Tag Archives: Older people

#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)

‘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.

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”.