Monthly Archives: October 2014

Ukip, immigration and a wholesome British breakfast to wake us up …….

All this talk about immigration has got me thinking about the kind of Britain I want to live in, and I’ve decided I like the Britain I currently live in, open borders an all….

Even though we may disagree we can all at least share a traditional British National Breakfast together.

Enjoy

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Care of older people: services should focus on enabling older people to flourish…

Ethically sustainable care: This approach moves beyond ensuring older people have the ability to flourish to consider whether they are actually flourishing.

As CQC yet again bring to government and wider societies attention the poor levels of care some older people experience, one wonders will we ever get to grips with this issue? The transformation of ‘care’ into a commodity that can be bought and sold by families and those who use services, like any other product, dominates current health and social care reform, however, discussion on what ethical principles underpin the delivery of such care has not emerged. This raises the question for me, is it wise to continue to build a system of care provision with no clear ethical foundation outside of that of the free market? Arguably, we need greater ambition in developing great care for older people and a more strategic approach to make real improvements. But how?

Developing ethically sustainable care for older people

Drawing on the ecology movement sustainable development is defined as “development that meets the needs of current generations without compromising the ability of future generations to meet their needs”. This captures two relevant issues; the need to support those older people currently requiring care, without compromising the future of the care system.

Need, capabilities and the ‘good life’

A first step in developing ethically sustainable care involves reframing our understanding of ‘need’. Need in a health and social care context is often used to refer to a function to be fulfilled, i.e. nutrition, physical care. Such needs are viewed as a necessary condition for survival. However, we should also view older peoples’ needs in terms of security, respect, love and justice. The failure to distinguish between different types of need has led to limiting our understanding of how to care for older people, and has subsequently influenced how service provision has developed. Amartya Sens’ concept of ‘capabilities’ provides an alternative approach Sen is concerned in this model with identifying what individuals require to flourish and live a ‘good life’. In this model it is recognised older people require different capabilities to flourish, depending on their personal circumstances and the community they live in, whether that community is within an in-patient/residential setting or in the wider community. Successive governments’ appear to believe an expansion in a consumer culture within health and social care provision is the only route to a ‘good life’ for older people, as it enables individuals to increase choice and control by becoming consumers of care, rather than receivers of care. Yet many older people are clearly not flourishing in a culture that defines the good life in terms of their ability to engage as a ‘customer of care’. A more useful way of thinking about this, from an ethical perspective, links Sen’s idea of capabilities and Aristotle’s vision of the ‘good life’. From this perspective achieving quality of life is central, rather than just meeting physical needs. In other words it is not just about achieving an ‘average’ notion of well-being but about the opportunities available to the individual which will enable them to develop their full potential, whatever that might mean for that individual. This approach moves beyond ensuring older people have the ability to flourish to consider whether they are actually flourishing. Commentators suggest there are five areas in which older people need to flourish to live a good life, regardless of where they live. These are: belonging to a family; belonging to a community; having access to material goods for sustenance, adornment and play; living in a healthy environment; and having a spiritual dimension to life. Arguably the commissioning and delivery of service provision based on achieving these five areas might enable older people to receive care that is both compassionate and dignified.

The way forward

Conceptions of what constitutes a good life are varied, however, within health and social care provision it is prudent to assume a good life involves at a minimum care provision that is not abusive to older people. Within the public sector the organisation and delivery of care is structured to focus on the meeting of targets rather than enabling the individual to flourish. The health and social care sector is arguably over managed and under led. In the private sector it could be argued a free market economy contains structural incentives for business to pursue a notion of the good life that supports the sale of a narrow range of care ‘products’, whilst there are not mechanisms in place to ensure the market operates within a clear ethical framework outside of the profit ethos. By not actively endorsing care provision from an ethical stand point the government and regulatory bodies may actually be unwittingly aiding the abuse of the most vulnerable within the care system. A shift in focus from human need to human flourishing has already begun with the development of the personalisation agenda and emphasis on voice, choice and control however, this agenda has been overshadowed by a managerial approach to consumerism and consumption in a low paid, low status care system and this is undermining the ability of the care system to develop ethically.

Markets and Values

Michael Sandel argues markets are not a mere mechanism designed to deliver goods, they also embody certain values, and the problem is these values ‘crowd’ out non market values like compassion and dignified care. Where values and ethics are weak we need a strong and active state to intervene, where both are weak those most vulnerable in society will continue to be exploited and abused. This begs the question can we afford not to have an ethical care system?

To see a wrong and not expose it, is to become a silent partner in its continuance (John Raymond Baker)

Good care for older people depends on relationships not target and tasks

More headlines confirm what we must all know by now, surely. The care for some older people in the UK today leaves much to be desired.

Old age must now be more feared than death!

Ultimately good care is about the relationship between the carer and cared for, and that involves the development of an emotional attachment that goes beyond our current ‘task’ focused system. Relationships are, in my opinion, the missing link in delivering compassionate care.

Traditionally successive governments have tried to ‘codify’ practice to make it ‘professional’ and ‘commoditized’ care to make it a deliverable ‘product’. Putting such frameworks around practise makes problems in the care system easier to talk about and resolve, i.e we need more training for carers, more training for leaders and managers, different providers, a mixed economy of care etc. However, what we are not talking about is relationship based care focused on supporting the emotional aspects of care provision.

There is no doubt in my mind caring for older people can be difficult,I’ve written before on ‘social defences’ used in professional practice to help carers protect themselves from the emotional and psychological stress they can experience when caring for vulnerable people. Our organisation and delivery of care services facilitates the maintenance of such social defences by reducing care into individualised elements where a succession of carers carry out particular tasks, and so we lose sight of the person. However, by developing a system designed to keep relationships ‘professional’ we have lost the key ingredient to delivering compassionate care. For those on the front line this must lead to very limited levels of job satisfaction and feeling one has made a difference to someone’s life, which is often the primary reason individuals choose to enter the caring profession.

In the Netherlands they use a model called ‘complete care’ in the care of older people. This involves developing relationships with people, not just carrying out care tasks on a patient.

Such an approach can cost more, in the short-term, but in the longer term the potential of fewer hospital admissions, reduced levels of depression and isolation of older people, along with lower levels of stress and burn out of carers, resulting in sick leave and expensive locum/bank nurse cover, must work out far more cost efficient (but more importantly ethical).

To achieve relationship based care will require a reorganisation of systems and structures currently in place, for example work rotas’, pay and conditions, shift patterns etc. The cost of such a reorganisation could be off set by those unnecessary costly hospital admissions which result from poor care provision across the sector.

If we really want compassionate care we need to focus on building a system built on developing healthy relationships, not targets and tasks.