Do we care enough for our older people in society?


As much as we welcome, Philip Hammond, the UK’s Conservative chancellor of the exchequer, £650million additional grant funding for local authorities in England to spend on services for older people and adults with long-term disabilities in his 2019/20 Budget. It is hard not to draw the conclusion that this is a pittance of the amount required to provide quality care services and respect the dignity of our older people.

Mr. Hammond claims this will help ease the ‘immediate pressures’ faced by social care services. But only £240million of this money is earmarked for propping up the social-care system. While the Association of Directors of Adult Social Services has been lobbying for £2.35 billion after enduring year-on-year funding shortfalls.

According to Labour MP Frank Field, co-author of‘A New Deal to Reward Kindness in a Forgotten Profession’, cuts to local-authority budgets have resulted in a ‘race to the bottom’ in the commissioning of paid-for homecare provision. The inevitable result is poor-quality, rushed personal care.

Emily Holzhausen of Carers UK says unpaid carers, some of them pensioners themselves, who are typically looking after other elderly family members, are ‘exhausted, demoralised and have lost vital community connections because there is not enough good-quality care’. They are ‘the backbone of the care system’ without whom ‘the system would collapse’, agrees Ian Hudspeth at the Local Government Association.

The King’s Fund says the system not only needs to make improvements in the quality of care that is provided, but also needs to find more resources. These will be needed to address an estimated additional 1.2million people’s unmet care needs, and to find an expected 700,000 more social-care workers by 2030 as the ageing population continues to grow.

Finding new and innovative ways to care for people

New, more efficient and innovative ways of providing care do need to be found. This needs to go alongside a better way of managing the demand on services, with an approach that is more preventative and also integrated with health, housing and benefits systems. A balance needs to be found between formal support, provided or commissioned by the state, and informal support that comes from family- or community-based care.

These are not just technical questions for the social-care sector to grapple with. They are far bigger than that, touching upon the issue of what kind of society we want to live in, and what we expect of each other. At root, there is the issue of what we regard as individual and collective responsibilities; and what the duties of the young are to the old; and the question of how elderly people come to decide for themselves how they should be cared for later in life.

A pervading sense of negativity towards older people in our society

The bookmakers Paddy Power have been criticised for its adverts portraying old people as zombies, albeit as part of its UK sponsorship deal with the TV series The Walking Dead. It is meant to be a joke, but older people’s charities didn’t find it very funny. Such ‘inaccurate stereotypes’ are described by Independent Age as ‘crass and utterly disrespectful’.

Some of us might be tempted to laugh this off as yet another overreaction from the permanently offended. Ofcom has yet to decide whether the four complainants (yes, four!) about the Paddy Power ad are enough to justify an investigation. And yet, this depiction of old people is not an isolated incident. It reflects a broader prejudice today.

‘Negativity about ageing and older people is pervasive in our society’, says Caroline Abrahams at Age UK. Whether it’s the nasty sentiment that Brexit voters are a bunch of selfish old bigots whose demise can’t come too soon, or that Baby Boomers have been piling up problems for moaning millennials, or that old people are just getting in the way with their ‘bed-blocking’ and their unreasonable expectation that younger folk should subsidise their state pensions, free bus passes, TV licenses and winter fuel allowances – again and again, we see generational disdain for older people.

Add in the damning inspections, abuse scandals, cuts to services, underpaid care workers that have so plagued the social-care sector in recent years, then it is hard to escape the conclusion that elderly people are increasingly regarded as a burden on society and a drain on resources. Once, they were seen as the repositories of wisdom and a source of support for hardworking families – now they are talked about as a barrier to youthful flourishing.

Summary

There is increasing economic evidence and a pervasive negativity in our society that sheds light on how older people are viewed in our modern society. This is not helped by the government of the day continuing to delay its decision on the funding of social care, and failure to acknowledge the valuable contribution of unpaid carers. We need to be wary of some in our society, who have a generational disdain for older people.

Technology and improved working practices in themselves will not solve the question of the kind of society we wish to live in. It seems to me it is incumbent on all of us to recognise the valuable contribution older people can make to our society, and in doing provide a purpose to their life. We need to harness the experience of older people as a resource to the benefit of all who live in our society.

Acknowledgements

Dave Clements adviser to local government and founder of the Academy of Ideas Social Policy Forum.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Concern about Liberty Protection Safeguards


In July 2018, the Government published a Mental Capacity (Amendment) Bill, which if passed into law will reform the Deprivation of Liberty Safeguards (DoLS), and replace them with a scheme known as the Liberty Protection Safeguards (although the term is not used in the Bill itself). Ministers say it will save councils £200 million a year and give ‘swifter access to assessments’.

The Bill draws heavily on the Law Commission’s proposals for reforming DoLS, but generally does not address some of the wider MCA reforms that the Law Commission suggested. So proposed reforms around supported decision-making and best interests are not included, although the omissions have proved controversial, and may be challenged as the Bill goes through Parliament.

Key features of the Liberty Protection Safeguards (LPS)

include:

  • Like DoLS (but contrary to the Law Commission’s suggestion) they start at 18. There is no statutory definition of a deprivation of liberty beyond that in the Cheshire West and            Surrey Supreme Court judgement of March 2014 – the acid test.
  • Deprivations of liberty have to be authorised in advance by the ‘responsible body’
    • For hospitals, be they NHS or private, the responsible body will be the ‘hospital manager’.
    • For arrangements under Continuing Health Care outside a hospital, the responsible body will be the local CCG (or Health Board in Wales).
    • In all other cases – such as in care homes, supported living schemes (including for self- funders), the responsible body will be the local authority.
  • For the responsible body to authorise any deprivation of liberty, it needs to be clear that:
    • The person lacks the capacity to consent to the care arrangements
    • The person is of unsound mind
    • The arrangements are necessary and proportionate.
  • To determine this, the responsible body must consult with the person and others, to understand what the person’s wishes and feelings about the arrangements are.
  • An individual from the responsible body, but not someone directly involved in the care and support of the person subject to the care arrangements, must conclude if the    arrangements meet the three criteria above (lack of capacity; unsound mind; necessity and       proportionality).
  • Where it is clear, or reasonably suspected, that the person objects to the care arrangements, then a more thorough review of the case must be carried out by an         Approved Mental Capacity Professional.
  • Where there is a potential deprivation of liberty in a care home, the Bill suggests the care home managers should lead on the assessments of capacity, and the judgment of necessity    and proportionality, and pass their findings to the local authority as the responsible body. This aspect of the Bill has generated some negative comment, with people feeling that             there is insufficient independent scrutiny of the proposed care arrangements.
  • Safeguards once a deprivation is authorised include regular reviews by the responsible body and the right to an appropriate person or an IMCA to represent a person and protect        their interests.
  • As under DoLS, a deprivation can be for a maximum of one year initially. Under LPS, this can be renewed initially for one year, but subsequent to that for up to three years.
  • Again, as under DoLS, the Court of Protection will oversee any disputes or appeals.
  • The new Bill also broadens the scope to treat people, and deprive them of their liberty, in a medical emergency, without gaining prior authorisation.

According to some campaigners there is fear that vulnerable old people face being ‘effectively imprisoned’ in care homes if Ministers press ahead with cost-cutting changes to the way that service users are assessed, campaigners fear. They argue that care home managers will become ‘both judge and jury’ in cases involving the freedom of their clients, many of whom have dementia.

At present the friends or family of those lacking the mental capacity to decide where they live can object to a home’s decisions about their care by applying for an independent review. But the Government is scrapping the existing Deprivation of Liberty Safeguards (DoLS) system because they say it is too slow and expensive.

But critics say the move will strip vital rights from the most vulnerable.

Crucially, the new rules would do away with the automatic right to a review by an independent ‘best interest assessor’. Instead, care home managers will carry out ‘consultations’ about what should happen to a service user.

Judy Downey, from the Relatives & Residents Association, said: ‘Care home managers will become both judge and jury in cases in which they may well be involved. That is neither fair nor appropriate. ‘She added: ‘Staff on our helpline hear far too many examples of people deprived of their liberty, seemingly for no reason except that it’s thought best by the care home.

‘At the moment they or their relatives can challenge such decisions. But under these short-sighted proposals they will lose that right, raising the frightening possibility that individuals will be effectively imprisoned in homes that are totally unsuitable for them.’

The Department of Health and Social Care said: ‘The Bill ensures that authorisations for people to be deprived of their liberty in care homes are determined by responsible bodies such as local authorities or clinical commissioning groups.’

Summary

Although some ministers claim the Liberty Protection Safeguards will save will save councils £200 million a year and give ‘swifter access to assessments’ it is questionable that the proposed changes will prove to be a smooth transition. Service user’s families and carers will not take to kindly to a care home manager determining what is the best for their loved ones, nor would one think that managers would welcome this new responsibility.

My major criticism of the new bill is that it relies on the profession judgment of social care workers and deprives relatives and friends from contributing to the decision making process.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

NHS Community Services Providers: Take Centre Stage


A report from NHS community services providers suggests that their services are at the point of taking centre stage. For many years now, successive national NHS policies have stated that community services should play a more central role in the future health and care system than they do at present. The most recent iteration of this ambition was the Five year forward view (FYFV) (NHS England, October 2014), but this initiative was only the latest in a long line of NHS strategic plans that sought to strengthen the position of the community sector and deliver care closer to people’s homes.

This argument in favour of stronger, expanded community services has been made for three overarching reasons:

  1. The NHS must radically improve its ability to prevent illness and support people to ensure their own wellbeing if it is going to be financially sustainable. Strengthened community services are crucial to bringing the right focus on preventing ill health, improving the population’s health and wellbeing, and tackling health inequalities.
  2. The disease burden is shifting as people are living much longer with multiple long-term conditions that cannot be permanently cured by hospital intervention. Conditions such as diabetes and hypertension require a very different type of interaction with patients and the public than, for example, a traumatic injury. Community services offer the most appropriate way to promote good health and prevention and provide joined-up care for an ageing population.
  3. Acute inpatient services, in both hospitals and mental health services, are under huge pressure and they are currently being used unnecessarily and inappropriately for patients who could and should be treated closer to home. It is better for patient care, better for performance outcomes, and better for the NHS budget to treat as many patients as close to home as possible, with community services once again at the heart of provision.

However, while the burning platform for this shift in the provision of care is the financial and operational pressures in the acute sector, the real driver for community services lies in good population health and prevention at scale. Too much time has been spent making the case for community services in relation to “moving care closer to home”, when it is the combination of all three reasons that makes the case. Concentrating solely on this defines community services in relation to what they are not, rather than what they are. This then colours the debate around community services, which continues to be acute-focused and about shifting services between settings rather than acknowledging the positive reasons for strengthening community services.

The analysis for this report is informed by an online survey of NHS trust chairs and chief executives representing 51 trusts that provided community services and 20 that did not. The contribution of these 51 trusts. This means over half of all trusts that we are currently providing a substantial amount of community services.

To complement the survey a number of interviews were carried out to gain a richer understanding of the issues facing community providers.

Despite the potential of community services, the survey and analysis found seven reasons why ambitions for the community sector have not yet been realised. And, in doing so, the report provides a clear manifesto for what needs to change if community services are going to take up a more important role: The seven reasons are:

  1. There is insufficient understanding of community services and the community provider sector among the national bodies, the Department of Health and Social Care, commissioners, politicians, patients and the public.
  2. Community services have been, and continue to be, an inconsistent national and local priority.
  3. There needs to be greater financial investment in community services.
  4. Demand for community services is outstripping capacity and supply.
  5. Structural inequity means that competition and procurement disproportionately affect community service providers.
  6. There are worrying staff shortages in key roles.
  7. There is a lack of national-level data and a national focus on an improvement approach for community services.

Summary

The report from NHS community services providers puts clearly the overarching reasons for more investment in community services. However, change is unlikely to come about unless there is a major shift in the policy of NHS to recognise the value and contribution of community services, who will then move more closer towards centre stage

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

 

Addressing the uncertainty surrounding end of life care interventions in care homes

end-of-life-care-for-people-with-dementia

If you ask them, care home staff, healthcare professionals, residents and their families would all wish for and want to achieve the same outcome: a good death. But how can that be managed with all the uncertainties at play and with so many people and points of view to consider?

What people want, their care needs, how to interpret and treat symptoms, and who becomes involved in the decision making when someone with dementia is dying can become a source of anxiety, upset and frustration for everyone involved.

What’s been missing until now is a way of framing those uncertainties that can help make sense of the challenges, acknowledge them and have productive and helpful discussions that bring about the best decisions.

Research carried out by Claire Goodman has found that care home staff, healthcare professionals, Residents and their families may not always agree on the best approach to end-of-life care.

Using three different studies, the research – presented at the Economic and Social Research Council’s National Centre for Research Methods Festival – tracked the care of older people in 29 care homes over a 12-month period. Altogether, 528 residents, 205 care home staff and 44 healthcare professionals took part in the research.

The research found that end-of-life interventions were characterised by uncertainty in three key areas:

  1. Which is the “right” treatment?
  2. Who should do what and when?
  3. In which setting should end-of-life care be delivered and by whom?

Treatment uncertainty was an issue when a resident had been stable with no signs of decline, who had previously recovered from a similar episode of ill health or when deterioration was protracted with periods of good health between episodes of ill health.

It was further complicated by how quality of life was defined. care home staff, residents and family members said it was about residents’ ability to respond, engage with others and appreciate the home environment. For visiting primary care staff, it was linked to whether the intervention would lead to recovery of function or improvement.

Even where an advance care plan had been put in place, these competing narratives of what a good outcome looked like could not always be resolved.

When it came to who should do what when someone was dying, there was uncertainty about roles and responsibilities at both an organisational and an individual level.

Decisions to treat were GP-led, but this was a complex process between care home staff, visiting healthcare professionals and families. Visiting GPs had the (clinical) authority to make key decisions about hospitalisation or treatments, but this was undermined by infrequent contact with, and partial knowledge of, residents. Healthcare professionals providing urgent or emergency care found navigating these relationships even more problematic.

Care home staff often lacked confidence, concerned that relatives might be upset and lodge a complaint, and that this could lead to issues with the regulator.

Even where working relationships were robust and treatment was clear, end-of-life care could still be adversely affected by the way services were organised and resourced.

There was a lack of confidence among staff about their ability to deliver proper end-of-life care if promises of services and resources from the NHS did not materialise.

From all these insights, the outcome of the research concluded that uncertainty is an inevitable and integral part of end-of-life care for people with dementia. Residents’ characteristics, the protracted period of dying, multiple and changing personnel involved, different definitions of quality of life and the realities of working across health and social care mean uncertainties cannot always be resolved.

In simple terms, even with access to evidence-based guidance on how to support people at the end of life in care homes, there are times when it will not always be clear if palliative care is the right treatment, who should do what and when, and if the person can be supported to die in the care home.

The acknowledgement of these uncertainties according to Claire Goodman should not be seen as a failure, but as something that has to be worked at over a period of time by all those involved. There needs to be opportunities for conversations between care home staff and NHS practitioners to work through the options available to them.

Although uncertainty is an inevitable and integral part of end-of-life care, it is of paramount importance that care home staff can demonstrate the continual involvement of those nearest to the person. Clear communication between the perspective parties involved in the end-of life care plan, and care staff learning from their experience, may help to address the uncertainty.

Claire Goodman is professor of healthcare research at the Centre for Research in Primary and Community Care at the University of Hertfordshire

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute

Managing Director

Bettal Quality Consultancy

Understanding the Requirements of Care Quality Commission Registration

Section 7 Describe how you will provide the service

This is the last in a series of blogs that I have written to enable people who are seeking registration to gain a greater understanding of Section 7 of the CQC Application for Registration Form requirements.

This section focuses upon how the service will address the five key questions (KLOES):

  • Are they safe?
  • Are they effective?
  • Are they caring?
  • Are they responsive to people’s needs?
  • Are they well-led?

 What CQC are looking for here? CQC needs confirmation that you have policies, procedures and processes in place that are capable of delivering care to meet the Key Lines of Enquiry. Here at Bettal we offer the Cared 4 Quality Management System that emphasises the importance of quality as well as compliance. Our quality Management System contains policies and procedures that are cross referenced to all the prompts of the KLOES.

However, it is not enough just to have policies and procedures in place. You will also need documentation that enables you to record and therefore demonstrate to inspectors that you can produce evidence of how you deliver services to service users and meet CQC Standards.

When advising our customers about meeting the requirements of this section, we identify the polices procedures and forms relevant to the Key Lines of Enquiry, and these are forwarded on by the customer to CQC as part of the application.

At this point you should remember that CQC want to know how you intend to assure the quality of care you intend to provide. You will need to consider how you will monitor and audit the quality of your service. How you will communicate with service users, and how you will survey their views of the quality of the service you provide and act upon suggestions for improvement.

 

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute

Managing Director

Bettal Quality Consultancy