Category Archives: Learning

‘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 and protected by family and the institutions that make up wider society?

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.

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Social workers to learn how to earn ‘public trust’ from Politicians … Really!

Politicians to lead task force that will guide social workers in earning back public trust …… Really!

Forgive me, I almost choked on my coffee whilst reading a piece entitled ‘Social work needs to earn back public trust‘ on the Guardians Social Care Network.

The government has set up a task force to guide the social work profession on how to earn public trust. A stellar line up of politicians which include Michael Gove, Theresa May and Iain Duncan Smith, those well-known advocates of social work and those they work with. When did Politicians earn the right to pontificate on how a profession might earn public trust I wonder? I must have missed this whilst reading about the numerous promises this government has reneged on since the general election, and which clearly must have enhanced the publics trust in them …..

I am a tad perturbed the government seems to have ditched the comprehensive Munro Review, which provided a very balanced approach to reform that focused not just on social workers and their education but also the political and organisational contexts which also shape social work practice, and arguably go some way to explaining the current problems that bedevil the profession.

The piece suggests the new task force will focus on robust assessment of qualifying social workers involving employers, academics and those who use services …. ummm sorry to mention this, but I do not know of a qualifying social work programme that does not already do this. Social work programmes across the land expect students to pass a number of academic theory assignments and law based exams alongside practice based assessments which involve numerous observations of practice and a plethora of meetings and reports provided by employers, those who use services and academics commenting on the student’s performance and fitness for practice over a 2 or 3 year period.

The article goes onto suggest the social work profession needs to ask itself ‘why the college failed’ and ‘why the public mood’ supports changes in the law where social workers can be prosecuted for wilful neglect. In response to the first question, from my perspective, the reason I did not join the college is that I felt it represented the voice of the government not social workers. To the second comment I would hazard a guess that 30 years of inaccurate reporting in the media, oft-repeated by politicians, and flawed serious case reviews have played a part in the general publics perception of the profession.

Just read the book by Prof Ray Jones which looks at why politicians and the media were so keen to blame and vilify social workers and Sharon Shoesmith, Haringey’s then children’s services in the case of Baby P, to gain some insight into why the profession is held in such low esteem by the public, aided and abetted by the media and government I would suggest.

I was surprised the piece did not mention the problems with inadequate IT systems, how social work now operates in a call centre environment where workers hot desk and have limited contact with their peers, or how workers work in their cars, making phone calls in lay-bys on their mobiles because they cannot access secure office space. Nor does it mention the failing court system, or the outmoded model of fostering and adoption which is no longer fit for purpose and in many cases just adds to the trauma of already traumatised children’s lives, it fails to mention the knock on effect of welfare reform, the lack of affordable good quality housing or the deterioration in mental health support services to both adults and children, it does not dig deep into the effect on frontline service provision of high levels of stress related sickness and social work vacancies, or the impact of temporary agency workers in providing important continuity when working with children and families.

I have worked with hundreds of hard-working social work students, many of whom are accruing debts of up to £40,000 to become a social worker in children and family services. Despite public and government distrust, and potential imprisonment, they are committed to being the best social workers they can possibly be …. because of this I believe in social work. Time for another coffee I think …..

The ‘McDonaldlisation’ approach to reform in health and social care is as unhealthy as a triple whatever with cheese and fries….

A couple of years ago a social work student suggested government policy wanted to make us all ‘beige’. I know what she means.

Of course commentators might suggest we are seeing a radical shift in emphasis across health and social care under the coalition resulting in an ideologically driven reshaping in our understanding of legitimate nature, and limits, of the state in individuals lives. However, how radical is an agenda premised on ‘consumerism’ and ‘consumer choice’? Policy designed to create a society of depoliticised consumers is hardly going to address the very real issues around equality and social justice that exist in Britain today.

In ‘Cameron & Co dream world’ delegating care provision to corporate providers is really about delegating power to places where there is limited protection for consumers, ‘choice’ takes precedence over ‘voice’. The McDonaldlisation of care is really a watered down version of consumer choice, and some believe by engaging with it you are living the neoliberal dream.

I have nothing against beige, or McDonalds, really, but a bit of colour and a change of diet would not go amiss in the current debates around the future of health and social care, and social work is well placed to provide the colour needed to create greater vibrancy in how we meet future challenges.

As government concerns itself with winning the next election we need to keep the debate going, we need tasty morsels to stimulate a much better quality of debate and deeper thinking about how to address current, and future, issues.

‘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
Follow us: @MailOnline on Twitter | DailyMail on Facebook

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.

 

 

 

 

 

 

 

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.