Category Archives: Dignity

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.

 

 

 

 

 

 

 

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Will Hunts vision of a ‘duty of candour’ really bring about cultural change in the NHS?

Department of Health Media have contradicted my suggestion in a previous blog that Mr Hunt has ignored David Behan and CQCs guidance regarding a ‘duty of candour’.  I’ve conteacted them four times for clarification without success. i can find no record evidence to support their assertion.

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?

(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 safeguaridng 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)

Hmmmm……….

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.

BASW call for ‘powers of access’ to protect vulnerable people…

Campaigners want to end the situation  where professionals in the UK, except in Scotland, feel powerless to help abused adults in their own homes.  Action and Elder Abuse and BASW are seeking additional powers of access into individuals own homes for professionals to help protect those most vulnerable, however, whilst this makes sense to many this issue is about much more than simply protecting the ‘vulnerable’.

At the heart of this debate is an attempt to understand how the relationship between the state and individual might be formulated to fulfill a mutual responsibility in enabling  individuals to live lives free from abuse without compromising their right to freedom.  In regards to the introduction of law to protect people from abuse we must ask how far the state can go in its interference with an individual’s right to autonomy and self-determination.  Is it possible to incorporate adequate safeguards into any developed public law that would ensure an appropriate balance between the two rights?

Beliefs about the role of the state,and ‘big society’, in supporting those most vulnerable have their roots in philosophy.  This provides the foundation from which government  identifies society’s needs, defining who is deserving and/or undeserving of support, along with providing a framework to shape how need will be met and protective services are structured in law to balance the rights and responsibilities of both government and the individual.

For example, Hobbe’s (1588-1679) thoughts on rights in the Leviathan suggests if everyone were to pursue their own rights at the expense of others life would be violent and dangerous. Therefore, he suggested a contract whereby individuals give up their natural freedom to do anything they want in exchange for personal security from a supreme ruler.  This is one of the earliest examples of a theory of government known as the social contract, which outlines the relationship between citizens and government.  John Locke (1632-1704), like Hobbe’s, was a major social contract thinker who identified three central rights he felt should be upheld by the state; the right of life, liberty and property. These were viewed as natural and inalienable, which meant they should be universal i.e. applicable to all.

Locke suggested that by living within a state we have an obligation to obey the laws enacted by the majority of its citizens to protect these rights.

Both Hobbe’s and Locke considered humans as inherently selfish whose pursuit of individual pleasure is destructive to society. Locke viewed poverty not as a result of structural economic failure but as the result of individual failure, suggesting that law can be used by the state as an apparatus to modify human desires which in the longer term will be of more benefit to the well-being of all society. This approach underpinned the development of the welfare  state throughout the 18th, 19th and 20th centuries.  However, such thinking has been criticised with Jessie Norman suggesting Hobbes and Lockes vision ignores the diversity of human motivation and has led to the polarisation of the individual and the state.  Hobbe’s social contract explains ‘the rightful existence of a moral state, giving it authority and legitimacy over the individual’ (Norman, 2010, p96), but Norman suggests this ignores two important factors.  Firstly, the influence of institutions, such as the family, church and marriage, which are based on affection rather than the need for procedure and purpose to give shape and meaning to human life; and secondly, how these might mediate between state and society to ensure the state does not undermine the caring spirit of society.

This is important in understanding how ‘Big Society’ might safeguard vulnerable people from abuse.  Norman (2010) presents Big Society as a return to previous patterns of care and protection based on phillic associations,  a ‘golden age’, where  people were consistently valued, respected  and protected by family and the institutions that make up wider society.  However, the World Health Organisation (2002) suggest whilst traditionally family harmony has been assumed by governments in the care of people, reinforced by philosophical traditions and public policy,  the abuse and maltreatment of family members is actually a timeless phenomenon across the developed and developing world.   The World Health Organisation states

‘The abuse of family members dates back to ancient times. Until the advent of initiatives to address child abuse and domestic violence in the last quarter of the 20th century, it remained a private matter, hidden from public view’ (2002,p125).

The proposed system from Action on Elder Abuse is also taking a philosophical stance.

The period in which governments have responded to the abuse of vulnerable people has developed in an era dominated by the liberal political philosophy of John Stuart Mill.  His work On Liberty (1859) has provided the foundation on which the legitimate nature and limits of the state has been established in the safeguarding of adults and children at risk of harm.  Mill stated ‘the struggle between Liberty and Authority is the most conspicuous feature in the portions of history with which we are earliest familiar’ (1859).  Going onto suggest liberty meant protection against the excessive use of power by government to interfere with individuals lives.   Mill’s notion of liberty supports the freedom of the individual against unlimited state control where individuals are regulated through legal or social coercion. The only time state action might be justified is in relation to those who might be deemed as possessing their full faculties is outlined in Mill’s harm principle, which suggests the state ‘should only regulate actions that directly cause, or have a very high probability of causing, unacceptable harm to others.  State intervention would be automatically justified where children are concerned, or for those adults who lack mental capacity, for example older people with dementia.  Decisions for such individuals can be taken legitimately by the state, or a representative of the state, in an individuals’ best interest if they are at risk of harm from others, however, individuals outside of these specific conditions always have a right to take risks, provided these do not harm others.

Whilst there should be a strong commitment to supporting those most vulnerable in society, I also believe it is important responses are framed from a philosophical perspective. Most professionals are not interested in exercising ‘power’ unless their is a sound philosophical and ethical foundation to do so. Get these in place and then the rest can follow….

It’s not just about ‘more resources’ in the NHS, it’s about how resources are best allocated….

Stephen Black writes in the Guardian about the negative effects of focusing on a ‘more resources to the frontline’ discourse in the NHS, suggesting this is far to simplistic. I think he has a point and wonder if it is even true, is it not more a case of using existing resources differently within a system of national health and social care?

The provision of dementia care is a case in point. The organisational culture of some providers in our current system leave some people with dementia neglected and without support where surviving the ‘system’ takes precedence over ‘thriving’, and often leads to unnecessary hospital admissions through poor levels of support at home. This is not about lack of resources but the poor allocation of resources.

As a social work practitioner I saw at first hand how good quality home care could reduce admissions to hospital. Good quality care at home can reduce, or even prevent, carer breakdown. It can support good nutrition which is essential to optimise both physical and mental health, for example by reducing UTI’s (urinary track infections) one of the core reasons I found for many avoidable admissions to hospital.

Avoidable and unnecessary admissions are incredibly detrimental to those whose lives are touched by dementia, not to mention extremely costly. Decisions re admissions are not taken lightly, however, GP’s are often faced with the dilemma of admitting someone with dementia to hospital because that is the only option, not the best option. Any savings made on reducing the cost of unnecessary admissions to hospital would, I’m pretty sure, more than cover any cost incurred in reconfiguring care services provided at home.

We know dementia care in the future is going to have to cope with growing numbers, so we need a system that is sustainable. The notion of sustainability in this context could draw on the ecology movement, where sustainability 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 important issues facing dementia care today, the need to support those currently requiring care without compromising the future of the care system to accommodate a growing number of users within budgetary constraints. At first glance the two may appear irreconcilable, however, by building on the drive for personalisation and person-centred dementia care, alongside reshaping organisational ‘cultures’ new concepts and models are able to evolve which can contribute to developing relationship based complete dementia care.

Complete Care: a model in practice – Buurtzorg Nederland

Providing a new form of service provision able to incorporate the principles of relationship based care snd capability, along with notions of ethical practice and sustainability will require a re-organisation of the way in which we currently use resources to deliver care at home. Research from KMPG International (2012) highlights how Buurtzorg Nederland might provide a blue print for such a model.

The founder of Buurtzorg Nederland, Jos de Blok a district nurse, became frustrated with the way traditional services were focused on policy, targets and administration rather than on care and compassion. So he decided to develop his own model where his role as a nurse regained its explicit social value to the community he worked with.

In the Netherlands, the financing and delivery of care in the community is highly fragmented with various tasks – such as washing the patient, serving meals and putting on elastic compressions – paid through different reimbursement schemes and, more often than not, executed by different professionals. As a result, patient care tends to lack coordination, making it difficult for the care providers to respond appropriately to changing patient conditions, which in turn leads to compromised continuity of care and low patient satisfaction.

At the same time, many home care service providers have cut costs by fine-tuning the minimum skill level required to accomplish each task. Dutch home care also tends to be focused on responding to patients’ current problems rather than preventing deterioration, meaning that interventions are generally added on only once the patient’s condition has already worsened.

To respond to these challenges, the home care organization Buurtzorg (meaning neighbourhood care) was created to focus on increasing patient value. Essentially, the program empowers nurses to deliver all the care that patients need. And while this has meant higher costs per hour, the result has been fewer hours in total. Indeed, by changing the model of care, Buurtzorg has accomplished a 50 percent reduction in hours of care, improved quality of care and raised work satisfaction for their employees.

How it led to productivity improvement

One of the keys to the program’s success is that Buurtzorg’s home care nurses organize their work themselves. Moreover, rather than executing fixed tasks and leaving, they use their professional expertise to solve the patient’s problem by making the most of their clients’ existing capabilities, resources and environment to help the patient become more self-sufficient, visits focus on the person not the task. Simply put, even though Buurtzorg professionals’ visits are not time limited the aim is to make themselves superfluous as soon as possible, versus other providers who tend to execute tasks without truly focusing on the patient’s overall capability.

Buurtzorg uses small self-steering teams (with a maximum of 12 nurses) who attend to an area of approximately 15,000 inhabitants and work together to ensure continuity of care. As a result, the professionals build durable relationships with their community, which further strengthens their ability to find local solutions for patients’ problems. Although the teams are independent and self-steering, they are supported by a centralized service organization which provides management information to both the team and the organizations’ leadership in order to minimize local overhead and maximize the professional’s face-to-face time with patients. Every team is responsible for its own clientele and is in close contact with those who use services, their families and doctors. Teams are also responsible for their own financial results.

Key results

In just two years, more than 2,000 nurses have joined the program despite the increasingly tight labour market for nurses in the Netherlands. Indeed, by 2011 Buurtzorg employed 4,000 nurses and nurse assistants working in over 380 autonomous teams.

Preliminary results show that Buurtzorg‘s patients consume just 40 percent of the care that they are entitled to and half of the patients receive care for less than three months. As a result, patient satisfaction scores are 30 percent above the national average and the number of costly episodes requiring unplanned interventions has dropped.

I spoke with Jos de Blok last week, in the years since it’s inception he is as enthusiastic as ever and rightly proud of the difference his teams are making to the lives of those who require support in the community, as well as the professionals delivering care. Surely these would be good outcomes for us all?

I’m no advocate of privatisation, however, I do believe models such as this could be utilised within a National Health and Social Care Service, which is publicly funded to provide sustainability for the future.

#Dementia care at home requires radical change, and we need to start with valuing those who provide care……..

It is estimated dementia effects’ 44 million people worldwide. Leaders from the G8 nations gathered in London in December 2013 to discuss the growing impact of the condition globally and to develop an international strategy to address dementia and its effects on individuals’ lives.

The summit set an ambitious target to identify a cure, or a significant disease modifying therapy, for dementia by 2025, agreeing to increase spending in the areas of dementia research and clinical trials globally to achieve this ambition. The world is working toward safeguarding all our futures in its commitment to tackle dementia, however, we also need to focus on the provision of services for those whose lives are currently touched by dementia, as well as creating new ways of developing and delivering support services to the next generation of dementia sufferers. There are around 800,000 people with dementia in the UK, and the disease costs the economy £23 billion a year. By 2040, the number of people affected is expected to double – and the costs are likely to treble.

Therefore, there are significant numbers of people who may require some level of care and support before the G8‘s ambitions are realised. Many of those who require such support would prefer to live in their own homes.

However, the quality of support in the home for some whose lives are touched by dementia is variable, sometimes abusive and of poor quality leading to breakdowns in care and avoidable admissions to hospital or residential placements which prove incredibly disruptive, and sometimes damaging, to individuals, their carers’ and families, as well as wasteful in terms of resource allocation.

The Care Quality Commission (CQC) first expressed their concerns regarding unacceptable standards of care provision in individuals own homes in their State of Care report published in 2012. Whilst CQC was able to report on significant improvements within provision in a subsequent report on home care provision in 2013, ‘Not just a number’, it found some care still fell below the standards those who use services have a right to expect, especially for those individuals with complex needs and dementia. CQC (2013) has identified issues related to a lack of skills and knowledge by staff, particularly around dementia and ‘concerns relating to safeguarding people who use services from abuse’ (p.5).

For example an overview of the returns from 15 local authorities in the South West on the Abuse of Vulnerable Adults (AVA, 2012) suggest that anything between 3.1% and 29.4% of all referrals are for people with dementia. However, the accuracy of these figures is called into question with a suggestion the wide disparity could indicate discrepancies in the recording of data, i.e. the person is identified as having mental health needs but the sub set of “dementia” has not been used. Figures from AVA also suggest anything between 26% – 51% of abuse occurs in an individuals’ own home where primary perpetrators of abuse can be social care staff, ranging from 0.5% – 54.3% and/or partners or family members who represent 8.9% – 44.1% of perpetrators. Whilst the large discrepancies’ in some of these figures can be attributed to methods of recording other research findings do consistently highlight the same groups of individuals as primary perpetrators.

Research undertaken by Cooper et al (2009) indicated that around half of the family carers’ for those with dementia involved in the study reported having been abusive in some way within the last three months. Reasons for such abuse can be complicated, sometimes it is unintentional and actions may be the result of carer stress and isolation or carers own physical and mental vulnerability, whilst, harm can sometimes be intentional. Whatever the cause the effect on the individual with dementia will result in poor outcomes. The consequences of poor, and abusive, care at home for those whose lives are touched by dementia is not only emotionally detrimental but can also be detrimental to their overall physical and mental health, as well as wasteful in terms of the allocation of scarce resources.

Research into care at home suggests many patients with dementia who are dependent on informal carers’ and family are often the group who end up with inappropriate hospital admissions resulting in costly care (Healthcare at Home, 2011). This research focused on developing understanding of out of hospital dementia care by considering what works and what does not work. It found good professional support services for those living at home were the preferred option by both users and providers of services, identifying four key areas of focus in the organisation and delivery of dementia care at home

1) Workforce organisation, configuration and support
2) Continuity of access and expertise
3) Hospital/residential home admission prevention initiatives
4) Socialisation and support in day to day life (Healthcare at Home, 2011)

These findings are consistent with the national overview of home care provision undertaken by the Care Quality Commission (2013) which identified concerns related to the lack of continuity of care workers, task focused care rather than person centred, how providers supported their staff to work with individuals with dementia, organisational practices in terms of Rota’s and time management, the monitoring of quality and the provision of adequate information to enable carers’ to recognise individuals and families preferences and choices to support them in living life the way they want.

Research by KPMG International (2012) suggests care processes have become imprisoned in the wrong physical infrastructure where health and social care systems swamp existing provision designed for the last century which are not fit to meet the demographic care challenges of the 21st century. Whilst we currently have a strategy to change the structure of service provision via self-directed support, personal budgets and personalisation it is unclear how successful these are. Research from Slasberg et al (2013) suggests self-directed support is failing to deliver either personal budgets or personalisation stating ‘However, it is even more serious than that as it is becoming increasingly evident that it is causing significant damage. This is not only in terms of wasted resources through the growth in bureaucracy that has no value, but also in terms of driving further wedges between practitioners and services users’ (p.103).

The importance of the relationship between those who use services and professional staff is evident in KPMG International’s research. They suggest employee costs are often an easy target for cuts when budgets are tight, however, evidence suggest such an unsophisticated approach to cost cutting actually increases costs in the longer term (KPMG International, 2012) as remaining staff become demoralised as they recognise the care they are providing is actually below standard.

This is highlighted in CQC’s national overview of home care services when they identify care provision has fallen below standard stating ‘What is concerning is that our findings come as no surprise to people, their families and carers’, care workers and providers themselves…’ (2013, p.2). Of equal concern is how do those professionals who may feel disempowered by the current system work with service users and patients to support their empowerment?

There is discontent within dementia services from both those who receive services and those who deliver services, and clear evidence of a link between the well-being of staff and organisational performance (Boorman, 2009).

The simple fact is standards of care are raised when carers, whether formal or informal, feel valued, cared for and supported.

‘Hundreds of thousands’ in need of care denied human rights protection

In a Report published on the 27th Jan 2014, the Joint Committee on Human Rights says that the Care Bill must ensure that all providers of publicly arranged or paid-for social care services are bound by the Human Rights Act.

Dr Hywel Francis MP, the Chair of the Committee, said:

“Whilst acknowledging the measures in the Care Bill which will enhance human rights, my Committee regrets the Government’s reluctance to fill a significant gap in human rights protection for a particularly vulnerable group. The Human Rights Act currently does not protect hundreds of thousands of people who are receiving care which has been publicly arranged or paid for, including care provided in people’s own home and in some cases in residential care homes. The Care Bill which is currently before Parliament should be amended to ensure that this gap in protection is urgently filled.

However, the government has won a vote to block an extention of the Human Rights Act 1998 to people who pay for their own care or use independent home care agencies. Norman Lamb argues people can challenge their provider through their contract. Therefore inequality to protection under the Act will persist.

The Human Rights Act (HRA) 1998 makes it unlawful for public authorities to act in breach of the fundamental rights and freedoms set out in the European Convention on Human Rights. Problems have arisen as original definitions of what constituted a ‘public authority’ were too narrow and excluded private and voluntary sector providers leaving many individuals outside of the protection offered by the Act. This loophole has been partially addressed in the Health and Social Care Act (2008). Section 145 of the act provides that individuals placed in an independent care/nursing home by a local authority are covered by the Human Rights Act 1998. To be covered the service user much be placed in residential accommodation under Part III of the National Assistance Act 1948. However, section 145 does not confer human rights obligations on other independent care providers contacted by the local authority, therefore, independent domiciliary care agencies will continue to fall outside of the Human Rights Act 1998. This amendment did not address the issue of individuals who receive publicly arranged social care in their own home, for example, by personal assistants employed under direct payments or as part of an individual budget. Therefore working in a manner consistent with human rights in an individual’s home is left to the discretion of the provider. The Care Bill provided an opportunity to rectify this.

The need for change was well made by the British Institute of Human Rights in 2008 when it suggested individuals receiving care services in their own homes are vulnerable to abuse. The BIHR argue that ‘those who remain outside of the HRA have no direct legal remedy under the Act against those providing care. Consequently, they are unable to directly challenge these shocking abuses as violations of their human rights’ (p3). The potential impact on the quality of care provided by these individuals is made explicit when the BIHR states ‘of equal importance is the fact that these providers are not given any encouragement to develop a culture of respect for the human rights of their vulnerable service users’ (2008, p.3).

Whilst it would be easy to dismiss such concerns as old news, more recent findings suggest little has changed for some. The Care Quality Commission (CQC) first expressed their concerns regarding unacceptable standards of care provision in individuals own homes in their State of Care report published in 2012. Whilst CQC was able to report on significant improvements within provision in a subsequent report on home care provision in 2013, ‘Not just a number’, it found some care still fell below the standards those who use services have a right to expect, especially for those individuals with complex needs and dementia.

We currently have a two tier system of care provision where some users of services are entitled to have their human rights protected, as conferred under the Human Rights Act 1998, whilst others are excluded in the name of the free market.

Surely recent experiences tells us the protection of those most vulnerable cannot be left to the free will of the market?

Adhering to the spirit of a ‘duty of candour’ is essential for cultural change in the NHS…….

A year on from Francis and the ‘C’ word dominates!

The Care Bill is at committee stage at the time of writing, at its 10th sitting. 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 and organisation to speak up if they identify moderate harm may then prevent serious injury, or even death?

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.

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.

I am currently undertaking some developmental work around dementia care at Plymouth University, exploring the relationship between thresholds and prevention in terms of Safeguarding Older People amongst other things, and came across a quote this week which I found 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)

Hmmmm……….

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.

A new year, but the same old story…..we need to change the narrative around care and the NHS

The Guardians front page informs us, yet again, the ‘soaring cost of long-term care threatens to ‘overwhelm’ the NHS. This follows hot on the heels of 3 years of dire pronouncements from Cameron and co on the viability and future of the NHS. The inevitable demise of the NHS is linked most often to the ‘demographic time bomb’, a phrase which succinctly stigmatises older people for ageing and justifies austerity measures and no end of initiatives from policy makers to introduce changes to meet ideological imperatives, rather than actually build on what has been a succesful economical healthcare system for over 60 years.

It’s time to drop the negative narrative which abounds whenever the NHS is discussed and embrace the positive contribution it makes to all our lives. Ministers and policy makers across all parties are not providing new and innovative thinking on the future of the NHS. Yes, Cameron, Osborne, Hunt, Gove and co really do think they are putting forward radical new plans, which appear to be centred around the ‘tyranny’ of choice and deeper privatisation of traditional public sector provision. This is not new , it’s a rehash of the same old neoliberal dogma beloved of Thatcher and Blair; transform health care into a product, and patients into consumers, ‘codify’ practice to make it ‘professional’ and ‘commoditize’ care to make it a deliverable ‘product’. Putting such narratives around practise makes problems in the NHS 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.

Many in government scream ‘consumer choice’ as if it’s the answer to every woe. However, for many the reality of choice is it’s a huge amount of hassle and the ‘choice’ is between equally dismal providers when all anyone really wants is one provider to provide a good service. My belief is the NHS is more than able to achieve this, yes reform is needed, however, the NHS is not just any old healthcare system, it is an expression of our values, our belief in a social institution based on equality and collectivity. It is also a proven alternative to free market competition. Lets not forget the reason for the existence of the NHS, it was founded on the failure of the free markets in a period of financial austerity – a time of new government and new political agendas.

Bevan said ‘Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community’

The NHS is not an indulgence, it tells the world something about us as a nation, it tells us something about ourselves. Reform is required, certainly, but please, lets just try to make sure reform builds on the success of the NHS, not just the narrative of austerity. We as a nation need to ‘own’ the NHS in our collective conscience, otherwise we will lose it to the medical equivalents of the energy companies and financial sector.

Is that what we really want?

How to develop a whole systems approach to Dementia care…

Richard Ashcroft makes some pertinent comments following the G8 dementia summit last week when David Cameron and Jeremy Hunt’s use of language took a ‘President Bush’ turn. We are now going to win the war on dementia by “fighting back” to combat the dementia “explosion” and subsequent dementia “time bomb” awaiting us. All well and good, however, talk of improving dementia services by politicians is a lot cheaper than bringing about real change, real change requires investment and a comprehensive strategy.

Some commentators are looking to France for inspiration. The French launched their dementia strategy in 2008 and are already beginning to reap rewards. One reason for this is a commitment to fund research, 200 million euros worth. Compare this to the UK, £26.6 million in 2010 (one eighth of that spent on cancer) and we can see we have a lot of catching up to do. However, it’s not that the UK is not spending on dementia. Estimates suggest dementia costs the UK £23 billion per year. Possibly the problem lies in how we spend the money. If we cast our eyes toward another European counterpart, the Netherlands, we can see how re-structuring care provision differently can work. ‘Complete Care’ provides a model we might like to consider, where district nurses work in teams in specific localities in providing care. There is no such thing as a 15 minute ‘task centred’ visit, instead carers can spend up to 2 hours on a visit, beginning with making a cup of tea and a having chat. This model has been highly successful in delivering person centred dementia care in the community which is high on quality yet costs less than our current approach.

However, it’s not just about health and social care services. Wider society also has a role to play,
and it is to be welcomed that big business, such as Lloyds’ Bank, is making a commitment to develop ‘a frontline force’ educated to recognise the effects of dementia. The Telegraph reports bank staff are to “look for dementia”, with Sir Win Bischoff suggesting he wants the bank to become “a dementia friendly bank”.

Great, but it is still not enough, we need ‘dementia friendly banking’. The abolition of cheques, closure of local branches, centralised call centres all over the world and the ever increasing need to remember a plethora of pin numbers and passwords is the antithesis to “dementia friendly banking”.

Arguably, the governments’ dementia strategy would also benefit from taking a much broader view on how to improve the lives of those affected by dementia. For example our biggest assets are the networks of support around us. These help reduce social isolation, and subsequently reduce the high levels of depression which often co-exist with a diagnosis of dementia. Family friendly work policies, such as affordable child care, flexible working and a decent wage would do much to support the inter-generational family approach to dementia care that many families are currently struggling to maintain. A dementia friendly housing strategy could make a significant difference, firstly in terms of provision for those with a diagnosis of dementia, and secondly, by enabling families to buy affordable homes in areas where they already have family networks. Instead of having to move away from older relatives, due to lack of job prospects and unaffordable housing costs. Both of these might then allow resources to be directed to those without networks of support. Arguably to “combat” the negative effects of dementia we need to take a whole systems approach.

Government and communities working together is vital to the future of all those touched by dementia. “Fighting” talk is all well and good but will amount to nought without a comprehensive strategy and adequate resources to support it’s delivery.

Improving care for older people is about building a relationship based system of care…..

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 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’, shift patterns etc. The cost of such a reorganisation could be off set by the impending spending by the NHS on privatisation and on commissioning costly training programmes. Yes training is always required but please focus on key people and problems. (The NHS sadly takes the ‘hospital gown’ approach to training – designed for everyone and fits no one!)

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

It is time to give professional carers the support to do the job they thought they were training for.