lists and medical distance. That, at least, is the plan.

Not everyone, of course, will be able to make use of such advances. Notably, those most vulnerable through age or lack of physical mobility may find little solace in virtual technologies (on a fairly fundamental level, arthritic joints may not even enable you to pick up the phone).

Of course the level of creativity the British health system is experimenting has much to do with economics, and the search for cost-effective solutions. Society and demographics today are no mirror image of 5 July 1948, the date when Aneurin Bevan, Labour’s visionary Minister, gave form to universal free healthcare for the people.

In Gibraltar, a vision for long-term re-structuring of our healthcare system needs to be set out. Simply wending down accustomed valleys will no longer suffice into future need. The longstanding format of dependence on hospital and residential home services needs careful readjustment and re-scaling in favour of a new emphasis: an importantly greater slant on structuring the system to significantly re-enhance domiciliary care (our current District Nurses department is one of the gems of our present system). This may, eventually, mean more investment flowing in that direction and away from the unquestioned systemic compulsion of institutionalisation.

Healthcare needs a re-set. A paradigm shift.

It requires Ministerial (not medical civil service) determination; for demographic, economic, and quality-of-life reasons. Bevan knew this only too well.

Without principle and vision, moving too heavily towards digital relationships leads us to management guru fixes, but takes us far from what healing and care must mean: human contact. Alienation is already too large a problem, affecting so many aspects of life in modern society. Piling on more is no way forward.

And with the character of Gibraltar now transitioning from small town to mini-metropolis, our needs and pressures will grow increasingly evident. (But that’s another article another time).

The challenge will not be easy; it will not be cherished by the four-year political cycle we are used to. It takes commitment to a longer transition to a society where families re-take responsibilities instead of assuming the frail and elderly can simply be ‘moved on’.

And yet reality dictates there will still be a place for residential and hospital care, even if social values change towards more home-based responsibilities, along with the structural readjustments the politicians will need to navigate. The careful nuance between moving away from reliance on institutions and assuming a renovated culture of family care implies not a metric of radically abolishing institutional care, but rather reducing reliance on it in favour of a pillar of more resourced domiciliary support.

This means the dominos will need to be re-aligned across the board.

Families and individuals will need help in many ways as our economy is readjusted. Our housing model doesn’t help; whereas when housing was Gibraltar’s most pressing problem, the up side was that families stayed together (largely because of no available options), today the majority are comfortably sectioned off in their individual worlds of individual cares. And the pressures of work, looking after children and so much more means time and the desire to take on the very difficult reality of caring for an elderly or otherwise dependent family member lead us down the open path of institutionalisation.

But there's no doubt, however unpalatable to acknowledge it may be; compare the life expectancy figures for those in residential care with those for individuals within their own homes. It’s an eye-opener. Statistics show that male and female care home residents typically have significantly lower life expectancy across all age groups compared with non-care home residents in the same age groups. As they say, it’s a no-brainer: healing and happiness are undoubtedly much more satisfactory when you get up when you want, eat when and what you like, are surrounded by those dear to you not strangers that come and go, cross-infection rates are lower, and you remain in control of your life in a way that is impossible within even the best of institutions.

Does this reflect negatively on our healthcare professionals? Not in the least! It’s an inevitability of what is achievable for those professionals in the one setting, but not within the other.

In these respects, then, I can only applaud and recommend Dr. Keith Gracia’s promising initiative for the establishment of what is to be known as a ‘Frailty Clinic’ (a concept already up and running within the British NHS), and which I hope the Gibraltar administration will take to heart. A platform for serious and explicit support and healthcare for the most vulnerable; where prevention and expert attention to the detail of elderly and vulnerable holistic care is not only medically and ethically to be welcomed, it forms an intrinsic part of what should be a vision towards shifting away from the habit of the institutional to a growing emphasis on more familiar and more positive later life outcomes. An intelligent long-term vision, a gradual and fundamental shift away from formal environments as an inevitable conceptual base; and a tilt, instead, towards a majority emphasis on domiciliary care which fits the changes facing us, present and to come.

The frailty quotient is rising. And rising at various levels and across sectors (the necessary emergence of Gibsams was no coincidence).

The bell, dear friend, is already tolling.

Felix Alvarez is the Chair of the Equality Rights Group/Action on Poverty