Dignity in Care. Next Steps for
Policy?
David Oliver
Westminster Food and Nutrition Forum
14th June 2012
I: Setting the Scene.
What do we already know?
What’s going wrong and why?
Ageing, health and services
• Population ageing in England
• Unhelpful, polarised attitudes
• What ageing means for health and wellbeing
– The good news (and wider psychosocial factors)
– Most older people are not miserable, ill, dependent or
institutionalised!
– The bad news
• What this means for health and care services
– “Older People R us”
– Including many with complex needs
Services fit for ageing population?
• Much great practice to celebrate/spread
• Many satisfied customers
• High ranking on several international
indicators
• Not all doom, gloom, sensation and scandal
• Growing interest in rebalancing towards:
• Prevention, Proactive LTC Care, Integration
• So old not in hospital or long-term care for wrong reason
Quality in Services for Older People?
• Experience.....(more in a moment)
• Outcomes/evidenced-interventions to deliver them
– e.g. national audits/reports on continence, fractures, falls, nutrition,
dementia, peri-operative care, CPR etc
• Safety
– e.g. Falls, pressure sores, hospital infection, drug errors, inpatient
mortality, preventable delirium, hospital discharge
• Efficiency & variation
• e.g. Atlas of variation in NHS and in Social Care, Audit Commission
Report on Health and Social Care Interface, Delayed Transfers, Hip
Fracture Database, Admission Rates, Placement Rates etc
• Continuity/Integration
– Reports on bewildering experience from patient/carer perspective (e.g
Glasby J “care transitions”)
– Reports on problems for whole systems (Future Forum, Kings Fund)
– Dis-integration, poor continuity is “lose/lose” for people and systems
Ageism/Age Discrimination
• Overwhelming evidence
• e.g. Centre for Policy on Ageing Reviews 2009
• e.g. Equality Act Consultation
• e.g. Surveys of managers, nurses, doctors
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System incentives and priorities
Attitudes and behaviours
Balance of training, education
Conditions of ageing relatively neglected
Worse access to care in older with same condition
Older people with functional problems/frailty written off as
“social”, “acopic”, “inappropriate” , “medically discharged”
etc instead of being properly assessed, diagnosed
• A point not to lose….older people need a diagnosis and skilled,
multidisciplinary care. Stop the false distinction between medical and
“basic nursing” care. Many wouldn’t be so dependent if the right thing
done for them by staff with right skills.
Back to …“Experience”
• Biggest issue affecting dignity
• Our starting point must be:
• “What do older people and their carers say
they want in their own care?”
Dignity in Older Europeans
(Woolhead) 400
older people. (Themes mirrored in 500 under 65s)
• Dignity of identity
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Maintain self respect
Undermined by disrespectful address or labelling
Attitudes of staff or family
Neglect of appearances and clothing
Exposure
Lack of privacy in personal care and mixed wards
Toileting
Nutrition (and assistance with feeding and drinking)
Care when suffering or dying
• Autonomy
– Retain independent control over lives for as long as possible
– Even where need for nursing home, can still be kept clean and tidy
• Human rights
– Importance of being treated as an equal, regardless of age
– Fighting discrimination
– Choose how you live and how you die (including advanced decisions)
Put another way…an “I” statement
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“I want to be treated as a person, not an object”
“I want to feel in control of my care or treatment”
“I want privacy when washing, dressing, toileting”
“I want help with eating and drinking”
“I want my condition to be taken seriously”
“I want to receive the best treatment available”
“I want to be spoken to politely, but not patronised”
Family Carers’ priorities?
e.g. RCPsych Audit of Dementia Care in General Hospitals 2011
• Care planning and support in relation to the dementia
(i.e. not just the acute condition) from admission to
discharge
• Care of patients with acute confusion
• Maintaining dignity in care
• Maintenance of patient ability in hospital
• Communication and collaboration
• Information exchange
• End-of-life care
• Ward environment
• Mirrors Patients’ Association C.A.R.E campaign
Patients Association CARE Campaign
• “As a minimum, all patients should get assistance
when they call for help, encouragement to eat
and drink, assistance with going to the toilet and
have their pain addressed”
• Communicate with compassion
• Assist with toileting, ensuring dignity
• Relieve pain effectively
• Ensure adequate nutrition
End of Life Care
Help the Aged. “Dying Matters: Listening to Older People”
• “I want to die at home if that is my choice”
• “I want to be told if I am terminally ill”
• “I want to make things easier for my family
and friends”
• “I want to die with my loved ones round me”
• “I want to die with dignity”
• “I want to die free of pain”
• “I want choice, information and control”
But we don’t always deliver on these
• 2008 All parliamentary enquiry into older people in
health and social care
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– “A disturbing picture, requiring an entire culture change”
NHS Ombudsman’s report “care and compassion” 2011
Patients association report
CQC Dignity and Nutrition Inspections 2011
Various reports on dementia care in general hospitals
2010/11 (e.g. “counting the cost”, RCPsych audit
• VOICES survey on end of life care
• Francis Report on Mid-Staffs...
• Common issues: Dignity, nutrition, communication,
respect, information, continence, privacy, discharge
from hospital, end of life care, pain relief, dementia
care, attitudes
Evidence on underlying reasons e.g.
(addressing these can deliver change)
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Leadership (“ward to board”)
Culture, values, attitudes
Skills, knowledge
Making it easier to do the right thing and
harder to do the wrong
• Organisational support/barriers
“Counting the Cost”, Dementia in Hospitals
1,291 carers, 657 nurses, 479 ward managers
PANICOA. “Dignity in Practice”
Tadd W et al 2011
• Detailed interviews with 40 older
people – recent discharged, 25 carers
• In depth interviews with 79 frontline
staff and 32 managers
• 617 hours care observation, 16 wards
4 hospitals. Key Themes:
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“Whose interests matter?”
“Right place wrong patients”
“Seeing the person in the bed”
“Influences on dignified care”
• Recommendations...
• Training Videos “a tale of two wards”
RCN Report on nurse staffing
• 9-10 RNs patients per RN
on older people’s wards
• 6.7 on adult medical or
surgical
• 4.2 on children’s wards
II: Moving Forward. How could
we get better?
Not all about policy or “the centre”
Also clinical, professional, organisational leadership
Death by awareness?/Groundhog Day?
• “I’m drowning here and you’re describing the
water”
• Melvin Udall. “As good as it gets”
• We have ample evidence already on:
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What older people and their carers want
What good practice looks like
Good service models to deliver it
What’s going wrong
Why ?
• Lets focus on solutions, solutions, solutions
Toolkits, campaigns
and guides
We have had endless
toolkits and
guides on dignity
per se
Constructive Solutions, relevant to 2012
no one “silver bullet”
• “For every complex human problem there is a
solution which is simple, obvious and wrong”
• H L Mencken
• We need to tackle the problem from several angles...
• Stop reducing everything to hospitals, nurses, “basic
care”, nurse-bashing, nursing degrees, SENs
“accountability” and “matron”
• Challenge the idea of a “golden age”
Generic Solutions....
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“Blue sky”
Beyond politics, any system, any government
A question:
“What is the necessary/sufficient role of
government, policy and “the centre” (including arm’s
length bodies such as commissioning board, NICE or
regulator)?”
• What has to be delivered by others?
Only 6 of 41 recs for government
• Recommendations for:
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Hospitals
Nursing/Res Homes
Systems
Universities
Educators
Professional Bodies
Regulators
Leaders
DH
Wider government
Commissioners
Professions
Advocacy Groups
• Recommendations for:
– Senior Leaders
– Team Leaders
– Professional bodies/societies
– Policy makers, government, NHS commissioning
board
– Think tanks and commentators
Dr Oliver’s Generic Prescription:
Non-government – driven “bottom-up”
• Systematic involvement older people/carers
– Training, Designing Services, Evaluating, Care-giving
• Education, training, skills
– So staff have the right skills to look after largely older patients
• Workforce in place to give care in right setting
• Focus on prevention/LTC/earlier support
– so older people only in hospital or care home when they need it
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Good practice guidance
Dissemination of good practice models
Facilitate implementation
Professional and Clinical Leadership and Accountability
– Colleges/Specialist Societies, Providers, Commissioners, Leaders in
organisations
• Transparent performance data inc. satisfaction/complaints
• Advocacy, campaigning from charities /think tanks etc
D.O. Generic prescription for policymakers/”the centre”
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Effective regulation, inspection
Follow-up with improvement plans
System rules, standards and incentives
Targeted/themed programmes or investment
Older people = key to efficiency challenge
Use of Law
Focus, scrutiny, momentum from politicians
Not just platitudinous “motherhood
and apple pie”
• These approaches can really deliver change
• Live examples in NHS include:
– Hip fracture
– Dementia in hospitals
– Stroke
NHS Operating Framework
NHS Commissioning Board and Outcomes Frameworks
We will have several outcome indicators, quality standards etc relevant for
older people, dignity, experience etc
Duty of quality
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NHS OUTCOMES FRAMEWORK
Domain 1
Domain 2
Domain 3
Domain 4
Domain 5
Preventing
people from
dying
prematurely
Enhancing
the quality
of life for
people with
LTCs
Recovery
from
episodes of
ill health /
injury
Ensuring a
positive
patient
experience
Safe
environment
free from
avoidable
harm
2
Duty of quality
Duty of quality
1
NICE Quality Standards
(Building a library of approx 150 over 5 years)
3
Commissioning
Outcomes
Framework
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4
Commissioning
Guidance
5
Provider payment mechanisms
tariff
standard
contract
CQUIN
Commissioning / Contracting
NHS Commissioning Board - Specialist services and primary care
GP Consortia – all other services
Duty of quality
QOF
Nursing & care, quality forum.
Themes...
• “Leadership”
• “Culture and values”
• “Involvement and feedback”
– Inc “friends and family” test
• “Time to care”
• “Energising for excellence”
• “Commissioning for quality care/experience”
Other Policy.... concerted action
• National CQUIN programme
– Dementia, Safety Thermometer
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Focus on discharge. post discharge care, readmissions
Monies for re-ablement/delayed transfers/social care
Best practice tariffs (e.g. Hip Fracture)
Development of whole year of care payments and new RRR tariff
National clinical audit programmes
Transparency in data
NICE guidelines and Quality Standards
CQC role (inc. 700 further DANI inspections)
National Dementia Strategy (and priorities in care settings)
End of Life Care and LTC strategies
Ongoing work on integration
Social care reform and Dilnot commission
NHS Constitution – rights, responsibilities, transparency, whistleblowing
Equality Act Age Duty
Human Rights, Mental Capacity Acts
What next?
• Will this momentum…
• And response to Francis report
• And professional leaders
– e.g. Age UK/NHS Confed “delivering dignity”
– e.g. RCN work on dementia
– e.g. RCP Quality Mark work
– e.g. Patients Association “partners in care”
• Deliver measureable change?
• Or a feeling “out there” that things have
improved?
No room for defeatism. There is plenty we
can do to improve care for our older
patients.
• And remember, it could
be us or our loved ones
• Thank You
• David.Oliver@dh.gsi.gov.uk
• David.Oliver.1@city.ac.uk