Monthly Archives: April 2014

The abuse of older people is an age old problem globally…..

As the BBC expose the abuse of older people with undercover filming on Panorama (9pm,30/04/2014), I wonder will we ever care about older people?

For many staying out of harm’s way is a matter of locking doors and windows and avoiding dangerous places, people and situations; however for some older people it is not quite so easy. The threat of abuse is behind those doors, well hidden from public view and for those living in the midst of such abuse violence permeates many aspects of their lives, most frequently perpetrated against them by those charged with providing their care. Regardless of where the care is provided, or who is delivering it, many older people today are at significant risk of harm.

At the heart of the problem lie the individual, personal and institutional attitudes of those charged with providing care for older people, which fails to treat older people compassionately. Our culture of indifference toward older people does a great deal of harm, not just to them, but to us as a society. I rememeber a quote from an article published  three years ago following  a report from the Health Service Ombudsman, that highlighted the abyssmal care older people received in hospital settings, the headline was ‘A society lacking in humanity’,  It’s still pertinent today.

“(F)or a while we may pause to express outrage. But we then move on to the urgent business of our daily lives. Spot checks and hit squads may arrest the worst practice… But they will not do much about a society that has hardened its heart against the elderly.” (, 16.02.11)

The question is what will soften those hardened hearts?

Government is reluctant to intervene and introduce a stronger legislative framework, Instead, it is seeking to extend responsibility for protecting older people from abuse to “Big Society” , stating ‘people and communities have a part to play in preventing, recognizing and reporting neglect and abuse. It is everyone’s responsibility to be vigilant whilst Government provides direction and leadership, ensuring the law is clear but not over intrusive’ (DoH, 2010, p.25).

However, is ‘Big Society’ able, and willing, to make the care and protection of older people its business, has it ever?

Historically older people, and old age, have often been viewed negatively, and this has arguably contributed to wider societies apparent indifference.  Cicero’s work De Senectute, written in 44 BC, points to the variety in individual experiences of ageing, acknowledging that for those who are poor and without mental capacity ageing is miserable, however, suggesting older people need to strive throughout their life to remain intellectually and physically able. A couple thousand years later not much seems to have changed, as research suggests those most vulnerable to abuse are the poor, women, and those over the age of 85 years with dementia.

The abuse of older people is clearly not a new phenomenon, it’s an age old problem, one not just confined to the UK.

Recognition of the abuse and maltreatment of older people throughout the world is not new. Research developed in the 1980’s in Australia, Canada, China, Hong Kong, Norway, Sweden and the USA confirmed this was an international phenomena. The following decade saw developments in Argentina, Brazil, Chile, India, Israel, Japan, South Africa, the UK and other European countries. Undercover filming in Italy last year showed the shocking abuse some older people experience in care, it’s distressing to watch, I cannot imagine how distressing it was for those experiencing it.

However, none of this means we can be complacent in the UK.

From a European perspective research suggests older people’s experience of ageing in the UK falls behind that of many of its European counterparts, with the UK performing most poorly on indicators such as income, poverty and age discrimination. The report states “the UK faces multiple challenges in providing older people with a positive experience of ageing, scoring poorly (although not always the worst) across every theme of the matrix” (WRVS, 2012, p.8).

It would be foolish to think the abuse of older people is just about problems with individual carers because we cannot ignore the effects of systematic inequalities in liberal societies that effectively exclude, or compromise the rights of older people. Older people’s experiences of ageing in the UK can be improved, and it is all of our responsibility to try and achieve this. However, we need a coherent strategy to bring about the change desired by many who work to support older people. Government in the UK tend to address issues associated with an ageing population within individual silos. Research from Europe suggests those countries taking a joined up approach, where government consider how factors such as income, health, age discrimination and inclusion interact, the more successful policy approaches are likely to be to improve the experience of ageing.

Addressing the abuse of older people is a complex issue, there is no one answer but a series of answers that if woven coherently together would make a difference.

It must be terrifying being an older person today in need of care and support.

In January (2014) I wrote a blog regarding the setting of the threshold for the ‘duty of candour’ suggesting Mr Hunt had ignored advice from David Behan on the inclusion of ‘moderate harm’.  Since writing the Department of Health Media Centre contacted me, via Twitter, to tell me Mr Hunt had not, as I suggested, ignored David Behan.  After several requests to the media centre for further clarification they have now sent me a link to a document published in March this year entitled ‘Introducing the Statutory Duty of Candour: A consultation on proposals to introduce a new CQC registration regulation’.

I think this was supposed to clarify the issue for me, instead it has left me somewhat perplexed.  It appears health and social care will be using different thresholds.

For Healthcare

In the regulations, the harm threshold for healthcare is set at the threshold recommended by Dalton/Williams to include ‘moderate’ harm. This means that all harm that is classified as moderate or severe or where ‘prolonged psychological harm’ has arisen gives rise to a Duty of Candour to the service user, or a person lawfully acting on their behalf. The Duty will also apply in cases of death, if the death relates to the incident of harm rather than to the natural course of the service user’s illness or underlying condition.

For Adult Social Care

‘……..we intend to use the existing CQC notification requirement for ‘serious injuries’ as the Duty of Candour harm threshold for adult social care. The notification requirement for serious injury is broadly similar in scope: CQC has indicated that it covers the ‘severe’ and some of the ‘moderate’ harm categories recommended by Dalton Williams. It also covers prolonged psychological harm. Thus for adult social care providers, the duty will apply to death, serious injury, some moderate harm and prolonged psychological harm, broadly consistent with the application in the NHS’.

So, there we have it.  I wonder how  the  ‘some’ moderate harm threshold will be implemented in practice.

As this is a consultation document I thought I would respond with my thoughts on the matter, however, this document was sent to me on the day the consultation closed.  The consultation period seems a tad short (26th March – 25th April), I wonder has anyone responded?

If I had responded I would have said in my view to really change the culture of care that currently exists in some areas of health and social care we need to take a zero tolerance approach to harm, whether its mild, moderate or severe, it has no place in health and social care .  Thresholds that are confusing,  and complexly defined, will do nothing to change organisational cultures.  What they will do is send mixed messages to providers, managers and employees because basically they are saying a little bit of harm is acceptable and indeed, even ‘some’ moderate harm might be okay!

The truth is the type of harm that was perpetrated against patients at Mid Staffs and places like Winterbourne View did not start at the thresholds now being suggested, they started with low-level abuse and failures to address them, probably  they did not meet a ‘threshold’ for intervention, and so a culture developed where many began to accept the unacceptable as ‘normal’ practice.

If we needed a lesson on how to take something positive that could bring about substantial change and make it so complex it is unworkable, this is probably it.








Did Hunt ignore Behan? Dept of Health Media say ‘duty of candour’ includes ‘moderate harm’…does it?

The Department of Health Media Centre contacted me via Twitter to tell me I was wrong in my suggestion that Mr Hunt  has ignored David Behan and CQCs guidance regarding a ‘duty of candour’.  I’ve contacted them four times for clarification without success.

So what does Clause 80 actually say about the level at which healthcare service providers need to adhere to a duty of candour.  Is it ‘moderate harm’ and/or ‘serious injury?

I’m still trying to find the latest wording of Clause 80 to update the infromation in my blog, to make sure it is as accurate as possible, any info you can provide would be really helpful.

(See the blog below that started this discussion)

Minutes from CQC’s public board meeting on the 22nd January 2014 state David Behan gave evidence to the ‘Duty of Candour’ review on the 9th January, followed up by a letter on the 16th January 2014. At that review David Behan expressed CQC’s view that the threshold should be set to include death, serous injury and moderate harm, to be consistent with the guidance published in the ‘Being Open Framework‘ and CQC’s interpretation of the term ‘serious’ in Robert Francis’ recommendations.

On the 23rd January 2014 the House of Commons Public Bill Committee published its’ latest amendments. One related to the ‘duty of candour’. Clause 80 on page 72, line 20, now reads

‘The duty of candour specified in regulations made under this section shall require
healthcare service providers who believe or suspect that treatment or care
provided or contributed to death or serious injury to a patient…..’

It appears the committee chose to ignore CQC’s views as ‘moderate harm’ is not included.

From my perspective this makes little sense and does not demonstrate an understanding of the potential of thresholds to provide not just openness in an organisation but also a preventative strategy. Surely enabling individuals to speak up if they identify any harm at all may then prevent poor, or abusive, practice developing into serious injury, or even death.  The fact that policies and legislation appear to be allowing mild (or even moderate) harm to occur surely will contribute to developing the culture we are seeking to eliminate.

Whilst a duty of candour is welcomed , I wonder now is the threshold set too high to really change the ‘culture’ Robert Francis identified as contributing to poor standards of care at Mid Staffordshire.

The latest overview of adult social care in England from the National Audit Office again highlights problems that exist when it clearly states

Safeguarding vulnerable adults from abuse and neglect remains a major risk throughout the sector…….In 2012-2013, 36% of safeguarding referrals were about alleged abuses by social care or health workers.’

The report also suggests a rise in incidents of abuse could be related to systematic cuts across the sector.  If this is the case the system will need more than a duty of candour and an emphasis on whistle blowing to make a difference.

Thresholds can be effective as a preventative mechanism, but not if they are set too high or used as an administrative convenience to ensure the number of reports are kept at a manageable level for the organisation, which is surely counter productive to changing the ‘culture’ of any failing provider of care.  In my view to really change cultures within organisations we need to take a zero tolerance approach to harm, whether its mild, moderate or severe, it has no place in health and social care.

I came across a quote this week which I find very pertinent in regards to how government policy/legislation translates into frontline practice

‘To assume that an official plan and its implementation in practice are the same is to fly in the face of facts. Invariably to some degree, the plan as put into practice is modified, twisted and reshaped, and take on unforeseen accretions’ (Herbert Blumer)


To change the current culture within some care provider organisations will require far more than the Care Bills ‘Duty of Candour’, it will require 100% commitment from all involved to adhere to not just the letter of the law but the spirit. I do believe this is a positive step forward, however, Government needs to take an active lead, and listen to people like David Behan, to ensure it is implemented to change organisational priorities at the highest level, otherwise the ‘duty of candour’ risks becoming just more empty words and another box to tick.

Do ‘thresholds’ condone harm and abuse in health and social care?

Reading and writing about the duty of candour has caused me to stop and reflect on the use of ‘thresholds’ in protecting those who use health and social care services from harm and abuse. I am beginning to wonder if I have lost sight of the real issue here.

The issue is some people are harmed by those providing their care in health and social care settings.   The latest overview of adult social care in England from the National Audit Office clearly highlights the problem  stating

Safeguarding vulnerable adults from abuse and neglect remains a major risk throughout the sector…….In 2012-2013, 36% of safeguarding referrals were about alleged abuses by social care or health workers.’

 We have thresholds in safeguarding adults and children.  The threshold is meant to determine the level of professional response, however, I’ve witnessed thresholds being used to justify a less than meaningful response.  What message are we sending to  professionals when we base safeguarding interventions on thresholds, the system will tolerate a little bit of abuse/harm?   Thresholds should be effective as a preventative mechanism, but not if they are set too high or used as an administrative convenience to ensure  referrals of allegations of harm and abuse are kept at a manageable level for the organisation. Surely  this is counter productive to changing the ‘culture’ of any failing provider of care.  In my view to really change cultures within organisations we need to take a zero tolerance approach to harm/abuse, whether its mild, moderate or severe, it has no place in health and social care.

I came across a quote in my studies which I find very pertinent in regards to how policy/legislation translates into frontline practice

‘To assume that an official plan and its implementation in practice are the same is to fly in the face of facts. Invariably to some degree, the plan as put into practice is modified, twisted and reshaped, and take on unforeseen accretions’ (Herbert Blumer)

My fear is the ‘duty of candour’ could become another threshold where’ low level’ harm/abuse /neglect is all but ignored, or even tolerated, by organisations.  As I have pondered the use of thresholds I have decided to forget them because I believe for  cultural change in health and social to become a reality  society has to feel shocked, appalled and outraged at any level of harm/abuse/neglect, then we will see real cultural change. 

Organsations such as health and social care are populated by the individuals that make up wider society, if we can get our priorities right outside of these organisations there is a greater chance of getting them right inside those organisations.

Vulnerable people suffering as a result of housing welfare reforms

Latest from Commons Select Committee: Vulnerable people suffering as a result of housing welfare reforms

Reforms to the support provided for housing costs – including the Social Sector Size Criteria (SSSC) (also known as the “Bedroom Tax” and the “Spare Room Subsidy”) and the household Benefit Cap – are causing financial hardship to vulnerable people who were not the intended targets of the reforms and are unlikely to be able to change their circumstances in response, say the Work and Pensions Committee in a report published Wednesday 2 April.

The SSSC is having a particular impact on people with disabilities who have adapted homes or need a room to hold medical equipment or to accommodate a carer. The Committee recommends that anybody living in a home that has been significantly adapted for them should be exempt from the SSSC. The Report further urges the Government to exempt all households that contain a person in receipt of higher level disability benefits (DLA or PIP) from the SSSC.

Dame Anne Begg MP, Committee Chair, said:
“The Government has reformed the housing cost support system with the aim of reducing benefit expenditure and incentivising people to enter work. But vulnerable groups, who were not the intended targets of the reforms and are not able to respond by moving house or finding a job, are suffering as a result.

The Government’s reforms are causing severe financial hardship and distress to vulnerable groups, including disabled people. Discretionary Housing Payments (DHPs), which local authorities can award to people facing hardship in paying their rent, are not a solution for many claimants. They are temporary, not permanent, and whether or not a claimant is awarded DHP is heavily dependent on where they live because different local authorities apply different eligibility rules.

Using housing stock more efficiently and reducing overcrowding are understandable goals. But 60-70% of households in England affected by the SSSC contain somebody with a disability and many of these people will not be able to move home easily due to their disability. So they have to remain in their homes with no option but to have their Housing Benefit reduced.”

The household Benefit Cap

The Benefit Cap is having an adverse impact on disabled people and their carers. This is particularly the case where the carer lives with the disabled person, for example a parent or adult child, but is not considered part of the same household for benefit purposes. The Government should exempt all recipients of Carers Allowance in this situation from the Benefit Cap.

Discretionary Housing Payments (DHPs)

The Government should review DHP provision when more data are available and increase funding, if necessary, to protect vulnerable people from hardship.

Local authority discretion in granting DHPs is resulting in access to funding depending heavily on where a claimant lives. Some local authorities are taking income from disability benefits into account in the means tests they apply for determining eligibility for DHPs. The Government should issue clear guidance to local authorities that disability benefits should be disregarded in any means tests for DHPs.

People with long term problems such as disabilities, who are unlikely to be able to move house or find work as a response to the reforms might need longer term DHP awards. The Government should issue new guidance to local authorities making explicit that it supports long-term DHP awards for specific categories of claimants. Local authorities will need clarity on DHP funding for at least three years ahead. The Government should announce decisions on DHP funding early so that local authorities can plan effectively.

Dame Anne said:
“Access to DHPs should depend on need, not somebody’s postcode.”

“DHPs will be needed for the foreseeable future to assist people affected by the housing benefit reforms. Local authorities need certainty about what funding the Government will make available for this, for at least the next three years. The Government cannot on the one hand expect local authorities to make longer-term DHP awards and on the other only outline funding levels for the short-term.”

“Disability benefits are intended to cover the extra costs arising from a disability; they are not disposable income. It is inappropriate, therefore, for them to be included in means tests for DHPs.”

Is it time to change the discourse on the NHS if we want it to survive ‘austerity’ …..

A positive start for new NHS chief, Simon Stevens, might be to change the constant  negative discourse that surrounds the NHS.  If first media reports are correct it’s not a good start.  Discussion already appears to be focusing on   ‘an ageing population’ and ‘budget cuts’.   Whilst these are real,  they  being used to undermine the long term future of the NHS to open the flood gates to further privatisation.  

I believe It’s time to see the NHS  as an important part of the answer, not the problem, in our health care provision of the future.  Here we have an organisation that provides health care to 60 million people.   Access is not dependant on how much you can afford, or the conditions of a policy drawn up by an insurance company more interested in clauses and small print that can deny you care.  The price you pay does not increase if you are found to be genetically predisposed to a certain condition.  Just imagine  a privatised healthcare system where health care provision was provided by profit-making companies like  SSE, British Gas or BT.  Not as out there as it seems, BT are big players in the expansion of TeleCare using their broadband in areas such as Cornwall. However, do private companies favoured by government adhere to the same founding values as the NHS where any type of care is concerned? Probably not if todays report on BT and the government is anything to go by.

The Commons Select Committee is very critical of the way in which the government and BT have behaved in the expansion of broadband to rural areas. 

The Rt Hon Margaret Hodge MP, Chair of the Committee of Public Accounts, today said:

“The Government has failed to deliver meaningful competition in the procurement of its £1.2 billion rural broadband programme, leaving BT effectively in a monopoly position.

BT’s monopoly position should have been a red flag. But we see the lack of transparency on costs and BT’s insistence on non-disclosure agreements as symptomatic of BT’s exploiting its monopoly position to the detriment of the taxpayer, local authorities and those seeking to access high-speed broadband in rural areas.

Now just replace ‘high speed broadband’ with ‘health care’.

Fanciful tosh on  my part, maybe, but it’s what I believe. I believe in the NHS, it has its faults, I’ve written about them many times, however, as an experiment in equity and social justice in health care provision it has been the most successful in the world.

I really do not want to lose it.