Tag Archives: compassion

It’s time to stop meeting needs and start focusing on developing a ‘good life’ for those who use health and social care services…..

The funding of the health and social care system is currently at the forefront of policy and is overshadowing any understanding of the values and ethics that should underpin care provision, to the extent a consumerist based system is viewed as superior simply because patients and service users become purchasers. However, evidence would seem to suggest this is not always the case. This raises the question for me is it possible to build a system of health and social care provision that is both affordable and based on values such as dignity and respect?

Developing a sustainable care system

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 important elements, the need to support those currently requiring care without compromising the future of the care system which is able to accommodate a growing number of users within budget constraints.

Need, capabilities and the ‘good life’

A first step might be to reframe our understanding of ‘need’. The concept of human need is a relatively new one, and is used in different ways. 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 might be viewed as a necessary condition for survival. However, we can also view need in terms of security, respect, love and justice.

The failure to expand our understanding of need has arguably led to limiting our vision of human needs, and subsequently influenced how service provision has developed across a number of patient/service user groups i.e. older people, learning disability. A more useful way of thinking about need, from a values perspective, is provided by Amartya Sen with his concept of ‘capabilities’. Sen is concerned with identifying what individuals require to flourish and live a ‘good life’. For Sen whilst some capabilities depend on the fundamental provision of the basic elements of life i.e. nutrition, warmth and shelter, others require particular kinds of freedoms and social relationships. In this model it is recognised different 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 lived in the wider community.

While the ‘good life’ is to some extent subjective it is also socially defined. In modern western societies it is largely defined in material terms as our ability to be consumers. A consumer culture within health and social care provision appears to be the route to a ‘good life’ as it enables individuals to increase choice and control by becoming consumers of care, rather than receivers of care. In this context care is viewed as a commodity, to be bought and sold. Thus enabling the individual to pursue their own version of the ‘good life’. Yet many people who use health and social care services are unable to flourish in a culture that defines the good life in terms of their ability to engage in a consumerist model of care.

A more useful way of thinking about this from an ethical perspective links Sen’s idea of capabilities back to Aristotle’s idea of the ‘good life’, where the good life was a life of happiness based on the exercise of rational capacity and moral virtue, but also requiring material means and relationships with family and friends. These were the essentials of a good life. Martha Nussbaum has expanded the specific capabilities drawing attention to the need for individuals to be free from state interference and free to form meaningful relationships with others to flourish. Nussbaum locates a capabilities approach around an individuals quality of life suggesting ‘it holds that the key question to ask is “what is each person able to do and to be?”. 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 develop their full potential, whatever that might mean for that individual.

This involves going beyond ensuring people have the ability to flourish to ensuring they are actually flourishing. This is pertinent to all service provision whether within the community or in-patient/residential setting.

Five areas important to flourishing and living a good life, regardless of the society/community you live in 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 commissioning and delivery of service provision based on supporting the development of these five areas might enable individuals in receipt of health and social care services to flourish and have if not a good life, a better life.

A 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 of those who are vulnerable. A first step might be to be more explicit in embedding the principles of capabilities and the good life to provide a solid foundation on which to build for the future.

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

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

The World Health Organisation (WHO) 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 is an important public health and societal problem.

As such, it demands an active response, one which focuses on protecting the rights of older persons, starting with  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 is more often 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). 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 the elderly. The old did not merely lose power, 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..

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, whilst his commentary did not discuss the issues raised in terms of ‘abuse’, if, as a researcher today, I were to hear such an account 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 policy today.

This suggests the abuse of older people has been going on for a long time, but has been hidden from public view, but we do know now don’t we.