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Welfare is cheap

Dionysus in the elderly home

"We can not cure dementia, Parkinson or MS. Cure and Care are necessary conditions in an elderly home, but this not sufficient. We are focusing at the last years of a person's life, at a person's happiness. People need something to talk about. Well-being is a crucial part of care that is often forgotten."

Interview by Hedda Post, translated by Julius op de Beke

Professor dr. Hans Becker is chairman of the board of the Humanitas Foundation, he was an economics professor at Erasmus University and thereafter he was for almost 13 years managing director of Humanitas Rotterdam. Under his leadership this organisation grew from 15 financially deprived elderly care homes to 28 profitable institutions.

In his dissertation "The invisible hand of cultural control" he emphasises the (Nietzsche) difference between the Apolinistic- ratio, typified by control, order, rule, regularity- and the Dionysian –emotion, typified by impulse, chaos, escape from rules. An orderly director of a care home who is sitting tipsy behind the bar with a few seedy old clients, under a regular Apolinistic view this would be clearly disapproved of. Hans Becker is doing it, he is not afraid of the Dionysian element. While around him all kind of things happen –his office door is always open, people call, enter his room; ask questions, crack jokes- he explains at very high speed his vision. “It is always about the proper balance between the Apolinistic and Dionysian attitude towards life, if the plusses of one side clearly surpass the minuses of the other side then this is the side you should opt for. Which attitude wins depends on the context; In any case a person cannot be reduced to a mere object in need of care constrained by rules and protocols, a person is always a somebody with a own life story”.

From structure to culture
“Top down organisations do not operate in this way which makes it difficult to get things done. A board of directors and/or a board of governors are always looking at the financial side first. When you propose something new there is always a financial risk, so many directors automatically tend to block any dramatic change. In a top down structure the client comes always last. That is a pity because the client is really the expert due to ample personal experience. Somebody who has had arthritis for 30 years knows that he has lost the battle but in the mean time he knows better than anyone else how one can best cope with this disease. It is not uncommon for him to be treated by somebody in a white coat, who perhaps read only one chapter about the disease, and who is going to tell him how and when and which pills he should swallow. Own experience should next to clinical knowledge also be used as input when it comes to finding a treatment.

I did not want to manage on the basis of rules and protocols. Adam Smith depended on the “invisible hand”, in his view individual supply and demand are in charge. This works well if we are many and equally endowed. I belief in a kind of cultural management that draws upon a number of basic shared values as was suggested by the American psychologist Karl Weick. When Weick was investigating danger, he put safety first. He noted that at the time of the accident with the mammoth oil tanker Exxon Valdez, when 42 million cubic meter of raw oil ended up in the sea, cleaners had actually noticed the cracks in the hull earlier, same thing with the man who was responsible for checking the oil level. However they did not say anything as it was not their business. Weick assumed that when everybody in a company is thoroughly indoctrinated with these few basic truths, every person will be sufficiently aware of the risks that an organisation is exposed to. I have copied this model, this time not focused on dangers and risks but on the spirit of our times. The attitudes of older people are constantly changing, every 5 years they are a bit different due to new developments, for example because of internet, mobile phone, kidney dialysis at home, education, changing values and norms. The organisation must also change and adapt to this but of course in the right direction.”

Better prepared to deal with the calamities of life
“What is this all about? What is our core-business? Yes cure and care, but this has not produced universally good results in the past. Just look at all these dark, murky, patronizing islands of misery that exist everywhere. Rattling and dribbling in a room with 3 other persons, with only a curtain to provide you with a minimum of privacy, to be cared for by a young woman who just took a course in communication and now calls you Mr Becker instead of grandpa. No this should be about happiness. And personal happiness has two sides. An individual side, being the master of your own life, responsible for your own deeds, money, house, being your own boss. This should not be taken away from people. If somebody wants to get drunk, -‘provided he is still in his right mind?’ Yes’ –then he knows best for himself. The other side o f happiness is the group side. We human beings like to live in a group, we want to be part of a pack, of a club of women, of the Evangelical Television Foundation, of a real family. When you visit grandmother and you have to sit in room with bare walls except perhaps for the obligatory fake yellow tainted Picasso print, on plastic chairs without anything to say or to do, then this is not a very happy family gathering; You look at your watch to see if you can already afford to leave. Here group synergy is very important, one should not just make sure that the clients are well taken care of, the family should also feel at home. When the family is enjoying herself, they tend to come more often and that is of course good for the client. You should therefore create a warm and cosy home with a pleasant ambiance. Grandchildren may need a playground, a pond or a children’s farm, adults like an internet café, a restaurant or a shop. Staff must also feel at ease, if they walk around with a sombre face, this is not good for them or for the client. Social psychology tells us that positive emotions are important. Positively thinking people are more tolerant and creative and they participate in society, they are better prepared to deal with the calamities of life.

To say NO, an automatic reflex
“The basic shared values of Weick to guide us are summarised in four core principles, they have to be internalised by everybody, from the director to the care taker and the delivery man.

The first core principle is that the client should as much as possible remain in charge of his own life. This is again about the individual side, about self respect and self responsibility.

The second core principle is self-activation. Use it or lose it. In spite of our good intentions we seem to have completely forgotten about this in our elderly care homes. “Sir, mam, please come in, we take your money and we gladly do everything for you, shopping, cooking, stitching of your clothes. Oh you have done needle work all through your life? Very nice but now we will do this for you.” This is not only very expensive care, it also causes people to loose their self respect. Not only do they have nothing more to do they have also nothing to talk about. It is by doing things that you get into touch with others, that you can tell a story, that you can be a human being among other human beings. The institution must allow people to take care of themselves; here too much care is actually worse than too little!

The third core principle is the extended family. Treat one another as if you were one big family. Your ways of doing and the entourage must resemble those of real family and its followers. Colleagues, clients and volunteers should treat one another as members of the same family.

The fourth and last core principle is the YES culture. This is the instrument with which one can facilitate the other 3 principles. This YES culture must implemented top down, it means that you should never automatically say no. Saying NO is often an automatic reflex, the smartest boys and girls in your class were usually both critical and negative. By saying YES you encourage people to come up with solutions. There is no hiding behind rules or protocols. Saying YES can lead to many new innovations, creativity suddenly emerges from all holes and corners. NO is an absolute killer of creativity. A manager must have the courage to make chaos, only on the edge of chaos will creativity have a chance. Family and clients deserve maximum support, if the other side is not able to say NO a lot can be gained. Yes I often have to act as a referee. Do you want to shower more or less than twice a week, it is not a problem for us. Every day kidney beans, OK fine but we may try to tempt you with other tasty food. In practice YES works most of the time, even if occasionally things still go wrong.

A loss of one million
“I force myself to say YES. In one home they asked for two parrots, 1250€ a piece. They were bought and it turned out that these birds mean an awful lot to many people, it keeps them all the time busy. Moreover they became an extremely important conversation piece. Pets and cuddle animals are allowed. A cat sitting on your lap can take away your attention from your painful knee. The client is talking about the cat not about her knee, which anyway we can not heal. Two large screen televisions were needed to be able to watch the soccer games of Ajax and Feyenoord simultaneously, of course they were bought. An extra billiard table, no problem. I started with restaurants, eating is much more than vitamins, protein and carbon hydrates. People should be able to have a cosy and tasty dinner together. With my first restaurant I ran into a loss of 1 million €. Everybody started yelling at me, the chief financial officer, the board of governors, and I myself was also upset. I started to lean towards NO, perhaps a restaurant was not such a good idea. Until I realised my mistake, our core business is cure, care and well-being. We were spending 50 million on nursing care, compared to this the one million losses, which was for the staff servicing the bar, yes that is what caused the loss, is peanuts. The barman is as important as the nurse.

I just keep on yelling yes, yes, yes and that is why the atmosphere is so cheerful, that is what attracts the family and makes them become active, they don’t simply want to sit on a chair and chat. They want to do more, accompany someone to the hospital, talk for an hour with a depressed person, help people getting dressed etc. Pets generate a lot of distraction and lead to interaction with other people. All this saves us a lot of money. I am now running a surplus, which is also not smart because next year the government may start to pay me less. Of my turnover of 100 million I pay 80 million for wages, this is my main cost item. It is possible to reduce these wage cost by making sure that people feel happy and are not all the time screaming for more attention from care providers to complaints that can not be helped anymore. Well-being can be bought cheap."

Reference:
“Levenskunst op leeftijd. Geluk bevorderende zorg in een vergrijzende wereld”.
(The art of living at an advanced age. Happiness promoting care in an ageing world)
By Hans Becker, Publisher Eburon 2003
www.humanitas.nu

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