Change that leads to better lives

Parliamentary and Health Service Ombudsman Report

This latest account of inadequate treatment and care of older people echoes the same findings from 20 years ago - so why is getting this right still so hard?

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Helen Bown, Head of Policy and Research at the National Development Team for Inclusion says it’s time for us to consider the underlying causes of these systemic problems.

This week’s Parliamentary and Health Service Ombudsman report takes me back nearly 20 years to the first national inquiry of NHS hospital treatment and care of older people that I was involved in (see Not Because I’m Old, the Health Advisory Service, 1998).

The four key issues identified by Ombudsman, Dame Julie Mellor’s report are common to many of the reports and best practice examples and repeated reports that have been shared over the past 20 years including last year’s Healthwatch’s report Safely home: what happens when people leave hospital and care settings (2015).

The key issues are still:

  • People being discharged before being ready to leave hospital
  • People not being assessed properly or involved in plans for their own discharge
  • Relatives and carers not being told when someone has been discharged
  • People being discharged with no home care plan in place, or being kept in hospital due to poor coordination across services.

Whilst I welcome the proposed actions to address these issues - namely, ensuring a better understanding around mental capacity; including older people, carers and relatives as partners in decision making; and better coordination and integration between different services - I continue to have a nagging concern that we will still be here in 12 months’ time (I hope not less) reading about the same kind of awful stories with similar calls for action, unless we take a step back and consider the underlying causes of these systemic problems - not least the rampant ageism in society and services which perpetuates these problems.

So, what can be done?

  • Change the language: those of you who have read the Ombudsman report will have noticed that I’ve changed some of the language already. This is because I believe it is one of the major symptoms of the real problem underpinning the system failures described. Firstly, the report talks about “patients” instead of people; it uses labelling language such as “the frail elderly” rather than talking about older people with particular care and support needs; and it talks about diagnoses and conditions rather than people’s circumstances and lives. Language is one indicator of how older people are viewed, treated and responded to – whether that’s in hospital, in a care home or being supported at home. Starting from now, we need to change the way we view and talk about, as well as with, older people if we want to change the culture and practice of services supporting them.
  • Planning with people not about them: the report emphasises, even if the headlines do not, the need to involve older people, their families and carers in plans and arrangements for their discharge throughout their hospital stay. It’s not just a question of informing those people once a decision has been made, or worse still, once action has taken place (as happened to some people whose stories have been shared). Conversations about how to help people get home safely, at the right time and pace for them with the support they need to continue living at home, should begin on the day of admission. Some excellent examples of proactive and inclusive discharge planning practices exist; such as basing third sector advocacy, information and volunteer support services within hospitals to ensure that local community links are established and domestic arrangements made before people return home (like turning on the heating, organising shopping, making sure someone else is around or aware before someone goes home, fitting alarms or other assistive technology etc). Which leads us onto…
  • Thinking about the full range of community based support: alternatives to care homes do exist but they are not well known, and more needs to be done to widen or extend the options that do exist (e.g. circles of support, Shared Lives, individual service funds, Homeshare, various housing with support arrangements) and promote them to older people, families and importantly health and social care staff involved in assessment and planning arrangements in order to facilitate safe discharge home, avoid readmission to hospital and avoid admission to residential care.
  • Working in person centred ways to make this happen: person centred practices are not new; they are at the cornerstone of all contemporary policy and practice guidance, but we know that in reality this varies widely and for some people it doesn’t happen at all. Being person centred means really knowing what’s important to someone, not just for them; it means keeping that person at the centre of all discussions and decisions about their support and ultimately their lives, as we have seen; it means empowering them to take control or as much control as they want with help from people they know and trust. This can mean going the extra mile if someone has no next of kin, or introducing an advocate to ensure their views are known, heard and acted upon. It includes but goes beyond mental capacity and deprivation of liberty, to everyone’s fundamental human right to be treated as an individual, an equal citizen with assets and contributions regardless of age, disability or need for support.
  • Focusing on cultural and attitudinal change as much as structural and system change: the recommendations in yesterday’s report primarily focus on what services and staff need to do better or differently. These things are clearly important areas to address. However, they are not enough, and on their own they will not address the underlying causes of poor treatment, inadequate care, thoughtless decisions and neglect. We need to start talking openly about ageism; agree ways of addressing age discriminatory practices and cultures locally (and nationally); and use the tools and resources that already exist which can help us all work together and adopt inclusive practices that meet people’s needs in holistic, person centred ways.

I think it’s time for a national debate on how we value ageing and older people in our society and we at NDTi, like many others, are keen to start a meaningful conversation so that these experiences and reports are not repeated every year.

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