Tag Archives: Safeguarding

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.
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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”.

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