Tag Archives: NHS Reform

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.

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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.

‘Time-poor nursing’- when will government understand ‘management’ strategies more suited to a car plant do not work on hospital wards?……..

Whilst The Guardian highlights the negative impact of ‘time-poor’ nursing practices on patient care it needs to be emphasised organisational structures that support a mechanistic approach also need to be addressed.

As the BMJ publishes a report which suggests nurses are being forced to “ration care” I am beginning to wonder if this government is incapable of learning from past mistakes. Since being in power we have had pronouncement after pronouncement on the need for ‘compassionate care’ leading to the vilification of many who try to provide such care, but who are impeded by organisational structures and ‘management’ strategies more suited to a car plant than a hospital ward trying to care for individuals when they are ill. Nursing staff do not generally enter the profession to provide poor quality care, on the contrary the majority want to provide the best care possible, however, once in the system the working practices in many hospitals seem designed to stop this occurring. Research suggests staff develop ‘social defences’ to cope with the disparity they experience.

Jaques (1955) initially used the concept of social defences ‘‘to refer to unconscious collusion or agreements within organisations to distort or deny those aspects of experience that give rise to unwanted emotions’’. The concept was developed later to take into account structural factors ‘‘arguing that social defences were the result of poor organisational structures. This provides a useful concept to begin to understand how structural systems interweave to produce an environment where poor quality care might flourish in a bid to meet the needs of the organisation and make care systems affordable.

Research suggests Nurses use social defences to cope with high levels of stress and anxiety associated with the job. Defence mechanisms include care for patients split into individual tasks undertaken by a number of nurses, one nurse 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 prescriptive tasks, and delegating decision-making. This may be reminiscent of current care provision within hospital and residential settings, where the lack of connection between patient and carer arguably facilitates an environment in which poor quality care becomes the ‘norm’.

Research by Calnan et al. (2012, p. 1) on the provision of dignified care for older people in acute hospitals highlights this point when they ‘‘found a lack of consistency in the provision of dignified care which appears to be explained by the dominance of priorities of the system and organisation.

Structures that depersonalise the caring relationship will not lead to the delivery of compassionate care. Compassionate care is more than a mechanistic task, it is emotionally and psychologically draining, staff need support not an organisational structure that is unsupportive. This government has to stop pointing the finger at the previous administration and learn from their mistakes.

I am reminded of the ‘Peter Principle’ which asks “Why does history keep repeating itself? Because nobody ever listens”. Quite.

(If you would like to read more on ‘Social Defences’ you can access a journal article I have written on the subject published in the Journal of Adult Protection)

NHS Direct and 111, why the surprise?

Why the surprise over NHS Direct?

As the Independent reports on NHS Direct pulling out of providing 111 services I wonder how the government might not have seen this coming?

Probably because faith in the free market is unshakeable across government as it chooses to ignore evidence of its failure. The free market is seen by many as the only way forward to address future resourcing issues. However, the re-branding of healthcare as a commodity ignores some simple ‘free market’ truths, pointed out by the economist Adam Smith several hundred years ago;  the purpose of the free market is to generate wealth for those who own the means of production, or the ‘masters of mankind’ as Smith christened them, it is not a charitable endeavour but a single-minded system driven by cash not compassion, who Smith suggested had a ‘vile maxim‘  of  “all for ourselves”.  The ‘masters of mankind’  in Smiths time were the merchants and manufacturers who supported policy that enabled them to make more profit, they were not concerned with how such policy and their actions might impact on others.  Today the ‘masters of mankind’ appear to be companies like NHS Direct or ‘big pharma’, financial institutions and banks, insurance companies, private healthcare providers.

This really should not come as a surprise as we have already seen some of the potential problems that can arise in the marketisation of social care. At a macro level those private institutions who have already taken over some areas of care provision   have been found lacking, which does not bode well for extending this strategy accross healthcare.  Take, for example, HSBC who were fined £10.5 million last year for mis-selling care bonds to older people.  The Financial Services Authority found unsuitable sales had been made to 87% of customers, with the average age of those who purchased bonds being 83 years of age, many of whom having already died before the scandal came to light.  Whilst £10.5 million might sound a lot it’s not for a company who was recently exposed as allowing the laundering of at least 7 billion dollars of drugs money through its bank and has set aside 700 million dollars to cover fines.

The selling of care related products and services by the private sector can leave individuals vulnerable in a variety of ways, look at the doubling of the number of private care homes going bankrupt leaving older people without secure housing or care provision. Latest reports in The Independent suggests nothing had changed as the bailiffs are set to move in on some care home providers.

Arguably, the ‘free market’ is anything but ‘free’.  A favourite of Mrs Thatcher, economist Friedrich Hayek compared the free market to a ‘game’ where there are winners and losers suggesting trying to regulate the market in the name of social justice was a waste of time. The current government, and opposition, appear to believe there is only one game in town when it comes to the future of our health and social care sector, they are wrong.  

#Elderly care condition critical: we need ‘active’ leadership to create a care system that is both ethical and sustainable…..

As the BBC (Panorama, 17th June 2013) and CQC yet again bring to government and wider societies attention the poor levels of care some older people experience, one wonders will any government ever get to grips with this issue?

Whilst there are calls from government for families to step up and support older people, government seems totally unaware that the majority of families already do, and it is as a last resort that families call on public and private sector providers. However, far too many of these providers are simply not good enough, and for this, government has to accept some responsibility.

The transformation of ‘care’ into a commodity that can be bought and sold, like any other product, dominates current health and social care reform, however, discussion on what ethical principles might underpin the delivery of care has not emerged.

This raises the question is it wise to build a system of care provision with no clear ethical foundation?

We need greater ambition in developing great care for older people and a more 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. 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 the individual to flourish. The NHS is arguably over managed and under led, with the aim seemingly to move older people into residential care as quickly as possible to free up beds. 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 regulating care provision from an ethical stand point government 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.

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? I guess those older people who have already suffered abuse would say we cannot.

To see a wrong and not expose it, is to become a silent partner in its continuance (John Raymond Baker)

Today is World Elder Abuse Awareness Day 15th June 2013: this is not about blame, it’s about change…………

The United Nations has designated the 15th June of every year as World Elder Abuse Awareness Day. Across the world communities come together on this date to shine a light on the problem of elder abuse.

The abuse of older people is not a new phenomenon unfortunately. The US was one of the first to identify the abuse of older people as a social and political issue that required action. Research developed in the 1980’s in Australia, Canada, China, Hong Kong, Norway, Sweden and the US confirmed this was an international phenomena. The following decade saw developments in Argentina, Brazil, Chile, India, Israel, Japan, South Africa, the UK and other European countries (World Health Organisation,2002).

In the UK staying out of harm’s way for many is just a matter of locking doors and windows and avoiding dangerous places, people and situations; however for some older people it is not quite so easy. The threat of abuse is behind those doors, on the hospital ward, in the residential institution or in the individuals own home, well hidden from public view. For those living in the midst of abuse violence permeates many aspects of their lives, sometimes perpetrated against them by carers’, professionals, family members or others known to them. Although government and society are increasingly aware of the abuse of older people it stills seems to persist. The Francis report highlights how poor care in a hospital setting actually constitutes abuse, we have also seen disturbing media reports regarding abusive treatment of older people in residential homes. Sadly even in individuals own homes some older people are not safe from abusive behaviour. This provides a disturbing view of how older people are valued in society and how some are cared for in the UK.

This is not about blame, it’s about change, let’s make a difference together.

You can get involved and make a difference by contacting Action on Elder Abuse, a charitable organisation fighting to improve the care and protection of older people across the UK, click here to find out how you can work together on the 15th of June to raise awareness and make a difference to older people in your community.

If you, or your organisation, is involved in the care and support of older people in the UK the National Centre for Post Qualifying Social Work have developed resources to help develop the skills and knowledge required in the workforce to ensure older people are protected from abuse and supported to live lives without fear. Please click here if you would like more information, or go to our website http://www.ncpqsw.com

If you know of an older person being abused contact your local social services Safeguarding Adults team, or ring Action on Elder Abuse helpline 080 8808 8141. If you feel someone is at immediate risk of harm contact the appropriate emergency services.

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.

The trouble with personalisation is, its not personalisation…….

Personalisation occupies a central position in social work with adults today and was at first welcomed by social workers as a positive step forward,   however, our understanding of ‘personalisation’ is somewhat different than governments.  This is not a surprise when we look at the driving force behind its development.  Personalisation was driven not by social work, but by the think tank DEMOS (favoured first by Tony Blair and more recentlyDavidCameron) and in particular Charles Leadbeater, a journalist and writer who spent ten years working for the Financial Times and who was an adviser to a number of major private companies, including Chanel Four Television and British Telecom.  A key document from DEMOS should have set the alarm bells of social work ringing in 2004.  The ‘Pro-am Revolution’  provided the rationale for delivering personalisation.  The pre title blurb sets the direction of travel

 ‘The 20th century was shaped by the rise of professionals. But a new breed of amateurs has emerged….’

The central tenet of the Pro-Am Revolution is that with the advent of new technologies and educational systems we no longer need to rely on professionals to undertake particular tasks because amateurs are now able to operate at the same level as professionals, but without requiring large organisational structures.  DEMOS looked specifically at areas such as web design and astronomy, suggesting the same premise could be applied to education and social care, going onto say ‘Pro Ams are creating new, distributed organisational models that will be innovative, adaptive and low-cost’ which will also be ‘light on structure and largely self regulating’.  Hmm sounds familiar.

 For DEMOS, a service user was a service user, no distinction was made between the needs of those with disabilities or mental health difficulties or older people (nor for that matter the difference between a web designer and older person with dementia!).  This resulted in a flawed conception of the people who use services and their ability/willingness/desire to manage their care and the markets that would provide care.

 The conception of personalisation in a think tank has never boded well for its implementation.  However, it has been useful at a political level as it has acted as a mirage to conceal a very different agenda linked to the equally nebulous concept of ‘choice’.

Clarke (2005) suggests choice is the engine of public sector reform, with choice seen as desirable in empowering individuals to move from passive consumers to activated and responsibilised citizens. Choice as a concept remains controversial for some as it is also viewed as a route along which the marketisation of public services can travel without challenge. Whilst this is a logical extension of the previous government’s agenda for Cameron and Co, for many in practice a free market approach to service delivery underpins many of the problems experienced in social care today.

Government has exploited the ambiguity in meaning of words such as personalisation and choice to enable the social work profession to retain a semblance of loyalty to its own values, whilst unknowingly carrying out the bidding of politicians with very different ideas about social care.  

Research has explored how organisations encourage workers to engage in an agenda they do not necessarily agree with. Courpasson (2000) introduced the notion of ‘soft coercion’ which induces, simultaneously, commitment and obedience to the organisation and its aims.  Ambiguity in meaning is one such instrument of soft coercion, however, you also need to ensure the workforce accept your perspective.  One strategy used by large organisations has been the ‘company song’, often represented by the company policy which provides an organisational mantra, for example ‘personalisation leads to greater choice’.  

Maybe it’s time to change the company song and for the social work profession to choose its own playlist, if it does not there will be many in government who will be happy to do it for us!

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”.