Category Archives: NHS Reform

‘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.

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

As CQC yet again bring to government and wider societies attention the poor levels of care some older people experience, one wonders will we ever get to grips with this issue?

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

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

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

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

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

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

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

Older people’s experience of ageing in the UK can be improved, and it is all of our responsibility to try and achieve this.  However, we first need a coherent strategy to bring about the change desired by many who work with older people.  Government in the UK tend to address issues associated with an ageing population in individual ‘silos’.  Research from Europe suggests those countries taking a joined up approach, where government consider how factors such as income, health, age discrimination and inclusion interact, the more successful policy approaches are likely to be to improve the experience of ageing.

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

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
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I’m afraid the type of ‘care’ received by those at Orchard View is not confined to Orchard View.

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

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

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

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

Older people’s experience of ageing in the UK can be improved, and it is all of our responsibility to try to achieve this. However, we first need a coherent strategy to bring about the change desired by many who work with older people. Government in the UK tend to address issues associated with an ageing population in individual ‘silos’. Research from Europe suggests those countries taking a joined up approach where government consider how factors such as income, health, age discrimination and inclusion interact , the more successful policy approaches are likely to be to improve the experience of ageing. However, any policy needs first to have a strong ethical foundation founded on a clear understanding of, and agreement to, promoting older people’s equality and human rights.

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

‘For a while we may pause to express outrage. But we then move on to the urgent business of our daily lives. Spot checks and hit squads may arrest the worst practice…but they will not do much about a society that has hardened its heart against the elderly’

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

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

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

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.

 

 

 

 

 

 

 

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

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

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

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

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

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

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

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

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

I really do not want to lose it.