Category Archives: Older People

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.

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

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

So what does Clause 80 actually say about the level at which healthcare service providers need to adhere to a duty of candour.  Is it ‘moderate harm’ and/or ‘serious injury?

(See the blog below that started this discussion)

Minutes from CQC’s public board meeting on the 22nd January 2014 state David Behan gave evidence to the ‘Duty of Candour’ review on the 9th January, followed up by a letter on the 16th January 2014. At that review David Behan expressed CQC’s view that the threshold should be set to include death, serous injury and moderate harm, to be consistent with the guidance published in the ‘Being Open Framework‘ and CQC’s interpretation of the term ‘serious’ in Robert Francis’ recommendations.

On the 23rd January 2014 the House of Commons Public Bill Committee published its’ latest amendments. One related to the ‘duty of candour’. Clause 80 on page 72, line 20, now reads

‘The duty of candour specified in regulations made under this section shall require
healthcare service providers who believe or suspect that treatment or care
provided or contributed to death or serious injury to a patient…..’

It appears the committee chose to ignore CQC’s views as ‘moderate harm’ is not included.

From my perspective this makes little sense and does not demonstrate an understanding of the potential of thresholds to provide not just openness in an organisation but also a preventative strategy. Surely enabling individuals to speak up if they identify any harm at all may then prevent poor, or abusive, practice developing into serious injury, or even death.  The fact that policies and legislation appear to be allowing mild (or even moderate) harm to occur surely will contribute to developing the culture we are seeking to eliminate.

Whilst a duty of candour is welcomed , I wonder now is the threshold set too high to really change the ‘culture’ Robert Francis identified as contributing to poor standards of care at Mid Staffordshire.

The latest overview of adult social care in England from the National Audit Office again highlights problems that exist when it clearly states

Safeguarding vulnerable adults from abuse and neglect remains a major risk throughout the sector…….In 2012-2013, 36% of safeguaridng referrals were about alleged abuses by social care or health workers.’

The report also suggests a rise in incidents of abuse could be related to systematic cuts across the sector.  If this is the case the system will need more than a duty of candour and an emphasis on whistle blowing to make a difference.

Thresholds can be effective as a preventative mechanism, but not if they are set too high or used as an administrative convenience to ensure the number of reports are kept at a manageable level for the organisation, which is surely counter productive to changing the ‘culture’ of any failing provider of care.  In my view to really change cultures within organisations we need to take a zero tolerance approach to harm, whether its mild, moderate or severe, it has no place in health and social care.

I came across a quote this week which I find very pertinent in regards to how government policy/legislation translates into frontline practice

‘To assume that an official plan and its implementation in practice are the same is to fly in the face of facts. Invariably to some degree, the plan as put into practice is modified, twisted and reshaped, and take on unforeseen accretions’ (Herbert Blumer)

Hmmmm……….

To change the current culture within some care provider organisations will require far more than the Care Bills ‘Duty of Candour’, it will require 100% commitment from all involved to adhere to not just the letter of the law but the spirit. I do believe this is a positive step forward, however, Government needs to take an active lead, and listen to people like David Behan, to ensure it is implemented to change organisational priorities at the highest level, otherwise the ‘duty of candour’ risks becoming just more empty words and another box to tick.

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

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

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

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

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

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

Complete Care: a model in practice – Buurtzorg Nederland

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

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

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

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

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

How it led to productivity improvement

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

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

Key results

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Care Bill is at committee stage at the time of writing, at its 10th sitting. Minutes from CQC’s public board meeting on the 22nd January 2014 state David Behan gave evidence to the ‘Duty of Candour’ review on the 9th January, followed up by a letter on the 16th January 2014. At that review David Behan expressed CQC’s view that the threshold should be set to include death, serous injury and moderate harm, to be consistent with the guidance published in the ‘Being Open Framework‘ and CQC’s interpretation of the term ‘serious’ in Robert Francis’ recommendations.

On the 23rd January 2014 the House of Commons Public Bill Committee published its’ latest amendments. One related to the ‘duty of candour’. Clause 80 on page 72, line 20, now reads

‘The duty of candour specified in regulations made under this section shall require
healthcare service providers who believe or suspect that treatment or care
provided or contributed to death or serious injury to a patient…..’

It appears the committee chose to ignore CQC’s views as ‘moderate harm’ is not included.

From my perspective this makes little sense and does not demonstrate an understanding of the potential of thresholds to provide not just openness in an organisation but also a preventative strategy. Surely enabling individuals and organisation to speak up if they identify moderate harm may then prevent serious injury, or even death?

Whilst a duty of candour is welcomed , I wonder now is the threshold set too high to really change the ‘culture’ Robert Francis identified as contributing to poor standards of care at Mid Staffordshire.

Thresholds can be effective as a preventative mechanism, but not if they are set too high or used as an administrative convenience to ensure the number of reports are kept at a manageable level for the organisation, which is surely counter productive to changing the ‘culture’ of any failing provider of care.

I am currently undertaking some developmental work around dementia care at Plymouth University, exploring the relationship between thresholds and prevention in terms of Safeguarding Older People amongst other things, and came across a quote this week which I found very pertinent in regards to how government policy/legislation translates into frontline practice

‘To assume that an official plan and its implementation in practice are the same is to fly in the face of facts. Invariably to some degree, the plan as put into practice is modified, twisted and reshaped, and take on unforeseen accretions’ (Herbert Blumer)

Hmmmm……….

To change the current culture within some care provider organisations will require far more than the Care Bills ‘Duty of Candour’, it will require 100% commitment from all involved to adhere to not just the letter of the law but the spirit. I do believe this is a positive step forward, however, Government needs to take an active lead, and listen to people like David Behan, to ensure it is implemented to change organisational priorities at the highest level, otherwise the ‘duty of candour’ risks becoming just more empty words and another box to tick.

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

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

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

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

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

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

Is that what we really want?

How to develop a whole systems approach to Dementia care…

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

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

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

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

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

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

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

More headlines confirm what we must all know by now, surely. The care for some older people in the UK today leaves much to be desired.

Old age must now be more feared than death!

Ultimately good care is about the relationship between the carer and cared for, and that involves the development of an emotional attachment that goes beyond our current ‘task’ focused system. Relationships are, in my opinion, the missing link in delivering compassionate care.

Traditionally successive governments have tried to ‘codify’ practice to make it ‘professional’ and ‘commoditized’ care to make it a deliverable ‘product’. Putting such frameworks around practise makes problems in the care system easier to talk about and resolve, i.e we need more training for carers, more training for leaders and managers, different providers, a mixed economy of care etc. However, what we are not talking about is relationship based care focused on supporting the emotional aspects of care provision.

There is no doubt in my mind caring for older people can be difficult,I’ve written before on ‘social defences‘ used in professional practice to help carers protect themselves from the emotional and psychological stress they can experience when caring for vulnerable people. Our organisation and delivery of care services facilitates the maintenance of such social defences by reducing care into individualised elements where a succession of carers carry out particular tasks, and so we lose sight of the person. However, by developing a system designed to keep relationships ‘professional’ we have lost the key ingredient to delivering compassionate care. For those on the front line this must lead to very limited levels of job satisfaction and feeling one has made a difference to someone’s life, which is often the primary reason individuals choose to enter the caring profession.

In the Netherlands they use a model called ‘complete care‘ in the care of older people. This involves developing relationships with people, not carrying out care tasks on a patient.

Such an approach can cost more, in the short-term, but in the longer term the potential of fewer hospital admissions, reduced levels of depression and isolation of older people, along with lower levels of stress and burn out of carers, resulting in sick leave and expensive locum/bank nurse cover, must work out far more cost efficient (but more importantly ethical).

To achieve relationship based care will require a reorganisation of systems and structures currently in place, for example work rotas’, shift patterns etc. The cost of such a reorganisation could be off set by the impending spending by the NHS on privatisation and on commissioning costly training programmes. Yes training is always required but please focus on key people and problems. (The NHS sadly takes the ‘hospital gown’ approach to training – designed for everyone and fits no one!)

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

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

Will welfare reform result in a ‘two nation’ society?

As David Cameron makes a U-turn on cigarette packaging and George Osborne finally understands government does sometimes need to intervene in the free market will others follow?

Our ability as an individual to stand against the power of big business is limited to say the least, however, some on the Tory right still expect individuals to form a ‘government of self’ and develop individualised systems of social protection (via ‘big society’). Such personal independence is beyond the reach of many.

However, David Cameron and George Osborne appear to have finally grasped that for ‘big society’ to truly thrive an active state is a necessity.

Commentators are suggesting Osborne is playing social democratic catch up on pay-day loans as the Conservatives have realised Ed Miliband has struck a chord with voters by focusing on the way markets are rigged against consumers.

Yet the prevailing ideology of the right is so strong it still continues to push the contracting out of public provision of services and privatisation, whilst resisting calls for regulation.

Such a singular approach does a disservice to us all. Some on the right adhere to a narrow vision of the ‘good life’, where the promise to those families who work hard, and are deserving, is that they can send their children to the ‘best’ schools (either private or ‘free’) whilst accessing privatised pension and healthcare schemes. However, those same ministers forget to mention how your future can be wiped out by an under regulated free market (think RBS and LLoyds Bank!). Meanwhile the rest of society, the undeserving, can live in a world marked by financial insecurity, mediocre education, rationed healthcare and an impoverished old age.

Economists have already christened such a scenario as the ‘dual economy’; two societies who live side by side, but hardly knowing one another, unable to imagine what life is like for one another. Conservative Prime Minister, Benjamin Disraeli, wrote of such a scenario in 1845, referring to ‘the two nations’

‘Two nations; between whom there is no intercourse and no sympathy; who are ignorant of each other’s habits, thoughts, and feelings, as if they were dwellers in different zones, or inhabitants of different planets; who are formed by a different breeding, are fed by a different food, are ordered by different manners, and are not governed by the same laws: the rich and the poor’

An alternative approach could be to try to close the gap between the dual economies by supporting a sense of shared responsibility between individuals, society and government. In this relationship government would protect the citizens it has been elected to serve from the abuse of power by the free market.

Individuals feel vulnerable and powerless because they are vulnerable and powerless. Is the average user of pay-day loans able to challenge extortionate interest rates on their own? Am I able to challenge the power of the energy companies as another cold winter approaches? Can any of us challenge the power of the financial industry at an individual level?

Many on the Tory right will scream ‘consumer choice’ as if it’s the answer to every woe, however, will changing providers of whatever service it might be really make a difference. I fear not, and that is why I want a government of politicians that understands where many in this country feel they are today, powerless, abandoned and hopeless.

That is not a good foundation from which to build our collective future. Control of one’s own destiny requires more than the fallacy of individual consumer choice in a free market economy, it requires an active and supportive state focused on the distribution of wealth, and the redistribution of wealth through the tax and benefits system along with regulation of key industries, such as the financial and energy sectors.

Well done Mr cameron and Mr Osborne, you are at last beginning to move in the right direction.