Speaking at the King's Fund event Enhanced health in care homes on 5 December 2017, Dr Zoe Wyrko, Consultant Geriatrician and Associate Medical Director - Quality Development, University Hospitals Birmingham NHS Foundation Trust, discusses the health and wellbeing benefits of an intergenerational approach, sharing learning from Channel 4’s Old People's Home for 4 Year Olds.
My name is Zoe Wyrko, I’m a hospital geriatrician in Birmingham please don’t think badly of me for it. Any of you who know me, because I do recognise quite a few in this room, know I often wear many, many hats. So where I am now a little bit of my work is clinical but actually a lot of it is about service development and the discussion in the last session I was in in this room was talking all about the lack of common sense in that there’s the person and there’s all this money and it belongs to the wrong people and everyone is obsessing over the money. At the moment I’m trying to get a million-pound business case through for something that is just pure common sense and very, very patient focused and the pain that both I and my project manager are going through on that, yes, I’ll just … yes. Not all of us who work in hospitals are bad.
So it’s reasonable to say that I've actually somewhat fallen back into the care home world. I’ll come on to that a bit more in a moment but, as I say, I really am purely hospital based, but I was fortunate enough to be asked to take part in a television program that some of you may have seen back in August. So these are the points I’m going to cover in the next 20 minutes and intersperse with some pictures of the fabulous older people I was able to work with.
This is Zena and I can honestly say that taking part in the program was absolutely life changing for Zena, she’s a different lady now to the one that she was back a year ago just before she moved into St Monica’s where this was all filmed. So, yes, the differences this has made are huge and it was only a tiny, tiny piece of work.
It’s good practice in any talk to actually: what is your conflict of interest? So this is me on my 18th birthday as a health care assistant working in a care home, and I started working in this care home when I was fourteen, I started as the kitchen girl because my mother was firmly of the understanding that the moment I was old enough to work I would work. So kitchen girl, cleaner in the summer holidays when the cleaners were off or the kitchen assistant was off and as soon as I got to 16 it was, “Right Zoe can wash people now,” and that’s how I started as a health care assistant. I did my A levels when I was 17 so I actually then worked full time that summer until I went to university to medical school the following September. So I did a bit more than just work experience and I mostly worked in this one care home, which is in Northampton and it’s called the Oakwood and it’s still there, 30 beds and I was really pleased that when some friends of mine were looking for a care home to provide terminal care for their father that actually this was one of the ones suggested and it is rated good and I was just really pleased to see that because I’ve got quite an attachment to this place.
I didn’t have any grandparents nearby, but my mum was a staff nurse in this care home, which was how I started working there when I was fourteen, and she had been taking me to spend time with some of the old people actually since she started there, and I was about six when she started work again after having me and my brother. So with hindsight I had a very early introduction to intergenerationality, to getting to know older people you’re not actually related to and I think back fondly to some of the older people I met during that time, particularly one lady called Peggy who had been on the long stay NHS wards, moved to this care home when they closed down. She couldn’t walk, there was no reason that she couldn’t walk other than she had been left in bed and become completely bedfast. She maintained her very, very sharp mind despite 30 years of being completely bedridden until her death. So this was a really important early introduction to me.
Let’s have a look at the published evidence for bringing older people and younger people together and really there is surprisingly little. Of the work that does exist much of it comes from China or Taiwan or their same communities in other countries, so looking at the ex-pat communities in the United States, and interestingly this is actually acknowledging the changes that their societies are undergoing at the moment. So this real move away from looking after older people within the home environment to older people moving into care homes or other institutions and how this is affecting the generations.
There’s then a small amount of work on projects that we all recognise so the sort of thing having shared music class or a shared movement to music class taking place once a week over a set period and then actually looking at the outcomes, so how did people feel about it, did it make them feel happier, did it make them feel better? Unsurprisingly results are limited but they’re generally positive.
Other bits of work have taken the typically skewed view that our society has that young is good and bad is old, and they’ve looked at how can bringing younger people and older adults together try and reduce the ageist attitudes in the younger people. So it’s all important but actually the older people are the more important thing in this and that was something that came out in the television program actually, that’s why all your saw about was really the older people and not what it was doing to the children.
I haven’t actually been able to find any published interventions where the focus is normalised meaningful interaction and those are three really, really important words for taking this forward. This is what we did in the TV program, it was just normalised, the children and the adults were doing ordinary nursery school activities together. There was nothing specific planned, nothing, “Oh, if we do this it will be good for people.” The studies that are out there haven’t actually measured the functions that we looked at either as part of the TV program.
Something to keep in your head it’s the meaningful interaction that seems to be the thing and it’s not just children visiting older adults. It’s those joint activities that have built the relationships that seem to have been what actually made the difference and seems to be what’s important going forward.
To be honest really this is common sense and obviously as a room full of interested people you all know this anyway. What I really hope though is that some of my very clever academic colleagues, because I have many hats but an academic one is not one of them, are going to be able to translate our preliminary work, possibly use it as a pilot study and actually take this forward. We all know it works but occasionally it’s really useful to have some absolutely brilliant evidence there when you really need to hammer something home to a policymaker or government and I really hope somebody does that so that this sort of thing becomes just normal.
How did it start? Well as with so many things in my life it started after an email from the British Geriatric Society. CPR Productions were looking for some experts who could give them advice about a TV program that they wanted to make and when I spoke to them, being my typical shy retiring self, I said, “Well, I wouldn’t actually mind being on it if you’re looking for volunteers.” So they filmed me and they showed me to Channel 4 and Channel 4 said I looked alright (laughter). That’s how I ended up doing it.
The principle was exactly as you saw, there was no special intervention, the older adults did ordinary nursery activities as decided by the children’s teachers according to the curriculums and guidelines that they have to follow. No specific physical or cognitive exercises at all other than possibly sleeping lions. Some of you may have seen the usually, well, perpetually grumpy Hamish rolling around on the floor and the reason that session came about was because several of the older adults asked Mel, the physiotherapist, if she could show them how to get up if they fell over. So she did that and it was thought, well, how can we integrate this into actually something useful, but literally the sleeping lions was the only specific activity and that was ad hoc at the request of the older people.
The set itself really was a little bit like Big Brother but that really upset the production team when I went in and did my bad Geordie accent. The good thing about that it was really easy for the participants to forget that they were being observed. So we could just watch them and you would just see the older adults doing more. So if I’d asked them to bend over and pick something up they would have told me they couldn’t do it, but actually when they weren’t thinking about it, so a child has dropped it or something has rolled under somewhere or, “Can you get me that?”, they just actually did it and got on with it without thinking about it, with none of that sense of worry or can I do this, how am I going to do it and it was just absolutely brilliant to watch that really.
There were several times even before Linda ran on sports day you’d actually see her getting out of the chair and you’re thinking she clearly doesn’t know that she’s doing that, she’s just not thinking about it.
The other thing was it was very firmly an experiment and it wasn’t research. The difference relates to the need for ethical approval prior to it taking place. If we had needed ethics to do this you still wouldn’t have seen it and also this relates to our ability to share and publish the result. I’ll come on a little bit to the ethics in a while, but all of the volunteers both young and old were seen by the psychologist who works with Channel 4 to ensure that they had the mental capacity to take part and be filmed and that it was an uncoerced decision. So I found it fascinating about how you get four year olds who really want to do this and it wasn’t the parents pushing them, but whatever technique they used it really does work and the children came from three local nurseries very close to St Monica’s where it took place.
Mel the physiotherapist and I had the job of deciding what tests we would do and it would be fair to say that we had to do quite a lot of expectation management with the TV people. Do any of you watch, is it, W1A the thing about the BBC? I’ve watched that with completely new eyes since making this program. They’d come up with lots of brilliant ideas like, “Dehydration is a massive problem in old people let’s do some blood tests to see how dehydrated they are,” no way. “Let’s do blood tests to look at nutrition,” absolutely not. “We need to measure cognition and thinking,” so okay. So I felt I spent an awful lot of time saying no to them and Mel and I were also incredibly consistent in our message that a short intervention such as this one was not going to produce any changes at all that we could measure and that Channel 4 mustn’t be too disappointed when they see that everyone is a bit happier and they’ve got a bit of nice TV and nothing else seems to have happened and, I can honestly say, it is lovely to be proved completely wrong at times. Mel and I were genuinely surprised by the results.
So the test that we did, some of which you saw on screen and some of which you didn’t see for very, very good reasons. You saw the activity tracker, so they had that on their legs, we did the Edmonton fragility scale and bits of this were touched on in the program, the geriatric depression scale which turned out to be a major feature of the improvement, Mel measured falls, we did Barthel. The facial analysis software which you saw a little bit of that is really interesting and I think may come out in the future. Grip strength was absolutely key. Grip strength was good to do because the volunteers found it quite fun to have a go at and in the scientific literature we know that grip strength is a massive indicator of outcomes of all sorts of things in the ways that we don’t understand, and this is something where my clever colleagues are doing lots of research at the moment, but it’s fun to do actually, it’s how strong am I?
The cognition app, again this was very TV, “We’ve got to have an app.” I was like, “Well, if you want to do it we’re doing clock drawing test as part of Edmonton.” “No, no, we’ve got to use this app.” We used this app it was an absolute disaster. I have really bad Raynaud’s and some days when my fingers are really cold my iPad will not recognise that I am human or alive. I don’t quite know what it was about the fingers of some of our volunteers, they appeared to have nice quite normal smooth skin and considerably warmer than my hands, but we couldn’t get it to pick up and about half the group had iPads and were used to using touchscreen technology, about half of them didn’t. One of the volunteers certainly did have cognitive impairment and many of you may have spotted who that was when you watched the program. It was lovely and really interesting to see the masking behaviours coming out as well for a few of them, “Well I can’t see it,” “Oh, well no that’s definitely not working at the moment,” and so it was ringing alarm bells in me but had got past the psychologist. I was so excited by the facial analysis software I put it down twice.
The results that we saw we saw improvements in the geriatric depression scale. So people who were depressed at the start were less depressed at the end and I’d actually expected to see that go the other way because I thought some people would be upset when the experiment ended so I thought we’d pick up negativity on that and we didn’t. The timed up and go test, which is part of the Edmonton frailty scale, again you saw that people got faster and people who’d insisted on using their walking aid to start with did it faster without their walking aids at the end. There was no coercion, none of it was for the telly, none of it was, “Go on, run a bit see how much you can do.” It was all done very, very professionally. Grip strength improved as well, they had done nothing at all to improve their grip strengths.
I was interested at some of the resistance training that you may have noticed if you’ve watched the program, which was small children sitting on the trolleys whilst the older adults were pushing them whereas I’m pretty sure if we’d said, “Let’s just pop a four-stone weight on your four-wheeled walker,” I think we’d have been where to go there, but the children were sitting on them. Just absolutely brilliant. So improving resistance training, all these things that we know are really good for health but just being done without anybody thinking other than this is an awful lot of fun.
The Edmonton frailty scale this was one as well I said to the producers that there’s no point us repeating this at the end but they wanted to film everyone doing their clock drawing none of which you saw in the end. We produced some really interesting results on that particularly on the people that I thought had a degree of cognitive impairment, just picking up subtleties on that but you didn’t see any of that on the program and some of the ladies improved their frailty scale particularly on continence. We did nothing on continence, there was no reason at all for continence to improve over this time period, but it did. Absolutely fascinating.
The first screenshot from the Christmas special just wait until you see this.
What I would like you to think about though is why test? So we did it for the TV because otherwise just filming old people may not be interesting to everybody although it is to those of us in this room. So what you didn’t see on the program is the couple of participants who were so stressed by the principle of being tested that I didn’t carry out the end of experiment tests. We just sat and had a nice chat and a nice cup of tea and all that instead, and these ones they were cognitively normal older adults they weren’t any of the ones I was worried about. They knew the results didn’t count for anything, they knew this was just for the television program, they told me they felt they were being silly, but they just weren’t able to do it. I reassured them they weren’t being silly at all.
This is where one of the frequent questions that I’ve been asked by people who want to set this up is, “What tests do we do? We really, really want to do some tests.” If we’re going to take this approach, which I think all of us in this room want to take, that mixing rather than segregating generations is the right thing to do, why on earth are we doing any tests? Is it to show that our particular scheme is better than the one next door because we get our old ladies running faster and running more? If so I think actually we need to reconsider our intentions in this.
I’ve had a local GP colleague go a little bit huffy with me because she sent me a really enthusiastic email which included ‘oh, we need to do this’ and I pointed out this is not a nice little research project for some registrars and that pursuing this without safeguards in place would mean you’ve got unpublishable work, but actually think about the people, this is people in their homes, why are we testing them?
One of my main lines that I say to junior doctors is to ask before they do anything at all, how is this test going to change your management, and I get them to do that from finger prick blood sugars to MRI scans and biopsies. Are we doing this test for the benefit of the person or are we doing this test for the benefit of us because we’re a little bit interested and would really, really like to know? I think that’s something we really need to think about.
We also have to think about what about the unexpected results? So we’re doing tests for no good reason and we pick up something serious that actually we may or may not be able to intervene with. So … and really do not underestimate the effects of being tested. However, I do understand that sometimes assessments and measurements are demanded by funding bodies and in these cases I think it’s reasonable to use a self-assessment quality of life questionnaire, something similar to that.
I’ve been working with colleagues in Solihull who are setting up a service that I’m going to show you some pictures of in a minute, and all credit to Maxine who’s the lady leading on the that. We opted to use the OPQOL-brief questionnaire for that. If you Google it it’s open access, it’s thirteen questions and it really is purely about how people feel about their life. So we’ve gone for that because she said we had to measure something.
So let’s tell you a little bit more about Solihull. The work has been led by Maxine Burrows and at the moment they are pairing one nursery with one residential home, the residential home is St Bernard’s in Olton and the nursery is called Tender Years Day Nursery. Both rated good by their various regulators and the first getting to know you session was held a couple of weeks ago and these square things they made getting to know you cubes, so with picture and a name and something about interests on. Five children working with five older adults and each organisation has been … so the nursery and the old people’s facility have been responsible for choosing the ones who they feel will benefit most from being part of this. They have their own dedicated space in the residential home so that the older volunteers can leave at any time they want to and there are two nursery supervisors there with the children at all times. One of the first things they did was make these getting to know you cubes. It’s going really, really well so far.
So these pictures and the next picture I’m going to show you are all taken with permission. This is Ivy and Oliver, you can see Ivy interacting quite nicely with Oliver there or vice versa. The staff chose Ivy because she normally only leaves her room to play scrabble. She’s normally quite withdrawn but she’s already said she’s loving it. So these photos Maxine sent me on Friday, so this is from just last week.
The children are obviously saying, “We’re off to visit our friends in the big house,” so they’re already using the word friends they’re not saying these weird older people, “We’re off to see our friends in their house that they live in,” and I think that’s brilliant about normalising different people live in different places. So in these pictures here, in the big one across the top we’ve got books being read and that’s Arthur and Harold and I can’t work out which one is the child and which one is the older adult because I just love it that everybody has got all the same names now. We have Martin and Shristy sharing some dolls, they’re not Shristy’s dolls those are Martin’s dolls and they’re his Rosie and Jim dolls because one of the Martin’s big hobbies was his narrowboat that he used to have but he doesn’t have anymore. So this is a picture of Martin and Shristy interacting and Martin is telling Shristy about the narrowboat that he used to have and holidays on canals.
You can see various pompoms around the place, back in the big picture behind the rollator frame they’re looking at pictures on an iPad and there are some pompoms there and Martin leaning out of his chair that’s the middle of a game of catch. So we’ve already got some of the … they’ve done the activity together, they’ve made the pompoms, they’re throwing them about, they’re playing catch, we’re encouraging higher levels of mobility and movement than you would normally get. That’s Martin’s Delta frame sitting just behind him.
So we’re at very, very early days yet but the plan is for a toolkit about what works and what doesn’t and how to get round the logistics to be shared firstly with other nurseries and care homes in this area.
One of my other hats I’m wearing, the one that’s connected with the business case, is I work with an organisation called Solihull Together, which is local authority, acute trust, community services, mental health, third sector all actually working together. We’re not an ACO but we’re trying to think in that way and do systems working and the Chief Exec of Solihull Council is so behind this project that’s hopefully going to be a big thing going forward.
On this I’d like to finish. I think we’re at an early phase in something really, really big but I feel really strongly that this has to be community owned. We mustn’t be in competition to be the first or the biggest or best, we need to do what really good care home practice is doing learning from each other, that bit works, that bit doesn’t work, how can we … so and so had that problem but got round it what can we do to learn from that? We have all these walls around care facilities, obviously places do have to have walls or the roofs fall down, but there are some organisations which have got a really, really good ethos about being part of the community but then there are others those walls go up and nobody seems to cross that threshold and that’s actually what we’ve got to break down and get our community back.
What we need to really do is make intergenerational working, learning and living absolutely normal again so that nobody thinks it special, so that nobody is going, “Yes, they’re doing that over there,” but actually everybody is doing it and if it’s not going on we need to ask why.
So this is from the Christmas special, I feel so sorry for the parents of the children because fake snow, these children have been overexcited about Christmas for even longer than ordinary four and five year olds. It’s going out on 18th December nine o’clock on Channel 4, there is snow, as you can see there is Christmas jumpers, there’s another concert and performance if you enjoyed that from the last time and there is actually a little bit of romance in this one and it’s just absolutely lovely. So please do watch. Thank you.