All cancer patients are vulnerable in their own way but no patient is more vulnerable than the elderly cancer patient, which is why my chosen subspeciality of geriatric oncology feels like an especially worthwhile endeavour to me. With global life expectancy soon to be 80 years, 70% of cancers will be diagnosed in older people, with 8% appearing in those over 85.
Elderly cancer patients are more likely to be frail and vulnerable from health conditions including cognitive impairment. They are at higher risk of falls, medication mix-ups, malnutrition and loneliness. To complicate matters, the elderly cancer patient is frequently caring for or being taken care of by another elderly person, so treating one patient necessitates thinking about the needs of two.
For these reasons, these patients are deserving of meticulous care and concern – to defend against undertreatment, shield against overtreatment and take care of the whole person. When socioeconomic disadvantage is added to the mix, every problem becomes worse.
Several years ago, as the evidence gathered for the merits of a dedicated geriatric oncology service, I started one at my hospital. Admittedly, service is a tall word for a clinic that didn’t have a nurse to complement medical expertise with the other help patients required to navigate everything from aged care to nutritional supplements and walking aids.
Despite the billions spent on hospitals each year, “cash-strapped” and “public hospital” go together. To any observer, funding a nurse that could keep elderly cancer patients out of hospital by supporting them better at home would be a no-brainer but I learned that if I “wanted” a nurse, I needed to write a business case.
I treated this advice with caution rather than my usual can-do attitude. Nothing in my medical training prepared me for writing a business case to help patient care.
I soon came upon similarly pressed colleagues who didn’t want to see their good ideas die. But I still couldn’t fathom it. As someone who only started examining my own finances when forced to by a mortgage, who was I to experiment with precious taxpayer funds?
I had no basis for the numbers I was being asked to provide. What grade nurse did I need and how much would that cost? How many hours were enough? Had I confirmed administrative support? How would the doctors be funded? Which billings codes applied to which activity?
I kept thinking – surely my time (and public money) was better spent treating cancer than writing a business case.
But one question kept me awake at night. Was my business case profitable, or at least cost-neutral? The rumour was that this was an essential precondition for approval. This reminded me of Plato’s “noble lie”, a lie told for the collective good. I was all for fiscal discipline and could keep adjusting the figures but everyone knows that, when it comes to health, you must spend money to save money. Nowhere is this truer than in keeping elderly patients out of hospital.
Luckily, I found someone at the hospital who could help. His questions were confined to my area of expertise. How long did it take to see a complex patient? How much paperwork did I do afterwards? What jobs could be best done by a nurse? What was a reasonable clinical load?
Then he got to work. Months later the business case was complete – indeed, it even showed a small profit! I remember feeling victorious that all the (after-hours) effort had been worthwhile.
Alas, during management changes and other indecipherable events, the idea died an anonymous death. The people who lost out were my patients.
Then Covid came, leaving no time for perceived novelties. At a time when the burden of suffering fell disproportionately on the very elderly, a by-now experienced cancer nurse to advocate for them would have been gold. But we had missed our chance.
Each year public hospital doctors undergo a performance review. My “performance excellence plan” involves suggesting ways in which I, one individual, can improve the functioning of a gargantuan healthcare system. My fellow doctors and I often wonder who looks at this closely and what it means.
It also doesn’t escape my notice that somehow the need to find a nurse for my patients has morphed into a quest for personal excellence, that too attached to a timeline. Like all ambitious doctors, I want to achieve this goal. But beyond advocating for a nurse, there isn’t much more I can do.
A colleague and I have sat down to create a new business plan in our spare time. It feels strange to be doing an important task in a piecemeal manner with little expertise. I can see why a friend who knows a thing or two about successful businesses is shaking his head at the inefficiency of it all.
This week an elderly woman fell in the waiting room. A homeless man needed an injection while he was in the clinic before he became uncontactable again. Other patients were struggling with problems of ageing. All needed a nurse more than a doctor. These patients can’t wait.
I hope someone who knows business cases the way I know medicine is reading this and saying, ‘This is ridiculous, let’s fix the problem.’
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is Every Word Matters: Writing to Engage the Public
