“A Questionable Bonus” – 2

Posted on July 31, 2011 by john graham

Back in April this year I wrote a blog which questioned an idea being considered by Health Minister – Paul Burstow.  Perhaps he should have been reading it, because recent research seems to support what I was saying.

About a quarter of GPs’ total salary is linked to bonuses for achieving certain targets like measuring blood pressure and cholesterol levels.  Sure enough the measurements increased and the GPs got their extra salary (£1billion in total every year !)  The unintended consequence was that in medical conditions that were not so easily measured – arthritis, dementia, back pain, depression – quality was significantly worse.  At that time there were no bonus payments for these ailments, so it is hardly surprising that less attention was paid to them.

To make matters worse, researchers at Nottingham University, who studied the high blood pressure measurements, found “little evidence” of effectiveness of pay for performance targets.

Posted in HEALTH | Tagged , | 2 Comments

“Dilnot Commission”

Posted on July 27, 2011 by john graham

My last blog on this subject was entitled “If The Cap Fits” published on 11th June 2011.  The Dilnot Report “Fairer Care Funding” was published on 4th July 2011.

I have deliberately waited a while before commenting on what should lead to the biggest change in social care funding for decades.  It remains to be seen whether the politicians will be bold enough to grasp the £2 billion nettle.  So far the first politicians’ responses have been very guarded and non-committal from all political parties.  They have been much more vociferous about the moral outrage of phone hacking and the appalling leadership of 80-year old Rupert Murdoch.

Our political leaders, including Andrew Lansley, the Health Secretary, have been almost silent on an issue which is far more relevant to the thousands of octogenarians on his doorstep.

Andrew Dilnot was given a highly complicated issue and one which the politicians had argued long about in the run up to the last election.  I heard him speak in the early days of  gathering evidence for his enquiry and he struck me as a very logical and clear thinker.  His training as an economist ideally places him in a position to address the central issue, which is “how care is to be funded in the future?”

So what are his recommendations:-

  • The first and most important issue is to put a cap on what people have to pay for residential care.  Although initially leaked / trailed as £50,000, this is now proposed as £35,000:- 

On the positive ……..this is a low ceiling to care costs which should encourage the insurance industry to step into the market quickly and at reasonable premiums;

Not so positive side ………it only applies to critical and substantial cases and does not include accommodation costs.

  • The means test ceiling has been very significantly extended to offer some support to elderly people with up to £100,000 in savings:-

On the positive side ………this provides state help to many more relatively poor older people;

Not so positive ………it adds complexity and many more people into the social service assessment process.

  • Accommodation costs are separated out from care costs and must be paid by the elderly person, although they will be capped at £10,000 per year:-

On the positive side ……..this enables a clear comparison with staying at home or moving to extracare housing.

Not so positive ……… presumably means tested pensioners will have to make a separate claim to the Local Authority for welfare benefit support.

  • Attendance allowance is kept and will still not be means tested, but it will be ‘re-branded’:-

On the positive side ………..this is a clear recognition of the value of this relatively small allowance, which enables people to stay at home longer.

Not so positive ………..re-branding is undoubtedly a code for limiting the personal discretion on how the allowance is used.  To save money, it might have been better to means test it.

  • Top-ups will be allowed, thereby opening the door to people to purchase better quality if they or their relatives can afford it:-

On the positive side ……. this will bring more money into the sector, though this has been going on for sometime with CQC and Local Authorities, often turning a blind eye.

Not so positive …….. home owners might be tempted to reduce their service to residents who can’t afford the top-up fees.

  • Portability will be allowed which will enable people to choose to move to other areas of the country:-

On the positive side ……..this should mean Local Authorities can no longer dictate where you have to live.

Not so positive ……..this is a marginal issue since most people wish to remain close to where they lived before.

Overall, I believe Dilnot has come up with a very good set of proposals in answer to the question he was set.  The £2 billion price tag will inevitably lead to much political debate before anything is done.  The assumptions about the level of the cap, the extension of the means test and the retention of attendance allowance will all, no doubt, be hotly discussed.  Quite probably it will suit the politicians on both sides to stretch this out until upto or even after the next election.  Prevarication only disadvantages the elderly themselves.

Dilnot has created a platform for the insurance industry to build long-term care insurance products which are vital to enable elderly people to have some certainty about future care costs.  The proposals also limit the States’ cost to only paying for the most critical cases and then only after the elderly have paid for most of their own care at home, as well as the first eighteen months or so in residential care (unless they insure themselves).  This is a good cost-sharing solution which has the potential to remove much of the financial uncertainty for older people.

 

 

Posted in HEALTH, Residential Care | Tagged | 9 Comments

“My Garden Age”

Posted on July 24, 2011 by john graham

My Grandfather was a professional gardener, who worked for a garden enthusiast and writer – Avery Tipping.  Together they renovated several manor house gardens in the Chepstow area of Monmouthshire.  At one time there were over 40 gardeners working for my Grandfather and their garden renovations included digging out large lakes constructing stone walled terraces and re-establishing extensive kitchen gardens, rose gardens, perenial flower beds and planting many trees.  Mr Tipping was the Gardening Correspondent for the News Chronicle and many of his gardens were featured in the Illustrated London News.

I only knew my Grandfather after he had retired and although he had a spectacular garden of his own, I did not spend long talking to him about his life.  I wish I had, because I am sure there was much he could have taught me.  Luckily he did pass onto me a love of gardening.

As I sit in my garden at the end of June, I am left pondering what he would have told me and how much can my garden tell me now about growing old.

It’s late June and the bursting buds of May and their floriferous fanfare in early June are now past.  There is a time for every season and May is surely the crescendo of spring.  My Grandfather gave my Mother the middle name of “May” – I am sure it must have been his favourite month given to his first daughter.

Lesson  —-  Cherish the time you share with your Grandparents, it’s too late to ask questions later.  That’s a lesson for Grandparents too.  You have much to pass on – family values, fond memories, living history and a wealth of understanding.  Better and more sociable than any computer game.

By late June the first flush of roses are over but individual blooms are still there to cherish.

Lesson  —-  Everyone’s an individual waiting to bloom, they all should be appreciated for what they are.  It’s not their age you should see, just the colour of their unique life.     Old age is a time to sparkle and shine,  that image paints memories in your mind for much longer than a lifetime.

The foxgloves are bent over slightly, but still beautiful in their country cottage memories.  The delphiniums at their very best – standing proudly upright to attention, like guardsmen – Royal in their blues.  The lupins in their yellow, white and pink dresses – ladies out in their Sunday best.

Lesson  —  Sundays, high days and holidays are always a time for dressing up.  It reminds you and everyone else of who you are.  I was always laughed at for getting dressed up at every opportunity.  Top hat and tails for a day at the races; straw hats and blazers for garden shows; union jacks and jazzy waistcoats for promenade concerts at Symphony Hall and fancy dress at every opportunity – a cowboy on an umbrella walk in the park; Bill or Ben for a garden quiz; King Henry VIII for a banquet; a white suited sailor to go dancing. 

Dressing down is not half as much fun, and many old people followed suit in dressing up and were younger for the day.

It’s good to have horizons.  Now I’m looking forward to all the memories and lessons in the garden in the months ahead.

Posted in SMILES | Tagged | 7 Comments

“Dangerous Road”

Posted on July 20, 2011 by john graham

I have cautiously written about assisted suicide and euthanasia only twice before, on 22 March 2010 – “Lucy died today” and then again on 6 May 2011 – ” A Die-Lemma”.   It is not a subject of rights and wrongs, so much as one with endless shades of grey.  Our ageing population is increasingly being described as a problem, euthanasia is an issue not far from the surface, but seldom spoken about.

Holland has a much more open discussion about assisted suicide and more liberal laws (though not necessarily better ) on euthanasia.  Advocates of the laws suggest euthanasia is a suitable way of dealing with dementia and avoiding suffering —– and expensive health care.

The supposed safeguard is that to “qualify” for euthanasia you must convince two doctors that you are suffering unbearably and that you are making an informed choice.                 An informed choice when you are demented must be difficult to say the least.

Last year in Holland 2,700 people chose to die this way – 21 of them with dementia.  It’s surprising that only 21 of the people who chose to die had dementia, because out of 2,700 people, most of whom you could reasonably assume would be elderly, at least 500 of them would probably be expected to develop dementia.  The implication of this is presumably very few of the 2,700 made a living will expressing their desire to die and only made their final decision when they became frail.     I wonder if these are the right circumstances to make such a decision ?

The economic burden is society’s or the family’s, not a forgetful elderly resident.  How long will it be before the pressure of getting old with dementia makes many more people reach for the same “final solution”.

Why not extend the argument on economic grounds to include many more chronic illnesses that affect older people?  That would certainly save a lot on National Health Service costs.

Why two doctors ?  Why not just one – how about Dr Harold Shipman – he certainly had plenty of prior experience and a clear motivation ? 

Why not leave it to care assistants as suggested by North Essex PCT ?  How long will it be before Beverly Allot is given a pardon and invited to carry on her idea of caring ?

 

Posted in Assisted Suicide, ELDERLY UK POLICY | 2 Comments

“Pill – Kill or Cure”

Posted on July 17, 2011 by john graham

I first wrote about the excessive amount of pills we all have in our homes way back on the 7th September 2010.

The “Pills for Everything” blog talked about the cure-all drug dependency culture we have developed thanks to the no-charge NHS.  Yes I know we now have prescription charges, and of course we have all paid through our taxes.  Nonetheless we continue to have “free at the point of delivery” expectations.  We also seem to have an implicit belief that pills work – greatly encouraged by “go away” doctors and “come here” pharmaceutical companies.

A reminder of the facts:-

  • 912 million prescriptions in 2007
  • £10billion spent on medicine
  • 10% of the NHS budget

In a rather more tongue in cheek blog – on 19th December 2010 I told the story of “Pilly Galore”.  A typical elderly person with a whole range of ailments from the serious to the insecure.  Secure only in the trust she has in her demigod GP – Astro Glax.

Some more facts:-

  • Every year millions of people are given unnecessary or inappropriate drugs
  • It is estimated £400m of drugs are wasted annually
  • Multiple prescription drugs often have side effects in older people
  • Up to 30% of all hospital admissions in the elderly are caused by inappropriate prescribing

Now comes the sting in the tail.  Recent evidence produced by researchers at Universities of East Anglia and Kent, published in the American Geriatric Society Journal, suggests that combining certain types of drugs is linked to a higher risk of dying or mental decline. Up to half of all elderly people in the UK are taking one or other of the drugs.  In some cases the combination of drugs were found to treble an elderly patients’ chance of dying within two years.

It is not my intention to give medical advice nor am I saying that individual drugs are ineffective or should not be taken.  You should consult your doctor before stopping taking any medication.

However, my point is that many elderly people are like Pilly Galore.  Taking a cocktail of drugs – some which may have been prescribed years ago and never since reviewed, and others which may have just been obtained over the counter without the GP’s knowledge.

For many years I was privileged to be involved with elderly people admitted to nursing homes, most of them recently discharged from hospital.  One of the first and most positive things our nurses did was to recommend to residents’ GPs that they stop prescribing much of the medication residents were receiving.

Taking people off unnecessary drugs like sedatives and antidepressants, often made remarkable improvements to the quality of people’s lives.  You have to wonder whether many of the drugs elderly people were given were more in the interests of carers than the elderly themselves.  A pill is a subtle form of restraint, now it seems a cocktail of pills may be your drink in the last chance saloon 😦 .

The Government, Care QualityCommission and the medical profession should step in and ensure that all elderly people have a medication review in the next six months.  It would save money and lives!

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“New Vision of Later Life” – 3 – Enriched Dementia Support

Posted on July 13, 2011 by john graham

What future for residential care?  Years ago I stood on a conference platform and suggested   ” no future at all ”  but this outdated form of provision has hung on, bolstered by the growth in the frail elderly population and the lack of suitable alternatives.  It is also the warehouse of choice for social service funded residents with dementia.  Not a good option, but an out of sight, out of mind one.

Sadly, dementia affects many of the people who are forced to move into residential homes.  Only in extreme circumstances can it be right to consign someone with dementia to a life lived with lots of other residents who also have dementia.      The confused leading the confused!

For the time being, and probably for a long time to come, the sheer size of the residential care sector and the continued growth of the frail elderly population makes this type of provision essential.  To make the best of it, requires a much more highly skilled and better paid workforce.

Set against the backdrop of the precarious Southern Cross example (click on the Archive and see my blogs dated 29 June 2011 and 5 July 2011), this is not a good place to start.  Nor is the Southern Cross situation an isolated case.  Many other residential care operators are heavily indebted and have been forced to put profit before quality.    When quality fails, occupancy falls and profit margins evaporate.

A rescue for this sector can only be engineered with a greater injection of funds.  In the short-term this can only come from the public sector.  Since there is no new Government money allocated to Social Services, new resources must come from a reallocation of NHS funds.  This will be difficult to manage and will be a hard-fought transformation, but in the end it is probably the only way of keeping the residential care sector alive.

                                    So what is the vision?

It seems sensible to start with dementia, since these patients are least able to be coped with satisfactorily within the NHS.

The first issue must be to improve diagnosis, since many elderly people who are confused, do not necessarily have a long-term condition of dementia.   However, left without proper diagonosis they may well end up in a dementia home.   The problem is that the fear of dementia is so great, that at the first sign of forgetfulness, elderly people are easily branded as senile.    In turn this can lead to late diagnosis, as residents and relatives fail to confront the situation for fear of being ‘put into a home’.    In fact their confusion and memory loss may be due to depression or something as easily treated as a urinary infection.    Mis-diagnosis or no diagnosis at all, just assumption, can start you on the slippery slope of marginalisation, isolation, and incarceration.

Once an elderly person has a confirmed diagnosis of dementia, they need a personalised care environment and individualised, rather than institutional support.   This suggests either smaller homes or sub-divided larger homes with a house group format.  Maintaining people’s individuality is a key to a happier life, even with deteriorating mental health.   It is possible for someone with dementia to lead a contented life, provided their support is tailored to their own personal needs, but to do this needs almost constant and skillfully observed attention and care.   That is why spouses are able to cope for so long providing care in the home.   They can read and interpret the early signs of distress and deliver an appropriate response.   They also provide familiarity and continuity in an environment which is slowly fragmenting for the confused partner.

In my New Later Life Vision for dementia, much more support would be given to carers.  They are a life line for their loved one – a last vestige of normality.

The dementing older person doesn’t just need wrap-around care, they need stimulation and interest in their lives just the same as anyone else.   The boredom of a residential care lounge, with residents sitting in a circle around the edge of the room, or mindlessly watching television, only exacerbates confusion.

The New Vision of Later Life for people with dementia:-

Initially, there would be much more support for carers and a greater emphasis on enabling the sufferer to remain at home.   This would also encourage people at the first signs of forgetfulness to come forward and seek help.   The first stage of better support would be a more extended observation and assessment of the condition to eliminate the possibility of mis-diagnosis.   Thereafter care at home would include frequent pop-in visits and escorted trips out to a social club, village hall or pub at least once a week.   This is designed to give respite to carers as well as to the dementia sufferer.   Several respite away breaks would also be planned each year to give relief from the slow decline into a lost world.   All this will only be afforded by greater funding of preventative care, starting with using Attendance Allowance specifically this purpose.

For people living on their own and for couples, eventually, a move to residential care may be an inevitable outcome.   To make it much more desirable, the new later life residential home will offer care and support based exclusively on the former life of the resident, not for them to live in the past, but to be surrounded by familiar things – beyond family photos – their own furniture and lifetime accumulated possessions.   Equally important, someone who understands the significance of all these memories and can plan a unique support plan around them.   The staff themselves would be specially trained in dealing with dementia, over and above the basic care skills.   In the ExtraCare Charitable Trust, after a three year study by Bradford University, we developed a new post of “Locksmith” whose job it was to design an individual Enriched Opportunity Programme for residents with dementia.    The “Locksmith” title symbolised the need to unlock the memories of a forgotten life and recreate familiar clues in a new life.

A number of specially skilled and trained volunteers would be needed to support this model of care.   They would be drawn from family members and people who had previous experience as carers for those with dementia.

An active challenging life planned together in this way can provide a much more positive outcome to living with dementia.

Posted in Dementia, HEALTH | Tagged , | 4 Comments

“Nutty Professors!”

Posted on July 10, 2011 by john graham

At the end of June, a report was published by the Royal College of Psychiatrists, entitled “Our Invisible Addicts”.  Judging by the ridicule it has received in the press, it must be a contender for “daftest research of the year”.  It’s central conclusion is that older men should be restricted to consuming no more than 1.5 units of alcohol a day – a pint of weak beer or a small glass of wine or a single glass of spirits.  For women over 65 their recommendation is even less – just 1 unit a day – which must mean they should never finish a drink?

This expert panel of addiction specialists ludicrously go on to suggest that GPs should screen all over 65’s for alcohol and drug misuse.  If they lived in the real world they would know that most older people cannot afford to drink every day.  Even those that do go to the pub more frequently often end up making a pint or a glass of wine last for hours.  As far as drug addiction is concerned, it’s certainly not illegal drugs they should be worried about.  Their biggest concern should be the medical profession themselves, and the pill-popping habits they have encouraged all of us to adopt.

This sweepingly callous, insensitive and inappropriate conclusion has meant that some genuine issues raised in the study may well be overlooked.  The report does point out that a third of all people who do have drink problems, develop them in later life.  It goes on to say that this is often because of bereavement, boredom, loneliness and depression.  These issues really do need addressing, though not with drugs or alcohol.

Friends and activity are far better support than pills and potions.  How about a drink at the local 🙂

Posted in HEALTH | Tagged | 4 Comments

“New Vision of Later Life” – 2 – Health Improvement Centres

Posted on July 5, 2011 by john graham

My second image of later life looks at the other end of the health care system.  The acute sector of the NHS looks after us very well throughout our childhood and our working adult life.  At its heart, the doctors and nurses do a good job of getting us better when we really need them, which is why they have been held in such high regard since the NHS was formed on the 5 July 1948 (63 years ago today!).

So what has gone wrong for the elderly? :-

  • The numbers of elderly people are increasing faster than NHS resources.
  • More things can be done to keep people alive for longer – e.g. hip replacement, recovery from heart conditions, etc.
  • The elderly are living longer so acquire more chronic conditions – e.g. arthritis, diabetes, etc.
  • Their condition is often complex and needs input from more than one specialist.
  • They take longer to recover so don’t fit easily with the new fast track NHS; rather they end up being seen as bedblockers.
  • Finally dementia/confusion is a feature of many older people’s condition which adds significantly to the caring work load.

Elderly people are a problem for NHS hospitals from start to finish and we should recognise that and adjust the approach to acute care of the elderly.  Acute hospitals still need to be there for acute conditions and surgical interventions, but many elderly admissions are for preliminary assessment which would be better done in less extensive and technological diagnostic environment, with less specialist consultants.  A bit like a cottage hospital but to give it a new name, lets call it a “Health Improvement Centre”.  Many elderly people may then never need to move on acute hospital care.  Equally after acute treatment, elderly people could be moved to this less expensive provision to be allowed to recover more slowly than young patients.  So what does this new facility look like?

Well the first thing is it’s not a hospital at all.  It is a virtual care environment where you stay where you are and the doctors and nurses come to you.  Equipped with more sophisticated diagnostic tools and backed up by properly trained specialist nurses for the elderly.  Available in your own home for a time limited period and paid for by your private health insurance.  Yes it is more expensive than at  present but its better quality.  The health outcomes will need to be proven to be better and recovery times will also need to improve.  The good news is that there is far less risk of cross infection (MRSA, Norovirus and C.Difficile).  There is also better opportunity for family support.

People who cannot stay in their own home may need a short stay at the Health Improvement Centre for initial observation and assessment.   Equally after recovery from acute treatment in hospital, they may need to convalesce or receive high quality rehabilitation in the Health Improvement Centre.  This would obviously cost rather more that care in your own home and should be funded out of a re-allocated NHS budget.

Posted in HEALTH | Tagged , | 9 Comments

“Fruit Juice Hopes Squashed”

Posted on July 3, 2011 by john graham

Just when I thought I had found the secret to eternal life, my hopes have been shattered.

My earlier posts on “Fruitful Research” (9, 23, 30 January; 15 May; 26 June 2011) seemed to suggest that a glass or two (or six) of fruit juice a day could cure everything from berry-berry to housemaid’s knee.

Scary headlines on the front page of the Daily Express recently (10 June 2011) pointed out the “hidden dangers in fruit juice”.  It must be serious because the announcement was heralded as if it was a new outbreak of small pox.  Just think of all those poor readers of the Daily Express reading this over breakfast.  They may well have had a heart attack there and then, or at least rushed off to the A & E to have their stomachs pumped.

Strange then that this dramatic health warning didn’t end up in any other newspapers, nor was it on “News at Ten”.  I suppose earthquakes, volcanic eruptions and even Wayne Rooney’s new hair-line are rather more important.

Evidently, new research at Bangor University has discovered that regular consumption of sweet drinks can dull your sensitivity to them.  This can lead to an even greater craving for sugary drinks, then you’re on the slippery slope to Type 2 Diabetes.

Not surprisingly, a spokesman for the British Soft Drinks Association, disagreed.

Fancy there being an Association I might even join.  I wonder if they have a magazine?  Maybe they organise trips around the world exploring for rare and exotic fruit?

I have only just managed to find a supply of cowberries and I am still searching for chokeberries.

 

Posted in SMILES | Tagged , | 1 Comment

“New Vision of Later Life” 1

Posted on June 29, 2011 by john graham

I have written a lot about the neglect of older people in the NHS, in residential care homes and in their own homes.  My blogs have been stimulated by the many reports over the last twelve months of malnutrition and dehydration in our hospitals; poor quality care and downright neglect in both hospitals and residential care homes.  Recently another report by the Equal Opportunities and Human Rights Commission confirms that care of the elderly in their own homes is abysmal too.

It’s depressing, shaming and overwhelming.  Where do we begin to put it right?  Especially at a time when the Government tells us there is no more money.

Firstly, let’s start by accepting that it’s all our fault and all our responsibility.  Care of the elderly starts with us.

When we are really young, we should cherish our grandparents – they are a font of knowledge, wisdom and experience, if we only take the time to listen.  They are free life experience. Mentoring consultants whose successes and mistakes we can learn from and grow.  For those who no longer have grandparents, there are plenty of older people alone out there we can adopt.  A little support offered – a lift to the doctors, assistance with shopping or just a chat over the garden gate, are the first steps of a more engaged society.

We have to also start with ourselves, because delegation or abnegation of responsibility to the State / Government clearly doesn’t work well and is destined to only get worse if we carry on as we are.  Particularly given the numbers of older, older people is set to grow exponentially in the next twenty years.

As we reach working age we need to start saving much more for our own old age, now that we know we can expect to live much longer in retirement.  Maybe 30-40% of our income needs to be squirreled away for our later life years.  OK, some of that may be used to buy a family house, provided that later on we accept that downsizing to a smaller home or even renting in retirement is a necessary means to liquidate our savings to pay for care and support if and when we need it.

None of us know how healthy we will be in later life.  The working age implication of this is that we need to insure ourselves, particularly to cover the cost of long-term care.  We also need to take a more preventative approach to our own health.  There are established and accepted links between issues like smoking and cancer, obesity and diabetes which we could heed and save ourselves a lot of pain and expense in later life.  The prompt to take notice might be the cost of long-term care if in future we can no longer rely on the State.  Long term care insurance companies could take a more proactive and holistic view of health insurance and focus on well-being rather than ill-health.

How much better our health care system would be if GPs, instead of just responding to ill-health issues, were also charged with promoting health and well-being.  Providing annual health checks for everyone and developing a personal health plan.  A good place to start would be with the older population who are more likely to be susceptible to health problems.  Certainly those who can afford to pay for regular check ups are more likely to have a positive attitude to looking after themselves.  They are also more likely to discover problems at an early stage.

This new vision of health care in the community starts with a Health Care Practice, ideally located inside a fitness centre so the elderly are part of an all age healthy life style.  There is a friendly and welcoming, smiling receptionist who makes you feel like a customer and not a nuisance to the busy doctor.  Tea, coffee, fruit juice while you wait – and today’s newspapers rather than long out of date magazines.  A well-being nurse to see you first and routinely measure your weight, blood pressure and take blood tests.  Then an on time and unrushed appointment with your personal GP – the one who deals with all your family and has done for years.  Someone who is familiar with your health history and doesn’t spend all of the consultation looking at a computer.  A friend who is aware of the importance of motivating you to look after your health by communicating effectively and ensuring you understand what you can do to improve your well-being.  You then leave with a health plan supported by helpful and easy to read literature.   The plan will be followed up with you by the well-being nurse at least twice before you see the doctor again in a years’ time – all being well.

So that is the beginning of my new vision for later life – an annual health check up and a monitored health plan funded by those who can afford it or by their private insurance companies in exchange for lower health care premiums. 

I will come back to how we deal with those who can’t afford it later.

 

Posted in HEALTH | Tagged , | 17 Comments