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)