Tag Archives: Dementia

#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.

The ‘Big Society’ will not necessarily lead to better elderly care treatment by @dianegalpin

A fantastic blog by our senior Lecturer Di Galpin for LSE Policy and Politics Blog a recommended read!!!

The ‘Big Society’ will not necessarily lead to better elderly care treatment.

Di Galpin looks at the Big Society from a philosophical standpoint and questions whether it can be achieved without encouragement from an active state.

‘Big Society’ and the future of health and social care

David Cameron suggests the Jubilee party was a ‘perfect example of ‘Big Society’.  Whilst it’s okay for a knees up, is it a suitable foundation for improving the quality of care  older people receive in Britain?

Unfortunately, David Cameron’s comments on Big Society do little to help us understand what “it” actually is, and to be honest, I am not even sure he  knows what it is beyond the usual sound bytes of ‘kitchen sink economic theory’*.  However, could the concept of Big Society actually have something to contribute to the debate on the future care of older people?

What is ‘Big Society’?

Big Society has been vilified as a return to the politics of the New Right,  a Trojan horse for smaller government,  and feted as the anatomy of the new politics  on which to establish the legitimate nature, and limits, of the relationship  between the  state and individual in a 21st century system of health and social care.  Phillip Blond is a central figure in the development of the concept of Big Society.  Blond  argues both the political Left and political Right have presided over a collapse of coherent cultural values and a shared commitment to a ‘common good’,  suggesting a redistribution of power from the ‘top’ (state) to the bottom (individual) is required, aligned with a more compassionate form of capitalism, to re-establish the common good.  For the current government this rests on the empowerment of local communities founded on voluntary networks of trust and mutuality.  From this perspective the purpose of Big Society appears to be to extend responsibility for the care of older people to local communities, rather than extending the responsibility of the state.

Policy programmes already implemented by the current government to develop Big Society include the National Citizen Service, which organise voluntary opportunities for young people, and the creation of the Big Society Bank, which will act as a central source of investment income for third sector organisations.  The Localism Bills’ accompanying guidance states ‘Big Society is what happens whenever people work together for the common good.  It is about achieving our collective goals in ways that are more diverse, more local and more personal (HM Government, 2010: p.2).

However, whilst at one level Big Society can be viewed as a mechanism of transferring more responsibility onto individuals, allowing the state to reduce public sector spending (Alcock, 2012) Big Society is also about believing in, and building on, the inherent ‘good’ within humankind.

Jesse Norman suggests Big Society involves moving beyond the ‘two way opposition of state vs. individual’ in the provision of care to ‘the three way relationship of enabling state, active individual and linking institution’ (2010,p.7).  For Norman the former is flawed because it ignores the diversity of human beings and their ability to act morally without interference from the state.  By justifying the legitimacy of the state, it polarises the individual and ignores the positive power and potential of individuals to create and maintain a ‘good society’, which cares for one another for altruistic reasons, rather than because the state legislate that society provide care and support.  Norman suggests state interference is a negative response to care provision, quoting Alex de Tocqueville (1805-1859)

“The more [the state] stands in the place of associations, the more will individuals, losing the notion of combining together, require its assistance.  These are cause and effect that unceasingly create each other.”

The ‘associations’ that mediate between individuals and the state can be conceptualised as operating within civil society.  Civil society is the space of un-coerced human action, the place where people take action as moral beings,  via all organisations and associations above the level of the family and below the level of the state.  The place where your jubilee street party was planned presumably.

Importantly for advocates of Big Society the role of government in this ‘space’ and ‘place’ is minimal.

How does this support the current approach to caring for older people?

From this perspective caring for older people, and ensuring care is dignified, is viewed as something we all agree is a ‘good thing’ and freely engage in, rather than something government should regulate or legislate for.  In this context government relies on ‘phillic’ associations, taken from the Greek ‘philia’, meaning friendship ties, affection or regard that are the essence of the space between individual and state.  Government would rather rely on these to guide human behaviour in the care sector than introducing legislation or regulation.

Hence, the governments  support for the introduction of a voluntary dignity code  (The Telegraph., 2012).

Big Society, freedom and money

However, whilst government may think treating older people with dignity and respect is viewed as a ‘given’, assuming we are all willing to  care for, and protect,  older people,  this is not necessarily true, as evidenced by a number of reports on the poor levels of care provision  older people experience across the care sector.

At the heart of the current debate are two related themes.  Firstly, an attempt to understand how the relationship between the state, private sector and individual should be formulated to fulfil a mutual responsibility in supporting dignified care for older people, and secondly  the affordability of care provision.   Successive governments since Margaret Thatcher have relied on a consumerist approach to improving the quality of health and social care provision. The question is has turning vulnerable older people into consumers improved their care?  For some yes, but for many of the most vulnerable older people in society, those older old people with dementia and who are frail, I’m not so sure.  However, what it has done is hide the abuse and mistreatment of older people from collective view for the last 30 years, and led society to engage in debate that does not move beyond the financial.  Research suggests this has had a detrimental effect on the moral health of society and academics are now suggesting the use of market mechanisms can change people’s attitudes and values, having a  ‘corrosive effect’.    Michael Sandel makes a pertinent point suggesting

It calls into question the use of market mechanisms and market reasoning in many aspects of social life, ……to motivate performance in education, health care, the work place, voluntary associations, civic life and other settings in which intrinsic motivations or moral commitments matter‘ (What money can’t buy, 2012, p122).

It is impossible to ignore the effects of systematic inequalities in liberal societies that effectively exclude, or compromise the rights of a variety of social groups.  Nor can we ignore the corrosive effect successive governments use of a consumerist approach to health and social care might have had on those ‘phillic‘ associations so vital to a ‘Big Society’.   The ‘Osborne Supremacy’  assumes the existence of a single unified ‘big society’ when it actually consists of many ‘societies’ with competing interests where the interests of powerful elites are advanced in the name of defending common interests, whilst the interests of marginalised groups, such as older people,  leave them without support.

Big Society or Big Con?

The answer will depend on your political and ideological viewpoint on the legitimate role, and limits, of the state in the provision of health and social care.  Whilst it is true Big Society clearly already exists, evidenced by the number of people already providing care freely in society, what is in doubt is whether it can be extended any further without an active state (Sullivan, 2012).

* Kitchen sink economic theory -this is a term used in my household to describe David Cameron and George Osbornes approach to the financial crisis.  It refers to a vision I have of a post war couple discussing there finances whilst stood washing up at the kitchen sink.  Gladys turns to husband Frank and says “money is tight Frank, what will we do?”  Frank turns to Gladys and answers “never fear mother, we’ll just have to tighten our belts, don’t worry we’re in this together”.  Of course Frank and Gladys are very naive and do not realise their actions will make no difference because the problem is a global financial crisis and not related to Gladys splashing out on a new apron!

There is a million reasons why ‘big society’ and ‘choice’ are not enough when providing care to older people

Research suggests as many as 500,000 older people are abused each year (Action on Elder Abuse), in the main by those supposed to be providing their care.  Therefore, since the election in May 2010 up to one million older people may have been abused.  

This information is not new, successive governments have been aware of this issue for many years but all have stopped short of introducing a coherent legislative framework to protect those most vulnerable in the care system.  The coalition appear to believe in the power of ‘big society’ and service user and patient ‘choice’ in a market led health and social care system.  My difficulty with this approach is it offers nothing new,  it looks no further than the rhetoric of the ‘free markets’  beloved of every government since Thatcher.  Nobody appears interested in thinking deeper and developing care from a philosophical perspective.  Surely we need to understand what motivates us to care before we can reform the system ?

Historically societal attitudes toward older people have always been poor.  In ancient Greece old age was portrayed as sad with historians arguing the Greeks love of beauty marginalised the old, especially women, sounds familiar!  Cicero’s work De Senecute, written in 44BC, pointed to a variety of individual experiences of ageing, however acknowledging that for those who were poor and without mental capacity ageing is miserable.  Sadly, all of this is still true today with research suggesting those at greatest risk of abuse and mistreatment are elderly women suffering from some level of dementia.  This,  along with the fact that the abuse and mistreatment of older people is a global issue identified by the World Health Organisation over a decade ago, suggests the issue  extends well beyond political systems and party politics in the UK.

I’m with social contract thinkers Hobbes (1588-1679) and Locke (1632-1704) when they suggest as human beings we are inherently selfish and our individual pursuit of pleasure is destructive to society, suggesting the law can be used as an apparatus to modify such human desires.  In my view the  continued economic approach to health and social care has fed such selfishness, to the detriment of certain groups in society, i.e. older people,  and we now require a strong lead from government.

Successive governments since Margaret Thatcher have relied on a consumerist approach to improving the quality of health and social care provision. The question is has turning vulnerable older people into consumers improved their care?  For some yes, but for many of the most vulnerable older people in society, those older old people with dementia and who are frail, I’m not so sure.  However, what it has done is hide the abuse and mistreatment of older people from collective view for the last 30 years, and led society to engage in debate that does not move beyond the financial.  Research suggests this has had a detrimental effect on the moral health of society and academics are now suggesting the use of market mechanisms can change people’s attitudes and values, having a  ‘corrosive effect’.    Michael Sandel makes a pertinent point suggesting

It calls into question the use of market mechanisms and market reasoning in many aspects of social life, ……to motivate performance in education, health care, the work place, voluntary associations, civic life and other settings in which intrinsic motivations or moral commitments matter‘ (What money can’t buy, 2012, p122).

So what can we do? Helen Sullivan suggests ‘a big society needs an active state’.   A useful first step would be for government to accept the Law Commissions recommendations on reforming the law in respect of Safeguarding Adults without delay.  Secondly, abandon the rhetoric of ‘choice’ and ‘free markets’  and develop a meaningful dialogue based on concepts such a honesty, morality and dignity from a philosophical  rather than financial perspective. A new approach might be to have a dialogue that goes beyond party politics (and winning the next election) and begins by asking big society what it wants to afford, rather than politician telling us what we cannot afford.

I am sure many will say we cannot afford to reform the system on philosophical grounds, I would ask those individuals “can we morally afford not too?”

The mis-treatment of older people in hospitals; is a ‘trip advisor’ approach really the best way forward?

At what point does the government stop relying on gimmicks, voluntary codes and recommendations from those without any power to implement change and actually take a lead to improve nursing care for older people? 

The Royal College of  Nursing’s research into the provision of care to older people suggested staffing issues were central to good nursing care, government have responded to this by suggesting we need to take a ‘trip advisor’ approach to raising the quality of services (photos optional presumably!).  However, this is only part of the answer,  problems extend beyond staff to patient ratios and will require more than patient recommends to improve quality.  Working practices imported from the business sector into care provision, along with a poor attitude from wider society and government toward the care of older people in the UK also need to be addressed.

Abraham (DoH, 2011) suggested the mistreatment of older people in the NHS is not just about people being too busy, but also about staff  being indifferent to older people,  i.e. showing no particular interest or concern about older people.  Coming from a professional background, where I have worked with nurses in hospital settings and as an academic teaching student nurses, it is fair to say I have never met a nurse   who has purposely set out on their career to mistreat an older person.  On the contrary, they have entered the profession because they want to care for people.  So what changes once on the hospital ward?

Arguably, such indifference radiates from wider society onto the hospital ward.   Both Government and society are disrespectful of older people, describing older people as a ‘demographic time bomb’, their care portrayed as an expense we can ill afford.  Once such an attitude is prevalent in mainstream society is it any wonder a culture of disrespect flourishes across society, leading to the de-humanisation of the older person, wherever they might be.  As Jo Webber of the NHS Confederation rightly point out; once in a hospital bed the older person no longer matters – achieving the task at hand efficiently is more important than the individuals’ dignity. This then provides the foundations from which poor practice in the care of older people develops across a multitude of care providers from public sector institutions to private sector providers through to the individuals that make up society.

Whilst external factors have an important role in shaping attitudes toward older people, this alone does not fully explain professionals’ indifference to older people when providing care.  Understanding what happens between individuals embarking on nurse training to actually working with older people on a ward is also significant. Menzies Lyth’s research provides an interesting insight from which to understand what happens once on the ward.  Menzies Lyth drew on  Jaques (1955) notion of  ‘social defences’ used by nursing staff to manage the anxieties inherent within their practice to understand behaviour within organisations.

Jaques (1955) initially used social defences to understand how nurses cope with the high levels of stress and anxiety associated with the job. However, it was developed later to take into account structural factors arguing that social defences were the result of poor organisational structure. This provides a useful framework from which to explore how current structural systems interweave to produce an environment where mistreatment flourishes on hospital wards.

Social defence mechanisms include care for patients split into individual tasks undertaken by a number of nurses; one person performs the same task to many patients rather than working with one patient to provide all their care. This facilitates a distancing between the patient and nurse, which protects the nurse emotionally. Organisational factors support a depersonalised approach by moving nurses around wards, which then allows the nurse to distance themselves from patients so as not to become emotionally involved.  Other social defences include a denial of feelings and over emphasis on professional detachment and strategies to reduce anxiety around decision-making, for example working in prescriptive ways, performing repetitive tasks, and delegating decision-making.  The lack of connection between patient and nurse arguably facilitates an environment in which mistreatment might develop, or is ignored.  Therefore, the organisation and delivery of care at a structural level within the NHS is of relevance to improving care for older people.  Higher staff ratios would be a good start because we have to ask is it possible, emotionally, for an individual to deliver high quality care with compassion and dignity consistently in the current system?

Poor levels of care appear endemic within the current system, the speed with which each new revelation now appears is in danger of convincing government and society such an approach is the ‘norm’, however, we must be careful not to just accept this as inevitable, or somehow acceptable in a time of austerity.  Indifference toward the care of older people represents the tangible outworking of a system of care that has lost its way; where commissioning outweighs compassion and meeting the demands of the system outweigh delivering care with dignity.

At what point does the government stop relying on gimmicks, voluntary codes and recommendations from those without any power to implement change and actually take a lead to improve nursing care for older people?

Dignity in the care of older people – “If you tolerate this then your children will be next” (Manic Street Preachers)

Improving care provision for older people is not just about today’s older population, it is about all our futures, our own and our children’s.

Securing dignity in care for older people is something society should strive for, however, change in the longer term requires more than a reorganisation of structures. Fundamental to change is how the care of older people is conceptualised in the UK.

The Commission on Dignity in Care for Older People has identified many significant issues, which if addressed could make positive changes to the future of care for older people.  Whilst such changes could make a difference, lasting change arguably requires new thinking at a philosophical and ideological level at all levels of society.

Ideologically government needs to shift its continued emphasis on a consumerist model of health and social care provision.  Whilst a consumerist approach is clearly of benefit to market providers, and the public purse, it is questionable whether such an approach is of benefit to older people.  Many of the problems experienced in private sector care provision originates from the under regulation of the care market, which, whilst enabling providers to cut cost and make profit, does nothing to address the poor quality of care many older people receive.

Models of management imported into health and social care from the business sector to support a consumerist approach exacerbate the problem.

Organisational structures support a depersonalised approach, for example working practice which allows carers to distance themselves from the older person, so as to reduce any emotional involvement between carer and cared for.   The breaking down of care into component parts, such as 15 minute visits, whilst, considered efficient from a resourcing perspective does not facilitate the building of a relationship between older person and carer.  Surely, care is more than a timed task to be done to another?

Managerialistic approaches taken from the business sector influence not just health and social care professionals, but also wider society.  Leading society to focus on the ‘management’ of older peoples care needs, such an approach serves to separate us all from the lived experience of the older person, care then becomes a transaction, intervention, a process, or target, by which governmental and wider societies’ need to reduce public expenditure is met, is cost really all that matters today?

Have we reached the position predicted by Zymunt Bauman  (2008) who, when considering if ethics has a chance in a world of consumers, suggests designing, elaborating, and putting into operation values of mutual hospitality must at some point become a necessity for the human species?  Bauman argues no place on the planet is spared a point blank confrontation with the challenge, because as  Levinas (1961) suggests, the moral impulse to care for one another is a poor guide for behaviour when one moves beyond a one to one relationship to plural others (the Third) because it cannot be sustained.  Something more is required, and that something requires substance.

A change in the philosophical foundations shaping our understanding of older people and their care should be the starting point.

German philosopher Immanuel Kant’s (1724 – 1804) ‘Categorical Imperative’ suggests everything in life has either a price or a dignity.  A need for example for material resources has a price because it is replaceable, but that which is irreplaceable has a dignity.  Morality, Kant suggests is one such dignity that cannot have a price. Arguably, compassion toward the most vulnerable in society is one such dignity that does not have a price, and is therefore above monetary value.

Dignity should not be viewed as an optional extra, dignity is integral to the care of older people across society.  In the longer term for structural change to be effective a deeper and more meaningful approach to care is required because if we continue on the current pathway, as the Manic Street Preachers might suggest “if you tolerate this then your children will be next”.

Do older people have fewer rights than animals? It sometime’s seems that way..

The mistreatment of older people extends well beyond the confines of the hospital ward when we consider research suggests up to 500,000 older people are abused or neglected in the community each year (Action onElder Abuse, 2007) and older people routinely receive inhumane and degrading treatment in residential care (Joint Committee on Human Rights, 2007).

Six years on from both these reports not much seems to have changed, even though cries of indignation from both government and society continue, so does the abuse.

Any attempts to raise awareness and improve care provision for older people is to be welcomed, however, the introduction of voluntary dignity codes and trip advisor type systems alone is not enough to address an issue that goes to the very heart of society; our indifference to older people. The Health Service Ombudsman (Abraham, 2011) highlights the culture of indifference that exists in the health sector citing incidences of older people leaving hospital with numerous physical injuries, mentally confused and soaked in urine, whilst research suggests older people living in the community dominate the abuse landscape, yet are invisible to wider society (Mansell et al,2009). The conviction of carers charged with abusing older residents with demnetia at Hillcroft Nursing Home confirms how little has changed.

The level of our indifference can be measured by the difference in response following the case of ‘Baby P’.

The tragic case of ‘Baby P’ not only provoked outrage, but a commitment from government to change the system, with ProfessorEileen Munro outlining how structural and organisational change was required to improve services for vulnerable children. Surely, it is time to undertake such a review in the provision of health and social care for older people?

We need to start from a very basic level before we reach the same level of response as that seen in childcare. The prevention of mistreatment of older people requires firstly a change in society’s attitude. A dignity code may help, eventually, but hard legislation would work faster and send a message that the mistreatment of older people will not be tolerated. Legislation relating to the mistreatment of children demonstrates the value of specific legislation. Whilst child abuse has not been eradicated legislation has changed society’s response to child abuse i.e. there is a broad consensus that it is not acceptable. Other examples of where legislation can moderate attitudes and behaviour to vulnerable groups can be seen in legislation related to racism and homophobia, whilst, again, it is acknowledged racism and homophobia have not been eradicated, it has arguably changed wider society’s response to groups who have been traditionally vulnerable to abuse in British society.

Munro’s review has highlighted significant flaws in the organisational structures and practices that exist in childrens’ services, many within adult services would suggest those same flaws also exist within the provision of health and social care to older people. This involves not just looking at individual workers but also the organisational culture they work in, what use is it having someone sign a dignity code if the processes and procedures within the organisation they work prevent them adhering to them?

Our current system of care provision leaves many older people vulnerable to mistreatment, this has to change, a voluntary code could help, but on its own it will do nothing to soften the hardened heart of government and society who express outrage but just as soon forget the plight of many older people.

http://www.telegraph.co.uk/health/elderhealth/9096635/Elderly-ignored-and-treated-as-objects-in-care-system.html