Game Theory: chess, Jenga, frailty and the future of the NHS

AIOiSvIVLiz Charalambous is a qualified nurse on a female, acute medical HCOP (Health Care for Older People) ward at Queen’s Medical Centre, Nottingham University Hospital Trust. She tweets at @lizcharalambou and is a regular guest blogger for the BGS.

During another busy shift last week, I worked with a student nurse who expressed an interest in the complications of older person care. I found the simplest analogy to be that of comparing frailty to the game of Jenga

Jenga is a game which involves removing one block at a time from a tower, until it is only a matter of time before the entire structure becomes so fragile that the whole thing comes tumbling down.

In older people, long term chronic illness is one such block; complications of unsupportive social situations, another. One urine infection, fall, or hospital admission can be the final block which causes their own personal tower to collapse, with devastating and life-changing consequences.

Likewise, the fast pace of providing healthcare to vulnerable older people resembles a game of chess, as players with differing agendas decide which piece to move, and subsequently corner their opponent. The major players in healthcare are currently battling to keep all the pieces on the table, as various stakeholders strategically move around obstacles to reach their intended goal.

Take politics, for instance. The rise of neo-liberalism, particularly over the last 30 years, has nibbled away at the edges of our treasured NHS with contracts galore, in areas such as estates, cleaning and food delivery services. The great British public may see little change in the NHS so long as doctors and nurses are still employed in in frontline services with NHS contracts, but this often masks substantial changes going on elsewhere.

For example, I worry that this rise of neo-liberalism may be underpinning the slow, steady stream of nurses who are becoming disenfranchised, realising their market value, and leaving the NHS to work for agencies which not only pay more, but allow for flexibility and control. The fact that agencies are able to offer these benefits speaks to a global shortage of nurses, with forecasts of both a decline in nurse numbers and an increase in demand. Play this against fears about immigration from right wing quarters, which threaten to destabilise the crucial contribution made by overseas nurses to the NHS, and you have a game with fewer and fewer players.

At the same time, new proposed contracts for junior doctors have resulted in a substantial backlash, with a letter from doctors to Jeremy Hunt expressing concern and around 3,500 doctors starting the process of applying to work abroad as a clever protest against such changes.

We need to look at why people are leaving. My suspicion is that many staff are under immense pressure, and often feel devalued. A recent paper highlights that nurses’ cognition is affected by dehydration while on duty, suggesting that we are not looking after our own basic needs while caring for those of others. The debate around nurses working long 13 hour shifts continues, with some saying it improves continuity of care, while others argue that it causes fatigue and poorer quality care.

Hospitals are a dangerous, delirium-inducing environment for older people: separation from routine and loved ones can often mean that they never return home. It is crucial that we provide good quality care when they arrive in hospital, by supporting the very people who provide it: not just front line doctors and nurses at the coal face, but the (often unseen) ancillary staff who wash the laundry and keep our hospitals clean, and are vital to the smooth running of the engine of healthcare.

The effects of political influence on caring for older people can be a game changer for staff and patients alike. As the complicated manoeuvres continue, I wonder if we will still have an NHS to be proud of in the near future, free at the point of delivery from cradle to grave, the envy of the world.

Bevan famously said that ‘The NHS will last as long as there are folk left with the faith to fight for it’. I begin to wonder how many folk will be left with strength to fight: this dangerous game has no winners, and with fewer players it may very soon become a case of ‘game over’.

One thought on “Game Theory: chess, Jenga, frailty and the future of the NHS

  1. I love your quote from Bevan.Whilst continuity of care is important,so is an alert on the
    ball brain to cope with the complex solutions to the multiple problems of the multitude
    of elderly facing the NHS for help.

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