Reframing Ageing

Public perceptions of ageing, older age and demographic change

July 2021

Attempting to change narratives is often known as ‘reframing’: making
conscious and intentional choices about what to include – and what
not to include – in communications in order to influence how people
think, feel, and act on certain issues. The language we use matters
because it can influence public opinion, which can in turn influence
policy choices and decisions.
The current ‘dominant view’ of ageing and demographic change is
summarised in the table on page 6 of the report. This is derived from our literature review and discourse analysis, which explored how ageing was talked about and represented across different parts of society.
The ‘alternative view’, also summarised, has been developed
over several years of researching ageing and how people experience
later life. Many working in ageing already advocate for this view and
ascribe to it, however it is clearly at odds with the current dominant
view. The gap between these two views represents the reframing
challenge. The report explores this and how we create that shift from the
dominant view to the alternative view.

Read the report at Centre for Ageing Better source: Reframing-ageing-public-perceptions.pdf

The Strange Revival of Mabel Dodge Luhan | The New Yorker

https://www.newyorker.com/books/under-review/the-strange-revival-of-mabel-dodge-luhan

Lessons will be learned

Margaret Flynn and Vic Citarella – authors of the Winterbourne View Hospital serious case review – reflect on what has followed the screening of the BBC Panorama \’Undercover Care: the Abuse Exposed\’ five years ago in May 2011.

The serious case review was published by the South Gloucestershire Safeguarding Adults Board in August 2012. In response to the findings and recommendations, politicians asserted that lessons will be learned and that they would set in train a number of continuing efforts to ‘transform’ services.[1]It was apt that they should deploy such terminology since, for us, the lessons have been stark:

Now it is evident that the number of people with learning disability referred to assessment and treatment facilities stubbornly refuses to reduce. The lesson? Stop registering these facilities and stop using public money to fund placements. Neither do we need yet another review to confirm that the act of commissioning a review only begins to address the heart-felt search of families for justice and healing. It\’s what comes after a satisfactory review that matters;

Change is a hard, slow process. Transformation programmes, such as the Winterbourne View Hospital Programme Board, are known to fail two-thirds of the time:  A long, drawn-out project executed by an inexpert, unenthusiastic, and disjointed team, without any top-level sponsors and targeted at a function that dislikes the change and has to do a lot of extra work, will fail;[2]provides an extreme caricature of what has happened. The lesson? Spend scarce resources on making sure the dice is loaded towards the converse – or better still towards prevention;

Sustained austerity and cuts in services for people with learning disabilities and their families cannot address the support needs of children, young people and adults whose behaviour is bewildering, troubling, challenging and even criminal. The lesson? The NHS spent a lot of money on commissioning harmful and inappropriate services at Winterbourne View Hospital.  The expenditure continues and should now be unequivocally channelled towards user and family controlled organisations. The stakes are high and soaring;

There appear to be many professionals who believe that ‘full-body restraint’ is a necessary skill for health and social care workers supporting people with learning disability. They should be directed otherwise. The lesson? This form of restrictive physical intervention leads to death, physical and emotional pain and severe injuries. Although Castlebeck’s restraint policy seemed OK, it was wholly ignored by its employees!

Health and social care practitioners are punished for their poor practice. In contrast, service commissioners and business owners seem to have an unassailable alliance to misuse public money intended for the care of people with learning disabilities. The lesson? Even though negligence and manslaughter are corporate crimes, there were surely offences under trades descriptions legislation and unfair trading practices committed by the owners of Winterbourne View Hospital and by the commissioners as the agents of the consumers. Yet thus far, no money has been returned and our recommendation that the costs of the serious case review should be met by Castlebeck Ltd has been ignored.

In a private health and social care market, inspection of practice has to be complemented by the use of regulatory powers in the boardroom and beyond. The lesson? Winterbourne View Hospital has taught us that in such a market an enforceable code of practice in ethical investment is essential. Consumers have rights. Company directors have duties. Investors have responsibilities.   It cannot be a matter of profit or loss or pressure to meet impossible financial targets because these overwhelm restraints against dishonesty and are incompatible with the delivery of humane care.

Winterbourne View Hospital is a case study in institutional abuse. Its name is synonymous with all that we must never let happen again to people with learning disability and with associated programmes of \’transformation\’ and \’improvement\’. Regrettably however, the serious case review remains a blueprint for many lessons still to be learned; particularly in respect of the conflicts of interest that can arise from the commercial provision of services.

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[1] https://www.england.nhs.uk/learningdisabilities/care/ accessed 26^th May 2016

[2] Harvard Business Review, October 2005

Cameras in Care Homes – Mixed Views in the Profession

Cameras in Care Homes – Mixed Views in the Profession, according to Andy Merker, Vic Citarella and Janti Champaneri

Last week, The Times told us that research into use of cameras to protect people in care homes had found the following proportion of stakeholders are in favour of their adoption:

• 90% of families with relatives in care

• 66% of staff

• But less than 50% of residents

The research, conducted by care home provider HC-One, came in the wake of CQC’s announcement that it is to issue a public information sheet for families and companies who want to film inside care homes.

Then, later in the week, respected commentator Roy Lilley wrote this in his blog: The CQC\’s Andrea Sutcliffe, inspector of care homes, is savvy enough to know she can\’t deliver 24-7 safe care for your Granny. She\’s given up and given permission for StreetWise relatives to sort it out themselves. She\’s handed her job to the relatives.

There\’s guidance on the way that StreetWise relatives neither want nor will be bothered about. It is a bureaucrat’s answer to a burgeoning problem that StreetWise families will sort out for themselves.

Roy’s conclusion is well worth including here:

If the law required CCTV in every care home, with the memory device only accessible by the client or family, we could make Andrea redundant tomorrow – and knowing her as I do [I am sure] she wouldn\’t mind at all.

The terms of the CCTV debate

A couple of days after all this I met with Andy and Janti to discuss the promotion of the embryonic Social Care Support Network at the Lahore Fort restaurant in Sparkhill, Birmingham (a venue chosen as we are thinking of hosting a Social Care Curry Club meeting as a way of giving the network some impetus).

Over a great buffet (a bargain at £9.95) inevitably, bellies perhaps slightly bulging, our conversation turned to this whole ‘cameras in care homes’ debate. And I have to say that in some respects it doesn’t matter what we concluded as the important thing was we debated the issues with as much relish as we tackled the buffet. Still, this is what we agreed:

We recollected that the Social Care Association had written a Parliamentary Briefing on the subject of care home CCTV in the late 1980s. Nostalgia then kicked in about the heyday, from our perspective, of professional debate. The policy, in the written piece, had been shaped in the cauldron of meetings, in actual formal debate and with postal interchange of comments.

Moving on, we thought the position emerging was a damning indictment upon CQC – and perhaps the regulator needs to look at what it is they are really measuring in terms of quality services. For those on the front line, the difficulty about good quality care is that it is what occurs at the interface between the carer and the service user. Frequently, this interaction involves deeply personal activities and/or issues for which we would usually require the utmost privacy/confidentiality. So ironically with most cameras in care homes currently sited in public areas few actually abusive interactions are captured – as perpetrators present themselves as all sweetness and light in such areas of the home.

Atrocities

Another aspect we discussed: the strength of the request for this kind of surveillance does not seem to be reflected quite so much by service users, in comparison to their relatives. And perhaps this is the more worrying aspect – the way in which social care has failed spectacularly to provide a guarantee of safe care sufficiently strong to secure the confidence of relatives.

The reality is that for most service users, support workers need to become involved in these intimate moments, and the difficulty is that abusers can use this mask of privacy to hide what they are doing. So atrocities can (and do) occur. And, of course, there is always the issue of the blind spots that cameras cannot see – which determined abusers will quickly work out.

Furthermore, it is not just deliberate criminal abuse that must be eradicated but any and all offences against dignity and respect – the insidious neglect that characterises poor social care practice. Here cameras could be a conscience, a training aid, a form of communication, as well as a reassurance to relatives that their concerns are either unfounded or are being properly addressed.

CCTV becoming ubiquitous in care settings may ultimately be the way that things may need to go.

However, the challenge has to be in what circumstances the tapes/disks would be accessible and in what ways would these tapes/disks be safeguarded from unauthorised viewing? Over our excellent repast we agreed that the kind of double key security one finds in safe boxes in hotels — with one held by the hotel, the other held by the guest — may be one way of ensuring controlled access. Perhaps CQC should be present when such tapes are viewed?

But there are definite thorny issues about the service user, and indeed the worker, giving informed consent. It is possible we will have a scenario where the camera comes to replace the call-bell, in itself a source of discontent in many care homes. Residents and workers will work out together why cameras are useful, what concerns they address and how they enhance personal and safe care. In dialogue with relatives they will then utilise them accordingly; we agreed that is a convincing scenario.

On our way out of the restaurant, we briefly turned to domiciliary care – surely we can have whatever cameras we want in our own houses, can’t we? Would the safeguards need to be different in these settings? Are there any guidelines that we could pinch from the experiences of Big Brother? (Perhaps more of the Channel 4 reality TV version rather than Orwell’s nightmare vision?)

In any case, we think this is a significant and professional topic for debate. We also believe that this issue does need to be actively considered by practitioners, as well as residents and their relatives, to develop a beneficial and safe way forward.

Saying farewell to the patron of the Lahore Fort we queried whether there might just be an upstairs room for a social care practitioners meeting prior to partaking of a buffet. A professional network facilitated discussion followed by all the curry you can eat, including pudding, seemed to us an offer practitioners simply couldn’t refuse.

Self neglect – Jackie Hodgkinson asks: when does a social worker say enough is enough?

Self neglect is a term that social workers are very familiar with. It often causes concern for both professionals and concerned neighbours and family. I can recall, within my social work career, many individuals who chose to live at home, in a condition that was considered by professionals as unacceptable. Was this their informed choice and was it in the best interests of the individuals? This depends on who you ask?

What is unacceptable? And who are we as a wider society to define how someone should or should not live, often those individuals had been what were considered as “eccentric” or “a bit different”. Using the definition of mental capacity as defined within the Mental Capacity Act 2005 would deem these individuals to have capacity to make what we may consider as unwise decision. Within society we make judgements based on how vulnerable we perceive a person to be.

Champagne lifestyle

If a young executive chose to spend their salary on a champagne lifestyle and then could not pay the bills at the end of the month would anyone pass judgement on this choice? If that person was a 79 year old man with motor neurone disease who enjoyed betting on horses and sometimes didn’t leave enough money for 3 meals a day, home care providers would instantly contact social workers with a safeguarding alert or his neighbours would be stating that he should be in a home! And asking how can we let someone live in this way.

The public expect that the adult social care department should protect all from harm and danger, regardless of the capacity of the individuals to choose how they live. Social work teams receive many phone calls from families or friends stating “it is a disgrace how you let people neglect themselves you should do something to stop it”. This implies we have the power to impose services and support on any unwilling recipient. A greater awareness of our statutory duties and the limitations of these perceived all-embracing powers is required to educate the wider public regarding when we need to intervene.

There needs to be more publicity on positive risk-taking, where social workers actively promote the human rights of the disadvantaged. We often see the potential in individual’s strengths or protective factors within them or their lives, where others see only problems.

Risk averse

In these risk-averse times, it is important to hold onto the concept of choice and respect for decision making. In my opinion as a social worker, it’s intrinsic to what social work should be about and is core to social work values. This requires a recognition at all levels of management and within wider society.

The Department of Health official definition of self neglect is the inability to understand the consequences of that failure. That definition of self-neglect excludes the individual who makes conscious and voluntary choices not to provide for him or herself. The person who denies themselves certain (accepted) basic needs as a matter of personal preference and who understands the results of that decision is ruled out.

Self-neglect implies a lack of wilful intent. Self-neglect is an act of omission. There is no perpetrator. Unlike perpetrator related abuse and neglect, self-neglect is not treated as a wrong-doing or a potential criminal act. Capacity is a highly significant factor in both understanding and intervening in situations of self-neglect. Decision-making autonomy by those who have capacity is widely recognised and respected. There is strong professional commitment to autonomy in decision making and to the importance of supporting the individual’s right to choose their own way of life, although other value positions, such as the promotion of dignity, or a duty of care, are sometimes also advanced as a rationale.

Research into self neglect

SCIE Report 46: Self-neglect and adult safeguarding: findings from research, examines the concept of self-neglect. The relationship between self-neglect and safeguarding in the UK is a difficult one, partly because the current definition of abuse specifies harmful actions by someone other than the individual at risk.

The perceptions of people who neglect themselves have not been extensively researched, but where they have, emerging themes are pride in self-sufficiency, connectedness to place and possessions and behaviour that attempts to preserve continuity of identity and control. Traumatic histories and life-changing effects are also present in individuals’ own accounts of their situation

What can we social workers take from research? Evidence demonstrates that self neglect is reported mainly as occurring in older people, although it is also associated with mental ill health in both older and younger individuals. Social workers when assessing levels of risk need to take into consideration both the inability to care for oneself as opposed to the unwillingness to self care. The other key determinant is the individual’s capacity to make the decision and understand the consequences of this action. The social work response will vary, dependent on these key risk determinants. Professionals will have a tolerance to someone who chooses to self neglect as a life style choice, perhaps that is how they have always lived. I once assessed an older person who chose to eat out of date food to save money even though they had £500.00 in the bank. Professionals, understandably, have a greater level of concern regarding those individuals who have made life style choices but due to onset of mental impairment struggle to understand the consequence of those actions.

Comprehensive risk assessments are core to all interventions. A balanced approach is required to ensure we are not foenough is enough.

cused simply on keeping people safe at all costs; all risk assessments should be person-centred, taking into consideration previous lifestyle choices. They should promote independence, choice and autonomy. They should also be reviewed regularly. Care plans should be lifestyle sustaining. Potential harm has to be balanced with potential benefit. Working in a multi disciplinary team, virtual or otherwise, enables us to gather evidence to make those decisions about when statutory intervention is required. We should check things through a mental capacity lens frequently. The profession needs to engage with the public about people’s rights, the wider duty of care and when

Jackie Hodgkinson is an independent social work practitioner and trainer