Dignity, Institutionalisation and the Francis Report

The reams of comment and response can be distilled into calls to do two things:

1. Treat people with dignity and achieve a return to the traditional values of caring that originally underpinned the NHS (primarily coming from care professionals).
2. Free the NHS from top-down bureaucracy and target setting (primarily from politicians and managers).

Neither narrative gets to the root of the problem nor helps us find a constructive way forward. Let me offer an alternative analysis – one that is endorsed by the content of the Francis report even if the conclusions are not written in this way.

The two core failings were:

• Ageism – the acceptance (if not belief system) by hospitals and a worryingly large proportion of managers, doctors, nurses and care staff that it is legitimate to accept lower aspirations and outcomes for older people than for others in society.
• Institutionalisation - the isolation of the hospital from the wider community and service systems that enabled it to operate, unchallenged, in ways that prioritized the interests of the organisation and those working in it, rather than achieving positive life outcomes for people needing healthcare.

Ageism

The ‘dignity’ response is about getting back to old values of caring – doing the ‘right thing’. I’m not going to disagree with the need for this, but on its own it is inadequate. By acknowledging that ageism was also a root cause we begin to open up alternative ways of changing hospital behaviour.

The Francis report described how the actions of staff across the care system as they neglected and abused older people went beyond a failure to care. It represented a denial of, and attack on, people’s human rights. They were not being treated as equal citizens.

These are deep-rooted things in our society, a society that has too many inbuilt prejudices about people who are different. At its more benign, we see people who are old, unwell or disabled as objects of charity and pity, assume they have limited potential and thus have limited belief and aspirations on their behalf. But parts of society go well beyond that and either implicitly or explicitly question the right of some older people to receive equal treatment, care and respect. The Francis report describes what happens when attitudes rooted in ageism are allowed to go unchallenged.

Acknowledging that the NHS needs to take action on ageism, rights and equality is thus an essential starting point to any response to Francis. Two years ago, the DH commissioned the NDTi to produce, materials and toolkits to help address age discrimination in the NHS. Having ticked the box that they existed, neither the DH nor NHS has done anything to promote them or require evidence of action. Why not?

(Incidentally, I have just been at the launch of the report on the confidential Inquiry into premature deaths of people with learning disabilities – hearing about how the NHS has been systematically failing to accord learning disabled people with the same rights as other citizens. The issues in Francis are not just about ageing).

Institutionalisation

Both the Francis and CQC reports describe how the interests of the hospital Trust and those of the people who worked there had become more important than the quality of care received. Whilst claims that NHS bureaucracy and targets were a root cause of this may well contain elements of truth – the problem is more fundamental. (Indeed I worry that blaming NHS bureaucracy is, from some, more about generating an argument to dismantle the NHS than about trying to find solutions.) The issue is not about bureaucracy, nor the NHS as an entity, but is about institutionalisation.

Those of us who worked on the NHS deinstitutionalisation programmes in mental health and learning disabilities will immediately recognise the symptoms. General hospitals have become isolated, inward looking entities. The voices of patients and families are not listened to because the hospital knows best. The hospital determines its own way of working with little real inter-action with the wider community or related service systems.

This is about culture – a culture informed by the rhetoric that hospitals and the medical profession are there to save lives (true, generally they do). Thus, they hold a privileged position that restricts the capacity of others to question how they work. A different context to life saving is needed. I’d suggest a narrative about hospitals being there to help people by addressing their ill health so that they can get on with the rest of their lives – before and after they enter and leave the hospital car park.

To do this, the hospital system has to see itself as an element within – and not the dominant or most important part of – a community and service system. Managers and clinicians need to take an interest in, think about and understand the wider context of their patients lives in the way that some of the more progressive GP practices are now doing.

Responding to Francis

So what does this mean in terms of action? It will be a long and complex change agenda, but here are four things for all hospital Trusts to start thinking about:

1. Acknowledge that age discrimination is an issue, and use the materials and knowledge about age equality to review all aspects of organisational activity and staff behaviour.
2. Understand and implement co-production – the genuine involvement of people who use the hospital service in all aspects of activity – from strategic planning through to individual care and treatment. Learn from community techniques of person centred approaches to design care delivery on the wards.
3. Start measuring life related outcomes rather than processes – look at how treatment enables the person to get on with the rest of their life. Think about community inclusion because if hospital treatment has a focus on how someone can continue their life on discharge, they will be less likely to be readmitted.
4. Understand whole-system change – work with local authorities, voluntary organisations, advocacy groups and primary care in ways that are about delivering everyone’s agenda.

The benefits from this should be significant – both for patients and the NHS Trusts. One NHS Trust Chief Executive said this week “Over 50% of the people in our beds have dementia and we don’t know what to do with them”. That is because you have to be part of people’s wider lives and support systems to help them effectively. If hospitals understand themselves as servants of their community, and actively address their own ageist behavior, then perhaps the Francis report will prove to be a catalyst for real change.