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.

Murdered for Medication

I saw this story on the Guardian website and was amazed that it was the first I heard of it.

Rachel Baker, the manager of Parkfields Nursing Home is on trial accused of murdering two women who were in her charge, and stealing their prescription medication that she was addicted to.

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Baker, 44, who ran the Parkfields care home in Butleigh near Glastonbury, Somerset, became addicted to drugs, including heroin, after being prescribed painkillers for migraines. She allegedly fed her addiction by “diverting” drugs prescribed for residents at the care home. She either stole the drugs from residents who needed them or exaggerated or made up symptoms so that drugs the elderly people did not really need were prescribed.

Baker has admitted eight charges of possessing controlled drugs and one of intending to pervert the course of justice. She denies the murders.

Just imagine the coverage if the victims had been 5 and 7 years old rather than 85 and 97 years old and that, I think, tells us all we need to know about society’s ageism.

Crisis and Discrimination

We had a meeting with our crisis team a couple of weeks ago. There is a general perception that they don’t like taking referrals for over 65s. It has increasingly developed into something of an ‘us and them’ situation so an attempt at some kind of reconciliary face to face meeting was planned.

Personally, I’ve had a few problems in referring. Firstly, they don’t accept any referrals for anyone with any kind of organic mental illness namely dementia. The explanation (although I never actually knew this until last week) is that no-one in the teams have any experience or knowledge of working with ‘these kinds’ of mental disorder.

Even with functional disorders, the input has been more than patchy. Certainly, I’ve had less than helpful responses to requests to refer – even within the ‘just passed 65 with no sign of dementia’ type of situations.

What was actually explained at the meeting (which in some ways helped but in other ways didn’t) is that they receive no funding for catering to the needs of over 65s so any referrals that they do take from us are just as ‘favours’.

I was interested that the explanations were not about ‘providing better services to the population’ or managing more appropriately crisis situations in the community to avoid hospital admissions but rather in terms of ‘doing your team a favour’. I mentioned this in the meeting. One of the psychologists later told me that he thought I might have been a little too ‘emphatic’ in my approach. I love our team psychologists!

Nothing actually irritates me more than this type of attitude though as it seems to have removed the actual purpose of the work that is being done and reduces the entire service the Trust provides  to a professional-led structure rather than a patient-led need.

Of course, this raises so many problems with the an institutional discrimination with the service that it shouldn’t be allowed to pass – but it does and it has.

Why somebody should have greater access to a service before their 65th birthday when the need can be exactly equivalent one day after seems to be a particularly short-sighted way of dealing with issues but it is also one of the reasons I am so eager to remain in this specialist team – so that these discrepancies are consistently challenged at an organisational level.

I know I am being a little one-sided and perhaps unfair but it feels sometimes that we are as much fighting within our trust for services as fighting together for the common good.

Such is the way in specialist services sometimes. And so I am free to argue on as long as I am respectfully argumentative and am able to retain an awareness of how far to push and when to stop.

This report then, published in the last week of the existence of the Healthcare Commission (which is consumed tomorrow, into the Care Quality Commission) which states that older people are often excluded from some of the mental  health services which are available to working age adults hit close to home.

the study showed older people were often unable to access the full range of services, including: out of hours services; crisis services; psychological therapies; drug and alcohol misuse services.

This reflects my own experiences so strongly that I had to check to see which trusts were surveyed for the research. In fact, these points ally closely with our experiences

  • out of hours and crisis services were often not open to older people and only took referrals for people under 65 or for conditions other than dementia. There appeared to be a reluctance to refer and a reluctance to accept referrals, due to workload and the age-appropriateness of the service offered. There was no clear justification for this.
  • Staff at several trusts said some older people had difficulties in gaining access to services for alcohol and substance misuse. Even when services were available they were either not offered in an age-appropriate way or were not available when staff attempted to refer to them. Many were geared towards younger people, usually males, and were felt not to be appropriate for older people who may feel vulnerable in the atmosphere.
  • In general the report makes for interesting reading but interesting reading is only useful if it leads to changes and effecting of change across the board.

    I was glad to see the study published, not least because it expresses similar experiences that hopefully can be challenged even more effectively in the future to provide a more equitable and cohesive service for all the members of the community that we serve.


    I admit, I had no idea what ‘Elderspeak’  term meant until I read this article in the Telegraph.

    Apparently it is

    defined by researchers as overly caring, controlling and infantilising communication – bears many similar traits to “baby talk”, including simplified grammar and vocabulary and overly intimate endearments.

    Maybe it’s just the circles that I move in but it’s not something I’ve come across a great deal. I can’t imagine myself ever calling someone I work with ‘sweetie’ or ‘dear’. But I can’t imagine myself saying that to anyone at all – let alone someone I was actually employed to work with as a professional!

    image zappowbang at flickr

    According to a study quoted in the newspaper article

    such verbal ageism can harm longevity by delivering a self-fulfilling message that older people are incompetent, frail and feeble, sending them into a negative downward spiral, researchers say.

    This is where the study makes much more sense to me. Language is enormously influential. It harbours the attitudes that we hold dear and sometimes it is a ‘looking glass to the soul’ where we might not necessarily want it to be.  By talking to adults in child-like terms we are indicating that we somehow have less respect for their capacity to understand and perhaps to the decisions that they make. It is not only patronising but it indicates clearly that we are making assumptions about someone else’s’ ability to understand.

    I have to say that I don’t use babytalk either. I personally find that children respond better when they are not patronised so the same thing holds true. Except children are more likely to have a family member speak up for them if they feel the treatment they are receiving is not appropriate.

    The study in question is described further in The New York Times.

    a long-term survey of 660 people over age 50 in a small Ohio town, published in 2002, found that those who had positive perceptions of aging lived an average of 7.5 years longer, a bigger increase than that associated with exercising or not smoking. The findings held up even when the researchers controlled for differences in the participants’ health conditions.

    In those terms it is very difficult to ignore. It isn’t just about the words that escape from the mouth as much as the effect that they have. I have to say, as well, there are some people who call EVERYONE dear, love and sweetie, regardless of whether they are 6 or 96. That’s not really the point though. I see it more as an issue about people who modify not only their attitude but their language specifically when they are working with older adults.

    There may or may not be cognitive impairment but that doesn’t entitle a person to less respect. Language can be simplified without being overfamiliar or condescending. And it does matter. If it makes someone feel that they have less validity as an individual, it is a part of the process of stripping away the humanity that is there.

    The  Telegraph article finishes with the insight of one of the respondents to the study saying

    “But I believe that the people who heap these endearments upon us are reacting to their own fears of ageing in a youth-oriented culture. My advice, darlings – get over it.”

    Which says it a lot better than I could have.

    image pamelaadam at Flickr

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    Safeguarding Adults?

    One of the key policies that I’ve worked a lot with over the past few years, has been the introduction of the ‘new’ Protection of Vulnerable Adults (POVA) scheme and the Safeguarding Adults procedure – when there is a suspicion of abuse of a vulnerable adult.

    And it’s usually a frustrating process.

    caution calamity meg calamity meg@flickr

    There is little legislation in place to allow for any action even where there is – in some cases quite open – evidence that abuse is taking place.

    Even after the forms have been filled, the strategy meetings have been convened, the police have confirmed that the CPS will not be able to take any further action because the victim of the abuse has dementia and therefore will not make a reliable witness – there is little that you can be left with.

    The frustrating part is that you can have a very strong idea of what is going on through allegations, people saying things, but as long as the Crown Prosecution Service see people with dementia being unable to serve as witnesses, prosecutions will not be forthcoming.

    Taking an elderly adult into residential care when they wish to stay in their own home is a draconian (and expensive) measure to take because the process of moving can be more permanent when someone is older. In fact, this article confirms that although there is no long term impact on elderly people who move into residential accommodation, when it is an imposed move, a higher morbidity rate can result.

    Sometimes, people are left in situations that compromise their safety, dignity and financial position because the alternatives are not feasible.

    I have been involved in two cases recently and without too many details, one is a standard (because unfortunately, it is probably the most common) financial abuse situation.

    Someone who has dementia has a family member who feels they can use the income, savings and benefits of their parent as ‘free money’. Is this enough reason to move someone out of the property? No charges can be brought because although there is no capacity, according to the law, she is giving the money willingly (of course, this doesn’t account for the distress that is expressed through lack of being able to visit the local shops and buy a paper).

    Another is a more tricky issue of possible physical and sexual abuse. Witness statements based on hearsay but fairly substantial – although not enough for criminal investigations.

    That did involve a move – but it was no thanks to the Safeguarding Adults ‘strategy’ meeting which seemed to consist of policemen apologising for what they were not able to do after consulting with the Crown Prosecution Service (no criticism of the police involved, they were equally if not more frustrated by this).

    And I shouldn’t even start on trying to get civil injunctions when someone lacks capacity. Civil injunctions are geared towards domestic violence and they have a part to play but when the person who wants to apply for the injunction is deemed to ‘lack capacity’ – there is a more convoluted and extensive procedure involving the Official Solicitor – none of which can be done in a reasonable time-frame.

    I think civil injunctions could potentially go part of the way in some circumstances although the need for proof is still there. I’m not sure what the answer is, but I wish the procedures had more teeth.

    I read in Community Care, well, on their website, that Ealing won a case to remove an adult from the care of her family who were ‘unsafe carers’. The article makes the point that

    ‘Vulnerable adult protective litigation is a relatively new legal area and many teams will not have the budgets in place to run a case such as this. Difficult financial choices will arise and it is to be hoped that, overall, a means can be found of taking necessary protective legal action without having to cut frontline services.

    The solution may lie in the new Court of Protection established under the Mental Capacity Act 2005. Future cases of this sort are likely to be heard by that court whose specialism and relative informality may make vulnerable adult cases easier to manage.’

    So perhaps the Court of Protection will provide a greater level of protection in the long run.

    One can only hope.

    But in the meantime Action on Elder Abuse have launched a survivors network for victims of abuse.

    I’m trying my hardest not to be cynical about this because any opportunities to help the victims of abuse has to be positive.

    But what I’d really like to see is an additional bump to the legislation and particularly the means of obtaining civil injunctions to cover more of the issues of adults who do not have capacity and a more streamlining (and quick) process.

    Ageism – the ‘acceptable’ face of prejudice

    Social workers are supposed to be a liberal group. We are trained extensively in anti-discriminatory practice. I can’t imagine there are any social work courses in the country that don’t, at least explore, the implications of discrimination, power and oppression even at the interview level.

    So it is particularly upsetting and distressing to see colleagues behave, speak or act in a way that seems contrary to those values that not only were emphasised throughout training and practice but that also carry through to every facet of life.

    We know that one of the fundamental foundations on which social work is based is that of combating oppressive practice and prejudices – so what to do when it is people and organisations you live and work in that are so prejudicial?

    I was confronted with this towards the end of last week. I still  have some anger – but the anger has changed from writing letters and shooting ’emails of indignation’ off in my head, to a more rational, ‘what can I do about this’ process. Time, although not as good a healer as it is given credit for, can produce some more rationality!

    Basically, the prejudice in question was ageism. It seems that our society is a lot more tolerant of ageism than other prejudices that are slowly, at least on an organisational level, easing out of the picture. But ageism is alive and kicking – and in some cases kicking very hard.

    The particular incident that annoyed me was the result of some casual comments which I followed up and found out that there were some changes ‘in the works’ which I seemed to regard older people as a separate entity to ‘adult’ services – and the people who work with some of the other departments are very anxious to divest themselves of all responsibility to older people because they are being presented as ‘different’ – but this was just one incident among many that I have encountered. From other teams who don’t work within Older People’s Services, from hospital wards, from GPs, from Commissioners within Social Services and most disappointingly from other Social Workers.

    A lot of the work of CMHTs (Community Mental Health Teams) seem to relate to risk and somehow the impression that I was getting was that risk to self is somehow less ‘cutting edge’ than risk to others. I can see how that can be much more obvious but the role is of looking at best interests and risk to self can be as damaging. The implication that older people do not have the same levels of risk to self or that the self in question has less value due to the age is something that has been making me increasingly angry and indignant.

    I know that the majority of the work that I undertake is with people who have dementia but people over 65 do not and should not suddenly lose the right to an equality of service and opportunities, just because they are over 65.

    The Independent writes about the growing implications for dementia for with an ageing population.

    Help the Aged conducted some research which presented (what a surprise) that the NHS claiming

    “The Department of Health has acknowledged that there are deep-rooted negative attitudes and behaviours towards older people and these are at the heart of failure to provide decent services for them.”

    The poverty, poor care, paucity of resources and lack of public funding experienced by older people in the UK would not be tolerated by any other section of society without people generally raising arms in a sea of disgust and outrage.

    Even today The Guardian has a leader about ageism within the National Health Service and working within the system, I see it very clearly and try to rage against it as far as I can  but I have my work cut out and it’s frustrating and upsetting.

    So why has it been possible to maintain an oppressive attitude to older people?

    Why isn’t there as much emotion and outrage when an older, vulnerable adult is abused?

    Are stories about older people dying (through neglect) in institutional settings or in their own homes not even reaching the front page of their local papers – let alone instigating national outrage and soul-searching which might lead to more changes in policy and quickly?

    I think when the stories are presented, people are disgusted and outraged but not to be same levels – adults can look after themselves, perhaps, people assume. Or they have families, friends, people to advocate for them where often they don’t.

    For me, I am asked (as I am occasionally and was frequently when I was on Post Qualifying Training) why I work with Older Adults or whether I find it ‘depressing’

    No, I don’t and partly it’s because I believe there is so much to be done in this area.

    It has the opportunity to be the most dynamic area of social work because there is so much to catch up on and I don’t know if I can speak in concrete terms but at the moment, there is no other area that interests me as much.

    I have strong beliefs that older people and carers don’t get the services, the respect and the focus that they deserve and that can be quite a forceful drive when some working days make you wonder why you went into this profession to begin with!

    Compare and contrast

    This article from The Guardian’s website compares the use of medication for older people with the safeguards in place when prescribing for children.

    It made a lot of sense to me. It is a part of the sensation that ageism permeates much of society and it is difficult to shake off and to rationalise.

    If someone needs support, they need support regardless of age. I’ve noticed a little bit of snootiness among colleagues even, when I tell them I work, primarily, with older people. They seem to think it is a less radical or less ‘important’ area of work. Personally, I can’t think of an area of social work which needs as much input or progression than older people’s services because there has been a lot of stagnation not least from the workforce itself.

    Conversely, that’s why there is so much progress that can be made in the area. I tended to think that it was because people don’t like to think about getting older or to think of what might happen to them – it is easier to disassociate the personal feelings if the ‘client’ is an ‘other’. A disadvantaged child. Someone with an illness or disability that we can approach from a ‘professional’ rather than ‘personal’ viewpoint.

    With older people, we all have/had parents, family members and can think of ourselves in the future as being ‘old’. I like to think that some of my personal experiences of family members and providing care, care services and knowing what works – can help inform my practice.

    Sometimes looking at the services from the inside can make one become more downhearted and frightened about ones’ own future and that of friends and family. But sometimes, it can make one very hopeful – and to be in a position to change that for some people and on a broader level, is a very particular and fortunate, I think.

    The injustices, inequalities and discriminations exist where they would not be sanctioned in any other service area. Just the attitudes of other social workers can be indicative of this. And that is one of the reasons I like working in this area. There is such a lot that needs to be done.