Rip it up and start again


This week is Dementia Awareness Week – the theme this year is: Remember the Person.

Weaknesses in the ability of people and/or their carers to hold so called ‘system’ leaders into account for upholding their rights is a stubbornly persistent issue in health and social care.  We seem to have an endless supply of shocking evidence where the ‘system’ failed to remember to see, hear and value the person, such as the abuses which took place at Winterbourne View (2012), Mid-Staffordshire (Francis 2013) or most recently the failure to investigate the deaths of people in the ‘care’ of NHS Southern Health Foundation Trust reported in the #Mazars report (2015). Perhaps even more worryingly however on a daily basis in social care we uncover evidence that people are experiencing poor care and support which ignores their wishes, feelings and beliefs. The daily churn of health and social care organisations, operating institutional routines that are the way things are done in that organisation, have always been done and no one wants to change them, legitimises people being treated as though they don’t have the same human rights as everyone else. For older people with dementia who are poorly enough to need a stay in hospital, this can result in really poor outcomes.

As commissioners we are told our role is to design responsive, high quality, accountable health and social care ‘systems’.  The ultimate test of such systems has to be the extent to which they are ethical – as measured by how well people’s human rights are upheld by the system.  Back in 2011 The Health Service Ombudsman published the Care & Compassion  Report on the outcomes from 10 investigations into the experiences of older people within the health care system.  The report findings were of a stark contrast between the principles and values of the NHS and the reality of the care and support received by people who were within the health system.  In 2016 the Ombudsman has just published a further report on the issue of how people experience the health care system – a Report into the Investigations of Unsafe Discharges from Hospital.  The report details the avoidably distressing experiences of 9 people, the most serious of cases which illustrate the gap between good practice and the reality of  hospital discharge processes and the system of care and support.  The underlying structural, organisational and practice issues which the report highlights will take more than just leadership vision and calls to accelerate pace if we are to see real, sustainable change to the fractured and institutionally abusive system exposed by the Ombudsman.

Social work training encourages that social workers and commissioners make an explicit connection between people’s outcomes from our interventions and ethical, moral practice.  Any judgement of the quality of social work and social care commissioning should clearly include practice being held into account by the people we are here to serve.  Being open to critically reflect on our practice with people can only strengthen the moral purpose and intellectual nature of social work and adult social care.  Strengthening of both is essential if we are to tackle the structural and routinised institutional abuse which people are experiencing and are able to legitimately make moral claims about the case for change.

The Ombudsman identifies four serious issues about how people experience the health and social care system: people being discharged before they were clinically ready to leave hospital; people not being assessed or consulted properly before discharge; relatives and carers not being told that a family member had been discharged; and people being discharged with no home care plan in place, or being kept in hospital due to poor coordination of services.  All four of these issues feel familiar and live issues in cases we are managing today to support a sustainable transfer of care home from hospital.  They are reflective of a system which needs to reconnect with its purpose and re-find its compassion as evidenced through flexibility, empathetic behaviour and enabling people to feel safe and exercise control over their daily lives.

Social work is rightly proud of its disruptive tradition.  Ultimately however, all the money in the world generated through what ever ‘personalised’ resource allocation system we can dream up as commissioners will only buy a person a service, not a dignified life.  Whilst obviously the most powerful voice will always be the person who experiences care and support (who else knows what happens in a care home or supported living setting at 3am when no one else is there to watch) there is an overwhelming weight of evidence telling us that we are long overdue major system disruption.  It is starting to feel like it is time to say – enough is enough – let’s rip it up and start again with a whole new way of doing this.  A more cooperative way of working together with the person at the heart of their own system.


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