Elaine McDonald, Kensington and Chelsea and Dignity

Yesterday, the High Court ruled in the case of R (on the application of McDonald)  v Royal Borough of Kensington and Chelsea. This was a further appeal by McDonald against a previous decision at a lower court.

Elaine McDonald is 68 year old woman who worked as a ballerina in her younger days. The press seems to be a little fixated on her former career, and she does have a more glamorous background than many who come to rely heavily on social care so perhaps it is no surprise. Ms McDonald suffered from a debilitating stroke in 1999 and had a further fall in 2006 which led to very poor mobility.  Although not medically incontinent, she required assistance to use the commode during the night.  She had been provided with overnight support to meet her assessed needs related to continence during the night however Kensington and Chelsea were suggesting that this need could be met by substituting this assistance with the provision of continence pads during the night which would, by their nature, demand that Ms McDonald remain in these pads until carers could come in the morning and at intervals to ‘change’ her.

sulle punte

frabattista @ flickr

I wasn’t surprised by the decision by the High Court because there are precedents that led the access of local authorities to resources to be a factor in relation to the provision of services.

In my own working experience, it is impossible to access any kind of home care support overnight except in some very specific cases where there is very high need support and even then, it is much much more likely to be provided to younger adults with physical disabilities. I can count on the fingers of one hand the amounts of times I’ve come across local authority funded overnight support in the last 10+ years of practice.

Sometimes I have to take a step back from what I regard as ‘normal’ practice to understand the outrage at this decision. I realise how I become attuned to ‘local authority’ think and ‘budgetary’ think and that’s quite an uncomfortable thought.

We get used to applying different definitions of ‘dignity’ and what is acceptable because we are aware of the thousands of Ms McDonalds that require support and the existence of a  finite resource. So do you support the Ms McDonalds and assist them to provide a fuller and more dignified life at home or do you provide 8 Ms Smiths with respite care over the year. These are the realities of the decisions and it shouldn’t have to be so.

Perhaps that’s why I’m less surprised by the McDonald ruling and less surprised by it.

There are though horrendous inequities in our system of the provision of social care. Where Ms McDonald in Kensington and Chelsea may be receiving a vastly different service from a parallel Ms McDonald in Newham.  I would venture a guess that there are thousands of potentially very similar cases to Ms McDonald bubbling under the surface ‘in the system’ but because they are not ex-Prima ballerinas and don’t have the will, way and means to bring cases and involve solicitors, we will never know about them.

If anything is, quite literally, the ‘dirty secret’ of social care and health care provision particularly for older adults, it is this.

We have different standards of what we class as being ‘dignified’ for ourselves as for others. What might class as dignity to an older adult has less value and invites less spending to an equivalent younger adult with exactly the same care needs. Those who shout loudest get the most – as far as care is concerned and as far as public interest is concerned.  The shame and pity of the ‘personalisation’ agenda and the flawed implementation of personal budgets in social care have exacerbated this problem further rather than provided a channel to allow for a more equitable system of care delivery.

It sometimes feel cruel and harsh, because it is a cruel and harsh system that it perpetuated by discriminatory systems. Would the warehouse-style very large residential and nursing care homes with 100+ beds be acceptable for younger adults with similar care needs? I don’t think so.   I don’t mean to imply that every large care home is bad and every small care home is good. That isn’t the case. It’s about a fundamental reassessment of what is acceptable in the provision of care for older people in our society.

Lucy at The Small Places covers the issue of dignity through caselaw, in an excellent, thorough and educational post.

I make no apology for my less erudite post and thoughts.  The more I work and the more I reflect, the more interplay I see between the basic conceits of ethics and ethical judgement in the role that I play as a part of this system that condones this mealy mouthed interpretation of human rights merely on the basis of cost and resourcing issues.

It is accepted because our society is inherently ageist. We don’t want to think or pay for the care of older people. We care more about our collective inheritances and potential house prices than the more collective thoughts about where the boundaries of an acceptable level of care and dignity lie.

If anything, this has impressed on  me the importance of constant reflection on my practice and my work. I can advocate to an extent, from within the system, for the dignity of those like Ms McDonald and I try to. Some I win and some I lose but as long as I make my voice heard through every step of the process I can help to feed the voices ‘from the front line’ back to the more senior managers.

I make judgements and I am the mouthpiece of the local authority. I am an employee but the second that I become complacent, the  moment I stop reflecting on the effects the decisions I make have and the instant that I join that local authority ‘group think’, I lose my ethical compass and my professional judgement.

I talk a lot about important qualities of social workers and social care workers. Respect, empathy and to that I’d add advocacy. It might not always be seen in the internal battles that we fight, but we have to try to fight so as not to accept a ‘normal’ that is defined on the bank balance sheets of the local authority accountants.

7 thoughts on “Elaine McDonald, Kensington and Chelsea and Dignity

  1. in my own experience as a social services manager for many years I identify with your comments about how we become normalised by the language and concepts used in the provision of care that seem to distance us from the reality of the the decisions we make on other people’s behalf.

    It is undignified to be required to sleep in your own faeces, that is simply.

    The argument of if we can do anything about it may well be complex.

    But that this woman faces misery and depression because of this decision is undeniable.

    That other people might have measurably more misery is not an excuse for that. (which is the implication of the court decision)

    People have the right to dignity….

    Thanks CB, great post 🙂

  2. As a manager then, you will know that this has been going on for decades. The thing is that dignity should be self-defining to the extent that people can. That is something the personalisation agenda should have encouraged far more rather than retaining a system of those who can, get and those who can’t get cast aside by ‘the system’.

    As for the answers being complex, I think the issue is more than the answers are costly and noone wants to pay so we try to ignore them until they affect us or those close to us. That is the shame of the system as it is now. If people like Ms McDonald and the many many many Ms McDonalds are to be cared for in a dignified manner, it needs a much greater root and branch change in the system and unfortunately having just been through a ‘transformation’ process, those on managed LA budgets who are more likely to be older people, particularly those without friends and family as advocates, those without capacity will have less of the ‘pie’ as others are able to access much better, more individualised care packages.

    The systems have not been put into place for more individualised care planning as we have not been given more time to spend with people to design care packages which are more attuned to their needs. We are just given more forms and told to ‘get on with it’ and with more targets, more tasks and more forms.

    If anything it is the ‘managers in social services’ as well as people like me who need to shout much much louder, speak out about what is being allowed to happen as not all the Ms McDonalds will have the wherewithal to challenge the current thinking about what is acceptable and what is not.

    Until people think in broader terms about what society finds acceptable for older people, it feels as if we will continue to be hitting out heads against a collective brick wall but everyone working in the ‘system’ needs to speak out and advocate and not being fearful or complacent within a system that almost seems to demand it.

  3. Hello CB

    Like you, my background is as a social worker with older adults and adults with disabilities. Like you, I think a lot of the apparent shock at this judgement comes because of the generally low level of media coverage of social care issues so that reporting on any case, particularly if there are a few emotive issues, may appear to be depicting a situation that’s novel or alarming. Any carer, service user or person working in the care sector would probably only be surprised by the large size of Ms McDonald’s care package relative to the apparent degree of her need. Again, the judgement isn’t a surprising outcome because of previous case law. It could be appealed. It would be very interesting if Ms McDonald’s claim were upheld. If it were, I think the overall outcome might be perverse as LAs would practice very defensively indeed to defend themselves from possible claims. I think it would be difficult to see temporary increases in care for particular crises or for in-home respite care if LAs thought there was a ratchet effect and no care given could then be reviewed or removed.

    It’s probably a good idea to make a distinction between what the papers say the people say and what the people say. I had a look at the comment sections in some of the news websites, expecting another orgy of social worker bashing but was actually surprised by what I saw. Some of the comments were spiteful, criticising Ms McDonald as simply selfish and saying she should be in a care home (where all old people belong, of course). Others were more thoughtful. I saw one comment from someone who uses incontinence pads and says, that though having to begin using them took a huge moral effort, that they are ultimately liberating because they permit the commenter to be more active. All of the comments seemed to have a shrewd awareness that £5 spent in one place is £5 you can’t spend elsewhere and that difficult choices have to be made.

    I have some experience of deploying overnight care. It was generally empoyed to relieve a live-in carer or to try and save a crumbling care package compromised by crisis, illness or a sudden onset of acute confusion in an older person and sometimes for palliative care. Generally speaking, apart from some very stable care packages, once overnight care was being used, other difficulties about health and the delivery of care generally overwhelmed the attempt to support someone at home after a short period. It’s a resource that should be more available but which I think would need to be deployed sparingly.

    One point that not all of the press coverage has highlighted is that the LA’s view was in part upheld because it offered alternatives, including a move to an ‘extra-care’ housing facility. Difficult to say, but these suggested alternatives do seem to have been meaningful compromises rather than nominal suggestions.

    Like you I would love it if we could routinely commission large care packages to promote dignity and autonomy for older people to a standard that physically fit and active people would find acceptable. Society expects people with some health conditions to accept less, be modest in their demands and appropriately grateful and the rhetoric of choice, so often employed in social care, can be completely hollow. However, equity is also an issue: I doubt even Kensington and Chelsea has may overnight support care packages clocking in at £22 000 per annum and speaking as a former ‘point of rationing’ myself, I observe that you’d get to the bottom of the budget rather quickly if this was a routine standard of provision. I do sometimes wonder if having to make these choices and present them to the people they concern might coarsen and damage me as a person and a professional worker? I’m sure care managers have all met callous and uncaring bean counters who sometimes seem almost angry at the LA’s clients for the degree and intractable nature of their needs. Perhaps they should get out of the office more.

    Ah well, at least Ms McDonald’s spirited campaign presents a different view of the older disabled person: confidently asserting their needs and taking some control. Better than the media’s other trope about dignity in the face of dependency and health adversity which appears to sympathetically consider the proposition that they should all catch the plane to Switzterland to do the decent thing by the Council Tax payers.

  4. recall as a student nurse in the 1970s being told we were advocates against the system for our patients. With the introduction of ‘Advocacy’ professionals the requirement that we all as care givers advocate for those in our care can get lost & I have been told in blunt terms by ‘advocates’ to get on with my job & leave them to theirs – sad really

  5. The rep from adult care who tried to explain the descision, made a comment that she didnt sign a contract with ILF ? Do you know anything more about this ?
    The “public” really have no idea until they need support themselves how much it is already limited.
    The descision was made because of cost, councils do not have enough money, so social workers become responsible for making cuts and take the blame yet again !
    Its time that senior managers spoke out about the realities of funding/social care, instead of trying to carry on with less and less, and allowing workers at the bottom of the pile to be blamed.
    We are all colluding with a system in meltdown. “Dignity” is a word that is a joke in the current system, those of us in the system know that, but dont/wont say.

  6. Totally agree with CB everyone in “the system” needs to speak out, and not be fearful. However clearly we are “fearful” as those of us in the system not using our real names…
    I have certainly been told that as S/Ws we are “agents of the department” certainly not advocates!
    Think the mealy mouthed responses from ken/chelsea say it all, the spokesperson made an attempt to be clear but it felt like she was gagged and was terrified of saying anything shed be in trouble for.
    Even Police managers are speaking more openly about the effects of cuts, can anyone imagine Managers in care doing that ? There is a strong culture of denial in L/As and passing the blame down. Just like current news of world issues, the workers at the bottom get the blame and the sack , those at the top, see to be getting away scott free!
    The “culture” at newspapers which is being highlighted now should really encourage all organisations to look at their own cultures, if done honestly suspect many would be horrified about what they found.
    What the public dont realise or try not to realise is that “dignity” costs money. With 120 billion or so in unpaid/evaded/avoided taxes there IS money there, cuts are not actually necessary but there is no political will from the main political parties to do things differently.

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