Category Archives: Dignity

To deliver good, safe, sustainable care, leaders need to think beyond traditional boundaries ……

Our care system is at breaking point. People are struggling to find a good care home when they desperately need it. With demand for beds set to rise, the time for action is now. Help us convince the regulator to confront the care crisis before it’s too late.’ (Which?)

CQC have confirmed in their State of Social Care report the problems many requiring social care already know, the system needs reform.

As Which?  and CQC yet again bring to government and wider societies attention to the problems and 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 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 an 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 versus 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?

 

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Social Work education; is there a future under neoliberalism?

As an ideology, neoliberalism perpetuates the belief that the market cannot only solve all problems but also serves as a model for structuring all social relations. It is steeped in the language of self-help, choice and individual responsibility,   purposely ignoring the effects of  inequalities in power, wealth and income and how these shape individuals and families lives. As such, it supports a society which cruelly others those who require support, and is scornful of a critical and politicised social work profession founded on compassion and notions of social justice, equality and respect.

Back in 2013 Michael Gove, then education secretary, claimed too many social workers had been filled with idealistic dogma and theories of society that viewed people as victims of social injustice. Gove vowed to “strip this sort of thinking out of the profession”.

More recently Ray Jones argues politicians are stealthily trying to take control of social work, possibly because social workers expose the failings of their ideologically driven policies?

Maybe this is why Government would like to diminish the role of Universities in social work education, to depoliticise the profession and create a beige curriculum.  A painting by numbers programme of training, rather than a vibrant colourful education that prepares social workers to support, and challenge those in power. The extension of neoliberal ideology and discourse into higher education already provides a framework to socialise academia into working in a manner akin to managerialism i.e targets/NSS, where knowledge is viewed as a commodity for customers (students) to purchase and consume.  Packaged as one dimensional capabilities rather than multifaceted knowledge and skills .

(see Grant and Radcliffe, 2015, whose paper on higher education in mental health nursing has many synergies with social work).

Arguably an effective social work profession is a political profession as well, able to critique and analyse, to challenge, rather than accept the status quo.  As Henry Giroux eloquently states

“At a time of increased repression, it is all the more crucial for educators to reject the notion that public and higher education are simply sites for training students for the workforce, and that the culture of education is synonymous with the culture of business. At issue here is the need for educators to recognize the power of education in creating the formative cultures necessary to challenge the various threats being mobilized against the ideas of justice and democracy, while also fighting for those public spheres, ideals, values, and policies that offer alternative modes of identity, thinking, social relations, and politics.

Pedagogy is always about power, because it cannot be separated from how subjectivities are formed or desires mobilized, how some experiences are legitimated and others are not, or how some knowledge is considered acceptable while other forms are excluded from the curriculum.”

Whilst we have a plethora of educational routes into social work, Frontline;Think Ahead;Step-up;Apprencticeships and HEI’s no one appears to be asking any political leader of any persuasion one very important question as far as I can see.

Given our politicians feel their governments policies and leadership over the last 3 decades has led to continuous improvements, why is society in such need for ever increasing numbers of social workers?

If we can move beyond the divisive  narratives of  ‘broken families’, ‘recruitment and retention’, ‘the demographic time bomb’, ‘austerity’ and ‘we can’t afford X’,  and consider addressing the structural issues that impact on individuals lives, such as housing, benefit reforms, energy prices, the environment, job insecurity, food insecurity, low wages, affordable higher education etc, we might then be able to formulate a different ideology, a different discourse, one that unites us for the good of all.

 

What is the point of ‘choice’ if your choice is between poor or inadequate care?

As CQC finds 32% of facilities in England inadequate or in need of improvement and says social care in ‘precarious’ state one wonders will we ever get to grips with this issue?

This latest report suggests

social care is in a “precarious” state – and according to Age UK the results leave elderly people and their families “playing Russian roulette” when they choose a nursing home or other care service. Inspectors making unannounced visits to care homes found medicines being administered unsafely, alarm calls going unanswered and residents not getting help to eat or use the toilet. Some residents were found to have been woken up by night-shift care workers, washed and then put back to bed, apparently to make life easier for staff

This is not just poor care but adult abuse.

Governments response is to promise more money for social care, however, I feel we would be foolish to rely on the same old political rhetoric. This amounts to no more than economic deception as successive governments continue to adhere to the neoliberal principles of the quality and responsiveness of free market provision and consumer choice. The current approach is failing to deliver either of these fundamental neoliberal principles as the care ‘market’ flounders.  According to research, carried out for BBC Panorama by Opus Restructuring and Company Watch, the care ‘industry is in crisis with 69 home care companies having closed in the last six months and one in four of the UK’s 2,500 home care companies is at risk of insolvency.

Anyone reading this who has sought to purchase care for their relatives can attest to the lack of ‘choice’ the current system provides. Indeed most would forfeit ‘choice’  to just have one provider who we can trust to provide decent care for our loved one’s.

What is the point of choice if your choice is between an inadequate care provider or one requiring improvement?

The primary issue, for me, is that care should never be treated as an ‘industry’ because the conflation of care and profit should never ever have occurred because marker values have altered our understanding of the value of humanity in care. Arguably, the discussion needs to go beyond financial issues to consider the greater deception of successive governments who have consistently ignored their failure to develop an ethically sustainable approach to the care and support of those requiring care, especially older people.

Let’s be honest, growing old in the UK is not for the faint hearted when we consider research and inquiries over the last decade. Action on Elder Abuse have consistently highlighted the prevalence of abuse older people experience in the community, leading in 2016 to the publishing of a ‘dosier of shame’ which outlined how the abuse of older people frequently go unpunished.

From a European perspective research findings suggest 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 (WRVS,210). 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).

This all provides a troubling vision of older people’s experience of ageing in the UK.

Successive Governments in the UK tend to address issues associated with care and an ageing population in 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 develop more successful policy approaches, which improve our care provision and the experience of ageing.

However, any action needs first to move away from the dogma of neoliberalism and take a long term approach with a strong ethical, rather than financial, foundation.  This needs to be founded on a commitment to promoting care as a humane act rather than promoting the care of those most vulnerable as a  product to be bought, sold and profited from.

Should care be a commodity to be profited from?

 

Arguably, the ‘free market’ is anything but ‘free’ with  the cost to many in society excessive in terms of compassion and inequality.

A report published by Lancaster University  entitled ‘A Trade in People’ expresses the failure of the free market in providing services to those most vulnerable in society when it writes

‘it is clear to us that the way in which the healthcare economy has been encouraged to develop by recent governments turns people into commodities and liabilities. For local authorities and CCGs they are liabilities that they have often sought to export to other areas and for independent hospitals they are a commodity and source of millions of pounds of income and profit.’

Whilst an economic and political system premised on the commodification of people and neoliberal theory maybe a reliable form of wealth generation for some, it is also associated with little compassion for those who require support, as well structural inequality and poverty for many.

Nobel prize winning economist Joseph Stiglitz is clear, we are now engaged in a battle which is ideological, describing free market neo-liberalism as  a stifling economic ideology which has run it course.

Neoliberalism has an insidious presence in our lives, much like the air that we breathe, everywhere, yet unseen. George Monbiot  provides a compelling argument against this ideology, which values the free market as the place in which citizens can exercise their democratic choices through consumer choice and the private provision of goods and services.    Supporters of neoliberalism maintain  “the market” delivers benefits that could never be achieved by government, and that the more unregulated the market, the better the efficiency. Within this framework everything we do, and every person is a potential commodity that can bought, sold and traded for profit.

However, for me,  the free market  is associated with a loss of compassion, dignity and respect for one another as an inactive state projects structural failure onto the individual, along with an outdated mantra of ‘private sector good, public sector bad’.

One need not dig too deep to see the flaws within the current system. The research by Lancaster University adds to a plethora of  reports, all stating the same thing. This system is broken!

Just consider  housing and the care of older people to establish the limits of the free market.

Shelter’s report on the barriers low-income households face in private renting exposes the private housing  market’s limitations,  clearly arguing significant government intervention is needed if it is to play an expanded role in preventing homelessness and housing people on low incomes.

The same issues arises in the care of older people, where significant market failure is a continuing problem.

Over two years ago the King’s Fund  highlighted what many in the sector already know, the free market is failing stating

‘Social Care is now a complex and sprawling sector – more than 12,000 independent organisations, ranging from big corporate chains to small family-run businesses, charities and social enterprises, which makes the NHS provider landscape look like a sea of organisational tranquillity. Less than 10 per cent of social care is actually provided by councils or the NHS – their retreat from long term care provision is virtually complete. But unlike the NHS, when a social care provider hits the financial rocks, bankruptcy not bail-out is the more likely scenario.  But a deeper problem is the failure to think through the consequences of shifting the bulk of our care provision to a private business model’.

This is supported by  Andrew Dilnot , former drector of the Institute of Fiscal Studies, who suggests social care is is a classic example of a market failure where the private sector cannot do what’s needed.

However, the effect of the failure of the free market and neoliberal ideology extends beyond money,   the real effect of failing markets rests upon the poorest and most marginalised in society, like the  residents of Grenfell Tower and those with social care needs in private institutions, the frail and vulnerable who require support.

The problem in government today is that many of those who govern this country are woefully out of touch and too quick to blame individuals for their descent into a commodified system of care, rather than look at their own role in the rising tide of compassionless care which threatens us all.

Michael Sandel argues the free market is not just a mere mechanism designed to deliver goods, it also embodies certain values, and the problem is these values ‘crowd’ out non market values which are really worth caring about and preserving, such as compassion’.

Where values and ethics are weak in any system which seeks to support those in need, we need a strong and active state to intervene, where both are weak those most vulnerable in society will continue to be denigrated and exploited.

‘Old age,more feared than death’…… have we ever cared about older people?

Has there ever been a ‘golden age’ where older people were consistently valued, respected cared for and protected by family and the institutions that make up wider society?

Phillip Lee

Government minster, Phillip Lee, suggests families in Britain  are too selfish to care for their elderly relatives, I wonder why this might be and has there ever been a golden age when older people have been cared for by families?

Firstly, whilst there are ‘selfish’ people in society from my experience of coming into contact with primarily women trying to care for elderly relatives, successive governments policies and economic strategies has done little to support them in this task.

From professional, and personal experience, caring for elderly parents has tended to fall upon women between the ages of 58 and 70 years of age. These women are also primary carers of their grandchildren, because their children cannot afford the high cost of childcare and/or afford to pay high rents due to unaffordable housing, or to afford a large mortgage due to inflated housing costs linked to government policies.  These woman are also trying to support themselves, because they now have to continue to work until they are 67 yrs of age until they can get a pension.

So these women still work to support themselves, they support their children, their grandchildren and their elderly parents. They are not rich women, they often work in low paid jobs, physical jobs, with no professional pension to fall back on.

Indeed in my view these women are heroes, and on top of that they contribute to the estimated £132 billion unpaid carers save the tax payer every year.

So I think it would be nice these heroic women were recognised and thanked by the Minister

 

 

The World Health Organisation suggests the abuse of older people occurs in many parts of the world with little recognition or response. This serious social problem is often downplayed or hidden from the public view, and considered mostly a private matter. Even today, the abuse of older people continues to be a taboo, mostly underestimated and ignored by societies across the world. However, evidence is accumulating to indicate that the abuse of older people in the UK is an important public health and societal problem.

The full extent of abuse is unknown, however, its social and moral significance is obvious. As such, it demands an active response, one which focuses on protecting the rights of older persons, and a change in our perspective on whom, and what, we value in society.

Although representations of old age and societal responses to older people have differed over time it could be argued old age has always been viewed as negative.

In ancient Greece old age was portrayed as sad, with the Greeks love of beauty marginalising the old. Although some commentators suggest the reality was more complex with the portrayal of older people in the classics as ‘both pejorative and complimentary’ (Thane, p.32). For Plato reverence toward old people was a guarantee of social and political stability, whereas Aristotle disagreed with such positive images. 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.

Arguably this belief still underpins social care legislation and policy today in respect of older people.

It has been suggested older people’s status in society is linked to their ability to participate in society from an economic perspective, especially in terms of activity in paid employment. Historically where older people have been unable to participate in paid employment, help and support has been provided through a mixture of family and state support, with an emphasis by government on the former rather than the latter. However, commentators suggest, post industrial revolution, another victim of change were older people. The old did not merely lose power, they also lost respect. The rise of the alms-houses, and institutionalised poor-relief, may indicate their children were increasingly shedding responsibility for their support and transferring it to the community.

Although Thane  argued, this may have been due to families own depths of poverty, rather than lack of care or a shedding of responsibility.

The abuse of older people was not something government identified as a problem throughout this period, although, self-neglect was identified as an issue which government sought to address in the 1948 National Assistance Act.

This is not to say it did not occur, for example, the 1942 Exceptional Needs Enquiry found most older people living with families were there under sufferance. They were often less well off than those who lived with strangers, and lacked essential items of clothing, bedding or household equipment as families used any provision, such as clothing coupons, for personal use. Whether this constituted abuse is not clear as many families who cared for older relatives were often living in poverty themselves and older people often willingly gave their families any support they could, even if this meant going without themselves. Of course, records do not exist to either confirm or deny whether such relationships were abusive or mutually supportive, however, it might suggest in terms of individual worth and personal identity, a cultural norm existed where the welfare of the younger generation was prioritised over that of the old by both young and old.

However, Peter Townsend’s landmark study  of long-stay institutional care for older people in 1950’s Britain, provides a little more insight into the experiences of older people receiving care. One of the interviews he recorded was with a matron of a small private residential home in Greater London, which Townsend suggested was by far the worst home he had visited, was clearly describing abuse, as defined in legislation today.

This suggests the abuse of older people has been going on for a long time. It is increasingly clear the abuse of older people exists, and as a society we cannot ignore it any longer.

CQC, older people & funding cuts:It’s not just about the money….

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 latest report suggests cuts to social care,  mental health and public health mean “the NHS is being stretched to the limit,” said Stephen Dalton, chief executive of the NHS Confederation, which represents hospitals. “Relying on political rhetoric that promises to protect the NHS but fails to acknowledge that a cut in social care results in a cost to the NHS, is an economic deception.”

Arguably, the discussion  needs to go beyond financial issues  to consider the greater deception of successive governments who have consistently ignored their failure to develop an ethically sustainable approach to the care and support of older people.

Let’s be honest, growing old in the UK is not for the faint hearted when we consider research and inquiries over the last decade.

In 2007 The Joint Committee on Human Rights suggested older people in hospital and residential care routinely receive inhumane and degrading treatment, whilst an analysis of outcomes for patients commissioned by the Royal Medical Colleges in 2010 concluded inadequate hospital care for older people condemned many to death.  The Health Service Ombudsman review of complaints, in 2011, suggested the National Health Service (NHS) is inflicting pain and suffering on patients, citing examples of older patients leaving hospital with numerous physical injuries, mentally confused, soaked in urine wearing other people’s clothes held together with paper clips.  Sadly the report suggested the individuals discussed are ‘not exceptional or isolated cases’ and clearly indicates the attitude of staff was indifferent to those older people for whom they were supposed to care.    Then in 2012 the Royal College of Surgeons found older people were discriminated against when being assessed for surgical treatment, with decisions being based on chronological age rather than clinical need, whilst Bingham   suggested the treatment of older people in care was so bad that in many cases it met the legal definition of torture. The  scandalous mistreatment of older people in Mid Staffordshire was exposed in the Francis Report in 2013, whilst in 2015 CQC reported on the continuing poor care older people received in care homes …. and so it goes on.

When we move away from  hospital and residential settings things are often not much better with Action on Elder Abuse consistently highlighting the prevalence of abuse older people experience in the community,  leading in 2016 to the publishing of  a ‘dossier of shame’ which outlines how crimes against older people frequently go unpunished.

From a European perspective research findings suggest 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 (WRVS,2012).  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).

This all provides a troubling vision of older people’s experience of ageing in the UK.

Older people’s experience of ageing in the UK can be improved, and it is all of our responsibility to try and achieve this.  However, we first need a coherent strategy to bring about the change desired by many who work with older people.  Government in the UK tend to address issues associated with an ageing population in 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.

However, any action needs first to take a long term approach and have a strong ethical, rather than financial, foundation founded on a clear understanding of, and agreement to, promote older peoples equality and human rights across the political divide.

‘Over 50’s more scared of dementia than cancer’: I’m more terrified of the ‘harrowing neglect’ in our care system ……

As The Telegraph report people over 50 are more scared of dementia than cancer, I have to say I am terrified of any condition which might mean I need to rely on our care system when I get older.

As someone over 50, and who is currently spending every weekend at the hospital bedside and my mother in law because I’m so scared that without family around she will be seen as nothing more than ‘care home fodder’, the thought of requiring care, either in hospital or outside of hospital, once you hit the post 80 mark is a terrifying prospect to me.

There has been too many high profile inquiries to suggest these are anomalies in the care system, for example, following the inquest into care at Orchard View the Serous Case Review into the deaths of 5 older people has been published. The coroner has heavily criticised the quality of care at the Southern Cross home, and expressed incredulity that many staff were still working in the care industry, stating that “there could be another Orchid View operating somewhere else”.

The Daily Mail reports

‘Britain’s worst care home’: Damning report into ‘harrowing neglect’ at £3,000-a-month home aims to stop ‘institutionalised abuse’ of the elderly: Serious Case Review has made 34 recommendations after examining failings at Orchid View care home in Copthorne, West SussexRead more: http://www.dailymail.co.uk/health/article-2652709/Orchid-View-care-home-receive-damning-report-published-today.html#ixzz34ELlbfW6
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I’m afraid the type of ‘care’ received by those at Orchard View is not confined to Orchard View.

In 2010 the Royal Medical Colleges concluded inadequate hospital care for older people condemned many to death. In 2011 The Health Service Ombudsman suggested the NHS was inflicting pain and suffering on older people, and was indifferent to older people. In 2012 Bingham suggested the treatment of older people in care is now so bad in many cases it meets the definition of ‘torture’.

Just for clarity Amnesty International has outlined the techniques used in ‘torture’, these include isolation, enforced trivial demands, degradation, threats, displays of power (i.e. controlling food and hydration, physical assault).

For some older people in care today, whether in the public or private sector, that is their care, torture.

No wonder from a European perspective research suggests older people’s experience of ageing in the UK falls behind that of many of it’s European counterparts (WRVS,2012).

Older people’s experience of ageing in the UK can be improved, and it is all of our responsibility to try to achieve this. However, we first need a coherent strategy to bring about the change desired by many who work with older people. Government in the UK tend to address issues associated with an ageing population in 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. However, any policy needs first to have a strong ethical foundation founded on a clear understanding of, and agreement to, promoting older people’s equality and human rights.

There is clear evidence in the UK that poor levels of care, in both the private and public sector, is far to prevalent in our care system. Whilst the focus currently is on the leaders and professionals charged with developing and delivering care, wider society too has a role in ensuring compassion in care is the ‘norm’ and not the exception, as The Independent suggests

‘For 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’

Whilst many older people receive good quality care, the majority provided by friends and family, far too big a proportion of those requiring higher levels of care are failed by care providers in our system. It is not good enough to keep using the same old rhetoric, better training (what type and where from?), minimum standards (we have these), ‘big society’ need to take more responsibility. We have heard all of this before, and still the abuse continues.

Both my mother (82yrs) and mother-in-law (86yrs) have made clear to me this weekend they do not want to end up in residential care, the very thought fills them with horror. They remind me of the older people I worked with two decades ago who used to equate a stay in hospital with the workhouse and its associated horrors.

It struck me, it must feel terrifying being an older person requiring care today.

Re-think on outsourcing: Mr Gove, privatisation and the ‘missing shade of blue’ …..

Academics and experts have expressed their concerns in a letter to the Guardian following the Department of Educations announcement that it is considering outsourcing children’s services to private firms.

Professor Eileen Munro rightly highlights the ‘fickleness and failings’ of the market, suggesting caution in establishing a market in child protection which could create perverse incentives for private companies. A recent headline highlights the less savoury side of outsourcing – ‘Now troubled children are an investment opportunity: 18% return on the most disturbed and needy children in care homes is the extreme end of Britain’s outsourcing culture’ (Polly Toynbee)

A poll in the Guardian found 95% of respondents felt private firms should not be allowed to run children’s services.

However, the outsourcing/privatisation of children’s services is already here, and it’s extension into child protection is the next target for this government.

The letter has achieved its’ purpose in highlighting the issue and stimulating debate, the question is where do we go from here? I agree with my learned peers, we have to move beyond the ‘outsourcing’ of child protection and focus on our primary concern that vulnerable children will be exploited for profit, not unlike the vulnerable patients of Winterbourne View Hospital. A hospital set up by a Swiss equity company who primarily saw it as an investment opportunity and when the abuse of its’ patients was exposed promptly closed it down, probably moving onto the next investment opportunity provided by this government in the outsourcing of services.

Sadly government chooses to ignore this aspect of outsourcing. However, they do not ignore the opportunity to expose the failure of ‘social workers’ whenever possible. Although, they are less than explicit about the serious structural issues that prevent social workers delivering good services. The Munro Review provided a blue print for change which was universally accepted, however, it has been quietly watered down by the present government, a massive mistake in my opinion, but not unexpected as it really does not fit their ideological agenda and the dichotomous thinking of Mr Gove and co i.e. public sector bad, private sector good.

The issue is not about ‘outsourcing’, it is about the principles, values and ethics of those we outsource to. It is really about profit being made from the lives of those most vulnerable in society which feels abhorrent. Personally I feel the time is right to abandon the notion there is only one way of constructing the world of safeguarding, whether child or adult, if we are to move forward in this debate.

In a famous passage in his Treatise of Human Nature the political philosopher Hume writes about ‘the missing shade of blue’. According to Hume, if we are shown samples of two different shades of blue we can conjure up in our minds a third shade that fits between the two: the missing shade of blue.

The point of interest in Hume’s writing is not that we can invent a new shade of blue but that we can invent new ideas which connect to existing ideas.

Those working daily on the frontline of child protection I feel sure are more than able to achieve this, however, I have little faith, or trust, in those in government to move beyond their preferred shade of Tory blue.

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.” (Independent.co.uk, 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.