Delivering dignity

This blog was contributed by Dianne Jeffrey CBE DL, Chairman of Age UK and Joint Chair of the Commission on Dignity in Care.

After many years’ service in health and social care I have seen much in both to be proud of. I have witnessed excellent examples of compassionate care, met many dedicated staff and seen how high-quality services have transformed lives.

Yet I have also been deeply saddened by the knowledge that in too many cases care has fallen short of these standards, letting people down when they are vulnerable and most in need of help.

Dianne Jeffrey CBE DL, Chairman of Age UK and Joint Chair of the Commission on Dignity in Care
Dianne Jeffrey CBE DL, Chairman of Age UK and Joint Chair of the Commission on Dignity in Carecare has fallen short of these standards, letting people down when they are vulnerable and most in need of help.

That is why I have been delighted to co-chair the Commission on Dignity in Care; an independent commission established by Age UK, the NHS Confederation and Local Government Association to bring together expertise from right across the care system, including nursing, social care, medicine and commissioning with the voices of older people and their families.

Our aim was to help health and social care sectors to find long-term solutions to tackling poor care that work on the ground.  We recognise that this is a difficult task, there are no silver bullets. Instead we wanted to understand the roots of poor care and find ways to support people to take action in their own organisations.

Today, just a little under a year since we began, we publish the Commission’s final report Delivering Dignity. The report’s main message is clear. Leaders in the health and social care sector must drive a “major cultural shift” to tackle the underlying causes of poor and undignified care of older people throughout care homes and hospitals.

The NHS already has ‘never events’, things that are considered so serious they should never happen, like operating on the wrong part of the body. The Commission has recommended ‘always events’,  things which should never be forgotten and should be considered as basic rules for the delivery of dignified care in every hospital and care home.

This may all sound a bit theoretical at first glance. However our report has made 37 clear recommendations for steps that could practically be taken by people at every level from front line staff to board members. Ultimately it is the individual actions of people in the system doing the right thing which adds up to major change.

Delivering dignity will mean changing the way we design, pay for, deliver and monitor care services as the numbers of older people in care continues to grow. Alongside the consistent application of good practice and the rooting out of poor care, we need a major shift in the system to ensure care is person-centred and not task-focused.

This will require empowered leadership on the ward and in the care home, as well as a lead from boards and senior managers. It will also mean changing the way we recruit and develop staff working with older people.

We have to work with older people to shape services around their needs, and listen to patients and residents and their families, carers and advocates so we learn from their feedback and continually improve dignity in care.

We are also clear that it is the leaders of health and social care who are responsible for driving better quality care.  Regulation and government action has a critical role to play, but it cannot alone deliver the cultural and organisational change that may be necessary.

In February we published an interim report to consult on our proposed recommendations. We were overwhelmed by the hugely positive response it received, with over 230 responses from across the health and social care sector, patient groups, members of the public and professionals. This clearly demonstrated to me just how passionately people feel about getting care right for older people.

Our next challenge is harnessing this passion and commitment to drive forward implementation of our recommendations.

I don’t underestimate the scale of this task and know we won’t see changes overnight. But from the very beginning we were determined that this wouldn’t be just another report that sat on shelf gathering dust.

In the autumn we will be launching an action plan. We will be seeking to work with people from across the health and care system, professionals and older people to make sure change happens.

Find out more about the work of the Commission and read the final report

Find out more about Age UK’s Care in Crisis campaign

Rights and resources – Supreme Court social care ruling

Local Authorities have statutory duties to provide social care to people who need it, but at the same time have finite resources. The way in which local authorities should reconcile their duties towards individuals with sound budget management appeared to have been established by the so called ‘Gloucester judgment’ (R v Gloucestershire County Council, Ex parte Barry).  This judgment ruled that local authorities could take their resources into account in setting their eligibility criteria for social care, but if someone met the criteria the local authority had an absolute duty to meet eligible needs. The local authority could not, once eligibility was established, use resources as a justification for not meeting needs.

However in the past couple of years the implementation of personalisation combined with unprecedented funding cuts has resulted in the relationship between rights and increasingly limited resources once more being tested in court, with the most recent case, R. (on the application of KM) v. Cambridgeshire County Council, going all the way to the Supreme Court.  This case was flagged up in advance as one which might overturn the ‘Gloucester judgment’ though in the event this did not happen.

Photo: Rosie O’Beirne

The main issue at stake in this case was the use of ‘Resource Allocation Systems’ (RAS) to calculate a personal budget. RAS are often used to allocate an amount on the basis of a standardised questionnaire. This means that the budget calculated might not be enough to meet the individual’s needs. However it is often not clear to the person how the budget has been worked out, or what needs the budget is supposed to meet, so This makes it impossible for the person to challenge the amount allocated on the basis that it is not enough.

However the law has not changed; local authorities still have duties to fully asses the needs of the individual, to consider whether they are eligible for support, and to ensure that eligible needs are met. In 2010 an important case, R (Savva) v Kensington and Chelsea Royal London Borough Council, underlined this point. Whilst the court agreed that a local authority could use a RAS to work out an approximate, or indicative, budget, it remained the case that once eligible needs had been established on the basis of an assessment of individual needs, the council was under an absolute duty to provide services that would meet those needs, or a personal budget with which to purchase them.

The person was also entitled to know how their budget had been worked out. The judge gave an indication of the level of detail required concluding that ‘I would consider it adequate to list the required services and assumed timings… together with the assumed hourly cost. That would not be unduly onerous. I appreciate that some recipients require more complicated arrangements which would call for more expansive reasoning but if that is what fairness requires, it must be done.”

All of this creates a fairly consistent picture, but during 2011, R. (on the application of KM) v. Cambridgeshire County Council appeared to overturn this position, with the Appeal Court concluding that in allocating a personal budget ‘the  local authority are not obliged to meet an individual’s needs in absolute terms’. This caused considerable alarm and resulted in a number of representative organisations supporting a further appeal to the Supreme Court (Age UK did not intervene as no older people were involved).

The Supreme Court judgment, announced last month, reconfirms the position established by Savva and concludes that the view expressed by the Court of Appeal was erroneous and based on a misunderstanding of the Savva case.

 So the law effectively remains as it was. Local Authorities have an absolute duty to meet assessed needs and must be able to show that a personal budget has been worked out on the basis of a proper assessment, and that it is sufficient to meet needs identified by that assessment.  The decision re-enforces the point made in Savva that a local authority must explain how it has calculated the person’s budget – the court notes that ‘failure to meet eligible needs may prove to be far less visible in circumstances in which it [the local authority] has provided the service-user with a global sum of money than in those in which it has provided him with services in kind. That point fortifies the need for close scrutiny of the lawfulness of a monetary offer’.

Age UK are calling on the Government to urgently reform the care system. More than130,000 people have signed our Care in Crisis petition calling for reform of England’s care system. Find out more about the campaign and how you can get involved.