Medical Matters: "Landscapes can be deceptive. Sometimes a landscape seems to be less a setting for the life of its inhabitants than a curtain behind which their struggles and achievements take place." - John Berger, A Fortunate Man.
Hospitals are understandably in the news, as the crisis in accident and emergency departments reaches one of its periodic peaks. However, most healthcare takes place in the community; and much of this care involves people with no formal health-giving role.
I was sitting in our local hostelry in the period between Christmas and New Year. A gentleman in his 80s shuffled in and asked the trainee barman for "a bottle of the brown stuff". The friendly, fresh-faced young man went through the names of some beers, but to no avail. Unaware of the older man's moderate level of dementia, an awkward silence ensued as the actual name of the product evaded his failing memory. Eventually he made for the exit amid a mumble of apologies.
Just then, the hotel owner came in, greeted the elderly man by name, and said, "Did you get your bottle of Cidona?" Relief spread over the faces of both the customer and barman. The owner then sat for 10 minutes with the old man, exchanging news and discussing the man's health. He left happy.
Our postman retires this week. Paddy is one of the nicest and most caring men I have known. He has spent years calling to the houses of our rural landscape. Not alone does he know everyone by name, but he has a fair knowledge of our daily routines. In many ways, Paddy is the eyes and ears of the community. Older people in particular will miss him. He is often the bridge between them and the local medical practice.
Sometimes this link is obvious, such as the time he came across a neighbour pinned under an overturned tractor and called for medical help. But often Paddy's role is more subtle. He may observe a slight deterioration in someone's wellbeing and gently suggest a visit to the doctor or a call to the public health nurse. Or it may simply be the short conversation that breaks the loneliness of someone living alone in an isolated cottage.
Paddy will be replaced. However, it may be some time before his successor will be able to offer the same level of informal care.
Much of the informal care giving such as that provided by Paddy and the hotel owner just happened. No one pays for it. No one organises it. Yet it is highly effective in preventing the need of medical intervention. It reduces the pressure on A&E departments - not by reducing the incidence of acute illness but by enabling the chronically ill and older people to survive in local communities.
The Inverse Care Law, first suggested by Dr Julian Tudor Hart in 1971, states: "The availability of good medical care tends to vary inversely with the need of the population served." It has been proven to apply to the uptake of childhood immunization, waiting times for cardiac surgery and a host of other health measurements.
However, according to research just published in the British Journal of General Practice, the opposite is the case for informal carers of sick people in their communities. The distribution of work by unqualified people providing unpaid care to their relatives or friends is almost completely appropriate to need. In other words, a Positive Care Law exists in the community.
As Dr Tudor Hart notes in an accompanying commentary: "This Positive Care Law is created and sustained by human forces - family, neighbours, community ties that have somehow resisted the socially diverse and dehumanising force of the market."
Admittedly, An Post employs Paddy to deliver letters and not to offer informal care. But market forces (and EU pressures) may mean his successor will drop letters at the end of a lane. As a result, the informal caring provided by postmen and postwomen will no longer be part of community life.
Market forces and changing social habits will also force the closure of village pubs. They will no longer be there as an informal refuge for the old and the lonely. It is ironic that while this erosion takes place, researchers should have discovered a model of care where provision is almost exactly matched to need.
We must reserve informal healthcare. And we must find ways of applying the law of positive care to formal medical care, such as that offered by our hospital A&E departments.
Dr Muiris Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he cannot answer individual queries.