Covid19 & the care of older people: We need an ethical approach by Government

The lack of care and support for older people in care settings during Covid19 has shone a very bright spotlight on the value Government places on older peoples lives. Arguably, the transformation of ‘care’ into a commodity that dominates current health and social care reform has drawn attention away from saving lives to prioritise saving the economy. This raises issues for many in the sector, not least is it wise to continue to build a system of care provision with no clear ethical or ideological foundation outside of that of over valueing the economy and free market, whilst undervaluing older people and the public sector in the provision of health and social care?

I believe as a society we need greater expectations of the quality of our care system, and Government needs more ambition in developing great care for older people, with a more ethical and strategic approach to make real improvements.

Developing ethically sustainable care for older people

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

Need, capabilities and the ‘good life’

A first step in developing ethically sustainable care involves reframing our understanding of ‘need’. Need in a health and social care context is often used to refer to a function to be fulfilled, i.e. nutrition, physical care, or in the context of Covid19 any bed as long as it is not an NHS bed. However, we should also view older peoples’ needs in terms of equality, respect, compassion and justice.

The failure to distinguish between different types of need has led to limiting Governments understanding of how to care for older people, and has subsequently influenced older peoples experience of ‘care’. Amartya Sens’ concept of ‘capabilities’ provides an alternative long term approach. Sen is concerned in this model with identifying what individuals require to flourish and live a ‘good life’. In this model it is recognised older people require different capabilities to flourish, depending on their personal circumstances and the community they live in, whether that community is within an in-patient/residential setting or in the wider community. Successive governments’ appear to believe an expansion in a consumer culture within health and social care provision is the only route to a ‘good life’ for older people, as it enables individuals to increase choice and control by becoming consumers of care, rather than receivers of care.

From surviving to flourishing

Yet many older people are clearly not flourishing in a culture that defines the good life in terms of their ability to engage as a ‘customer of care’ or as a body to be moved to free a bed up for someone more deserving of life during the pandemic. A more useful way of thinking about this, from an ethical perspective, links Sen’s idea of capabilities and Aristotle’s vision of the ‘good life’. From this perspective achieving quality of life is central, rather than just meeting economic needs. In other words it is not just about the economy and achieving an ‘adequate’ notion of well-being but about the opportunities available to the individual which will enable them to develop their full potential, whatever that might mean for that individual.

This approach moves beyond ensuring older people have the ability to flourish to consider whether they are actually flourishing. Commentators suggest there are five areas in which older people need to flourish to live a good life, regardless of where they live. These are: belonging to a family; belonging to a community; having access to material goods for sustenance, adornment and play; living in a healthy environment; and having a spiritual dimension to life. Arguably the commissioning and delivery of service provision based on achieving these five areas might enable older people to receive care that is both compassionate and dignified.

The way forward

Conceptions of what constitutes a good life are varied, however, within health and social care provision it is prudent to assume a good life involves at a minimum care provision that is not abusive to older people.

Within the public sector the organisation and delivery of care is structured to focus on the meeting of targets rather than enabling an individual to flourish. The health and social care sector is arguably over managed and under led. In the private sector it could be argued a free market economy contains structural incentives for business to pursue a notion of the good life that supports the sale of a narrow range of care ‘products’, whilst there are not mechanisms in place to ensure the market operates within a clear ethical framework outside of the profit ethos.

By not actively endorsing care provision from an ethical stand point the government and regulatory bodies may actually be unwittingly aiding the abuse of the most vulnerable within the care system. A shift in focus from human need to human flourishing has already begun with the development of the personalisation agenda and emphasis on voice, choice and control however, this agenda has been overshadowed by a managerial approach to consumerism and consumption in a low paid, low status care system and this is undermining the ability of the care system to develop ethically.

Markets versus Values

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

 

Social Work: has there ever been a ‘golden age’ for older people when they were valued by Government and wider society?

As Amnesty International challenge the UK Government actions toward older people in care homes during Covid19, I wonder 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 (2002) suggests not, stating whilst traditionally family harmony has been assumed by governments in the care of older people, reinforced by philosophical traditions and public policy, the abuse and maltreatment of older people is actually a timeless phenomenon across the developed and developing world.

‘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’ (WHO,2002;p125).

Representations of old age and societal responses to older people have differed over time, with old age being viewed as both negative and positive by different societies. In ancient Greece old age was portrayed as sad (Thane, 2004) with Minois (1989) arguing the Greeks love of beauty marginalised the old, stating ‘Western history from antiquity to the Renaissance is marked by fluctuations in the social and political role of the old…the general tendency however is toward degradation’ (p.7). Although Thane (2004) suggests the reality was far more complex with the portrayal of older people in the classics as ‘both pejorative and complimentary (p.32), although this usually referred to high status men and comparisons are culturally as well as temporally nuanced. For Plato reverence toward, and ‘the authority of, older people was a guarantee of social and political stability’ (Thane, 2004, p 36), whereas Aristotle disagreed with such positive images.

Although both Plato and Aristotle agreed social stability, in a hierarchical society, should be the main goal of welfare provision (George,2010). 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, suggesting older people need to strive throughout their life to remain intellectually and physically able.

Arguably, this belief still underpins care policy today for older people.

However, it is difficult to determine accurately how such representations of old age influenced support and care for older people throughout this period, although, more recent history provides some insight into the relationship between the state, older people and their care and protection.

Perceptions of ageing, in the 17th and 18th centuries, was also not homogenous; however, two variables were identified as constant in terms of vulnerability to abuse and maltreatment; gender and participation in the economy.

Firstly, the relative absence of positive images of older women from the discourse on ageing with Thane (2004) stating ‘…..with the coming of the Renaissance, youth – associated with rebirth and creativity- was celebrated and hostility to old people pervaded European culture, creating a literature of lamentation and invective about old age, directed especially against old women‘ (p56).

Secondly, older people’s position in society has been linked to their ability to participate in society from an economic perspective, especially in terms of activity in paid employment. Where older people have been unable to participate economically 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, Stone (1977) suggests post industrial revolution

“Another victim of change was the aged…the old did not merely lose power as the patriarchs of the lineage, they also lost respect. The rise of the alms-houses, and institutionalised poor-relief, suggests that their children were increasingly shedding responsibility for their support and transferring it to the community.” (403-404).

Historically, Thane (2004) argues, this may have been due to families own depths of poverty, rather than lack of incentive or a shedding of responsibility.

Such changes though did occur and a more coherent and consistent approach to supporting older people in the 19th and 20th centuries was required, resulting in the English Poor Law which George (2010) suggests was a draconian approach founded on Locke’s view of the deserving and undeserving poor and the role of welfare provision. Although, the focus was on relieving poverty rather than concerns regarding the abuse or maltreatment of older people.

The care of older people became more of a focus for government due to the weight of numbers, increased by advances made by the medical profession in the treatment of older people, and following the introduction of a national insurance system and the National Health Service in 1948. The responsibility of the emerging welfare state was extended to include a more formal approach to ‘social protection’ where the state played an active role. This provided the foundations for the current system not just in terms of actual provision but also from an ideological perspective in definingthe role of the state in society.

The abuse and maltreatment of older people was not something government identified 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 abuse 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, lacking essential items of clothing, bedding or household equipment as families used the older persons entitlement, such as clothing coupons, for their own personal use (Thane 2004).

Whether this constituted abuse is not clear as many families who cared for older relatives were often living in poverty themselves and Thane (2004) suggests older people 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 older people by both younger and older people themselves.

Whilst there no clear evidence of abusive acts being perpetrated against older people in the community Peter Townsend’s landmark investigation into long stay institutional care in the 1950’s , entitled The Last Refuge, provides an insight into the experiences of some older people receiving care. The study took a qualitative approach using in-depth interviews. One of the interviews recorded was with a matron of a small private residential home in Greater London, which Townsend suggests was by far the worst home he had visited, his commentary does not discuss the issues raised in terms of ‘abuse’ or ‘maltreatment’. However, if, as a researcher, I were to hear such an account today I would make a referral to the local authority and the regulatory body for residential care, the Care Quality Commission, as the interview is clearly describing ‘abuse’ as defined in contemporary policy related to safeguarding adults at risk of harm today.

This suggests the abuse and maltreatment of older people, as an issue that is recognised (named) requiring a response from the statutory sector, is something that has developed over time.

Given recent events during Covid19, and Amnesty International analysis, do you feel older people are valued and respected in the Uk? What is informing your thoughts and analysis? Useful Reading/Refs https://www.amnesty.org.uk/press-releases/uk-older-people-care-homes-abandoned-die-amid-government-failures-during-coronavirus https://books.google.co.uk/books/about/Major_Thinkers_in_Welfare.html?id=iJ6J8o-CfR0C&redir_esc=y

https://academic.oup.com/sw/article-abstract/9/4/117/1861290?redirectedFrom=fulltext https://www.who.int/ageing/publications/elder_abuse/en/

Older people still dominate Safeguarding practice, will this ever change?

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

Latest figures in respect of Safeguarding referrals under s42 of the Care Act 2014 found for the 2016-17 reporting year there were 109,145 individuals that were the subject to a safeguarding enquiry, an increase of 6 per cent on 2015-16.  Of these individuals at risk, 63 per cent were aged 65 or over and two thirds of these were over 74 yrs of age.

This will come as no surprise to many within the health and social care professions, and indeed many feel the numbers could possibly be an underestimate given previous statistics. For example a House of Commons report on elder abuse published in 2004 stated

Other witnesses also commented on the estimate of “half a million” older people abused at any one time. Both Bill McClimont, Chair of the UK Home Care Association, and Sue Fiennes, National Lead for Older Peoples Services of ADSS, suggested that the figure was an under-estimate. Mr McClimont commented that it was likely that there was greater reporting in the part of the care sector that was currently regulated. As regulation spread to other parts of care, detection and reporting were likely to rise.

This may well be accurate when we consider the abuse of older people is a global issue.

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 has accumulated 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  argues, 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, both nationally and internationally.

How will we ever change this I wonder?

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

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

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

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

Developing ethically sustainable care for older people

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

Need, capabilities and the ‘good life’

A first step in developing ethically sustainable care involves reframing our understanding of ‘need’. Need in a health and social care context is often used to refer to a function to be fulfilled, i.e. nutrition, physical care. Such needs are viewed as a necessary condition for survival. However, we should also view older peoples’ needs in terms of security, respect, love and justice.

The failure to distinguish between different types of need has led to limiting our understanding of how to care for older people, and has subsequently influenced how service provision has developed. Amartya Sens’ concept of ‘capabilities’ provides an alternative approach Sen is concerned in this model with identifying what individuals require to flourish and live a ‘good life’. In this model it is recognised older people require different capabilities to flourish, depending on their personal circumstances and the community they live in, whether that community is within an in-patient/residential setting or in the wider community. Successive governments’ appear to believe an expansion in a consumer culture within health and social care provision is the only route to a ‘good life’ for older people, as it enables individuals to increase choice and control by becoming consumers of care, rather than receivers of care.

Yet many older people are clearly not flourishing in a culture that defines the good life in terms of their ability to engage as a ‘customer of care’. A more useful way of thinking about this, from an ethical perspective, links Sen’s idea of capabilities and Aristotle’s vision of the ‘good life’. From this perspective achieving quality of life is central, rather than just meeting physical needs. In other words it is not just about achieving an ‘average’ notion of well-being but about the opportunities available to the individual which will enable them to develop their full potential, whatever that might mean for that individual.

This approach moves beyond ensuring older people have the ability to flourish to consider whether they are actually flourishing. Commentators suggest there are five areas in which older people need to flourish to live a good life, regardless of where they live. These are: belonging to a family; belonging to a community; having access to material goods for sustenance, adornment and play; living in a healthy environment; and having a spiritual dimension to life. Arguably the commissioning and delivery of service provision based on achieving these five areas might enable older people to receive care that is both compassionate and dignified.

The way forward

Conceptions of what constitutes a good life are varied, however, within health and social care provision it is prudent to assume a good life involves at a minimum care provision that is not abusive to older people.

Within the public sector the organisation and delivery of care is structured to focus on the meeting of targets rather than enabling an individual to flourish. The health and social care sector is arguably over managed and under led. In the private sector it could be argued a free market economy contains structural incentives for business to pursue a notion of the good life that supports the sale of a narrow range of care ‘products’, whilst there are not mechanisms in place to ensure the market operates within a clear ethical framework outside of the profit ethos.

By not actively endorsing care provision from an ethical stand point the government and regulatory bodies may actually be unwittingly aiding the abuse of the most vulnerable within the care system. A shift in focus from human need to human flourishing has already begun with the development of the personalisation agenda and emphasis on voice, choice and control however, this agenda has been overshadowed by a managerial approach to consumerism and consumption in a low paid, low status care system and this is undermining the ability of the care system to develop ethically.

Markets versus Values

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

 

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

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

This latest report suggests

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

This is not just poor care but adult abuse.

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

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

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

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

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

From a European perspective research findings suggest older people’s experience of ageing in the UK falls behind that of many of its European counterparts, with the UK performing most poorly on indicators such as income, poverty and age discrimination (WRVS,210). The report states the UK faces multiple challenges in providing older people with a positive experience of ageing, scoring poorly (although not always the worst) across every theme of the matrix (WRVS, 2012, p.8).

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

Successive Governments in the UK tend to address issues associated with care and an ageing population in individual ‘silos’.  Research from Europe suggests those countries taking a joined up approach, where government consider how factors such as income, health, age discrimination and inclusion interact develop more successful policy approaches, which improve our care provision and the experience of ageing.

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

Should care be a commodity to be profited from?

 

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

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

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

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

 

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

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

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

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

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

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

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

The King’s Fund  has highlighted what many in the sector already know, the free market is failing stating

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

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

However, the effect of the failure of the free market and neoliberal ideology extends beyond money,   the real effect of failing markets rests upon the poorest and most marginalised in society, like the  residents of Grenfell Tower and now those older people who have lost their lives due to Covid19, abandoned by government in private care homes.

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

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

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

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

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

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.