Spending priorities

Considering the degree to which the Government has kept us all focused on the need for thrift in the last 18 months, and the constant reiteration of just how much we cannot afford, it came as a little surprise to suddenly discover just how much we can apparently afford. All is not doom and gloom after all!

On 10 January the decision was finally announced that the HS2 rail link was to be given the go-ahead, with half an hour shaved off the journey from London to Birmingham at a cost of £32 billion and an eventual claimed beneficial return of £47 billion. However, according to fullfact.org the actual overall cost is more likely to be £62.5 billion (see http://tinyurl.com/73l3zhf) when all the costs are factored into the plans.

Not surprisingly, I weigh this expenditure against the cuts in services to older people and I struggle to rationalise it. Of course we need to invest in our infrastructure if we want Britain to remain effective and efficient. But...this just seems like screwy priorities, and insensitive timing. We can't look after our old people but we can build new track and buy new trains?

Of course, in truth there will be more benefits from HS2 than just that half hour journey saving, but still, the timing is wrong and the message is wrong on this one. And, with every instance of poor and abusive care that can be attributed to a lack of funding, I think that feeling will grow.

However, it is far more difficult to challenge the next spending announcement without ending up with some strange and unwelcome bedfellows. Over the weekend the Government announced that Britain will increase its funding for Neglected Tropical Diseases from £50 million to £245 million between 2011 and 2015 as part of a global push to eradicate diseases including river blindness and elephantiasis. Now that spending announcement is definitely a two edged sword. No one in their right minds would not want to see such diseases wiped out; the misery they bring is colossal. It is right that we play our part in such eradication. But...

... in the current climate it is difficult to understand why a similar commitment cannot be given to the care of our older people? Services are creaking at the edges, regulation is increasingly meaningless, and adult safeguarding remains a poor relation. And again, every time I watch care homes being closed against the wishes of the residents, care criteria being re-written to make it harder to get support, and NHS care lacking any semblance of care, I can't help wondering what on earth happened to our priorities?

How did we ever let it get as bad as this? Shouldn't our politicians be just as passionate, just as vociferous, and just as moral on elderly care as they are on tropical diseases? They say 'charity begins at home' but actually, that's a small minded, parochial and churlish approach to life. Perhaps they should say that 'charity is just as important at home'.

A few positive announcements about what can be done for our older people would not go amiss!

The NHS

Last week David Cameron announced that he would launch an initiative to make nurses take better care of patients, with an emphasis on hourly ward rounds by nurses, and with patients (i.e. ordinary members of the public) empowered to assess and inspect hospital standards. At the same time, according to media reports, he emphasised that the majority of nurses were doing a brilliant job. Which, perhaps, is a very good reflection of the almost schizophrenic approach that is adopted toward the NHS - it is a wonderful institution, but it needs to do better because it delivers some appalling care.

Of course initiatives of this type capture the headlines, as do announcements of increased inspections by the NHS regulator. They reassure people that the Government is addressing the problem, is taking action, is on top of things. But what these initiatives don't address is why nurses and doctors at times provide poor care, or care that is plainly abusive. Why do nurses have to be told to do hourly ward rounds? What are they doing instead of being on the ward? Why do we need the public to assess and inspect hospital standards? Why aren't the hospitals doing it themselves?

I guess our difficulty is not with the initiatives - we're all for more public involvement in public services, and people may certainly benefit from seeing nurses more frequently. But, it is the fact that such initiatives don't address the underlying attitudes and problems at their root which is of concern. The Dignity inspections six months ago showed nurses on the wards, but those nurses were ignoring their patients, neglecting their patients, and in some cases falsifying the records of their patients. Why? Unless we address those basic questions we can't realistically expect to see change.

Last week (yes, the same week as Mr Cameron's announcements) the Economist Intelligence Unit published research on healthcare provision for an ageing European population. 80% of health professionals expressed concern about how they would be treated as they grew old. They were sceptical that current policies were comprehensive, realistic or sufficiently funded to address future demand.We can understand their anxieties. The report suggested that an effective strategy needed

• a focus on preventive healthcare 
  
• better integration of health and social care 
  
• Medical training to focus on the future healthcare needs of ageing populations 
  
• Negative attitudes towards older people to be challenged.

Sounds like a plan!

The need for action

2012 has started in the same way that 2011 ended, with publicity about the lack of care of older people and about the abuse of vulnerable adults. Mencap have published yet another damning report about care of people with learning disabilities within the NHS, while AEA and 59 other organisations placed a letter in The Telegraph about the urgent need for reform of the care system for older people.

Of course, we know that there are plans for improvement, and perhaps a greater willingness to highlight and acknowledge the failings of our large institutions such as the NHS, but none of these address the 'here and now' in a meaningful way - a point we have been consistently making to the Department of Health. Carrying out CQC inspections might highlight (some of) the inadequacies in social and health care, but without an immediacy of action they do nothing to protect or improve. And, as we discovered with the Southern Cross whistleblowing helpline, simply establishing such a system doesn't mean people will use it, unless there is simultaneous action to create the right culture for its use.

Any Government in power right now would face multiple challenges, as a consequence of years of successive Governments (of all political hues) failing to address key issues in social and health care. But what we clearly need now is a consistent, effective improvement strategy that impacts immediately on the quality and reliability of care. This cannot wait until 2013 or 2014 when we may get the promised social care and adult safeguarding legislation. There is a growing public awareness (however crudely established) that older people are being failed. The subtleties of long term planning will not easily deflect that awareness. There needs to be some real and substantial actions now, if Government is going to demonstrate that the issues are being taken seriously and addressed seriously.

To paraphrase: it is the best of times and the worst of times, to be in Government.

A duty to act

Imagine. Your mother ate in the local Chinese restaurant last month, got food poisoning, and died yesterday. And today you discovered that Inspectors from the Environmental Services Department had visited two weeks ago and had recorded the poor standards of food hygiene. They had given the restaurant 28 days to come up with an improvement plan.

So, you challenged the Council Department today, because the implications of their failure to take action to shut the restaurant meant that you had visited, your mother had eaten. And now she was dead. They tell you that, where their Inspectors saw issues of concern, they immediately highlighted them to the restaurant who had a duty to act. They expected to see evidence of food hygiene improvement in the restaurant's improvement plan, and would be making follow up visits in the future to check on the state of play. Oh, and they deeply regretted the death of your mother, which of course was the responsibility of the restaurant.

Just fiction.

In October we published a detailed critique of the CQC inspections of hospitals under the Dignity and Nutrition programme. Now, you can't die from undignified care, but you can from inappropriate or lack of nutritional care. And you can die if a hospital is wrongly issuing Do Not Attempt Resuscitation Notices (DNAR), which was the case in a number of them. We recommended that the Department of Health take action. We didn't ask for them to issue national guidance; simply that they should emphasise the guidance already in existence, produced by the professional bodies. Because it is good guidance, and ultimately the DH has responsibility for the NHS. We are not aware that they have yet done so.

Today the Guardian newspaper carries an article on DNAR notices which suggests that hospitals have been warned to improve their use of these notices by CQC. Eight have been 'told to adhere more rigorously to local policies', according to the article. Bear in mind, CQC passed hospitals as meeting standards, even though they had identified DNAR issues. No inspection report contained a recommendation or requirement in relation to DNAR, so when CQC says these matters have been followed up in subsequent inspections this can only have been triggered as a consequence of external scrutiny rather than their own systems. We can't help wondering about their legal duty of care to someone placed at risk by such failings? Yes, the hospital would be liable, but what about the regulator who took no immediate action to ensure improvement?

Of course, to go back to our chinese restaurant, it is true that the quality of the food and the hygiene of the kitchens is the responsibility of the restaurant owners. But, the public outcry if the Council failed to take immediate action in response to serious failings would be guaranteed.

Isn't DNAR as deadly?

CQC is no joke

For months we have been highlighting concerns about CQC, the regulator for social and healthcare in England.

Looking back, we have questioned their reliance upon desktop inspection, their irrational interest in spy software to replace inspection, the opportunistic press releases, more latterly the quality of the inspection processes adopted by them in relation to the Dignity and Nutrition inspection of hospitals, as well as some of their more recent commitments in relation to inspection frequencies. We have questioned them in private meetings, we have sought information through Freedom of Information requests, and we have challenged them in media broadcasts.

Our fear is that CSCI has been replaced by a cynical organisation that is more interested in managing its corporate image than the reality of care and health standards, one that is 'cute' in all the worst sense of the word in knowing what to say, what not to say, and how to say something - rather than honestly answering questions and giving genuine commitments.

Our fear is that we have a regulator that focuses more on image than substance, and that  is skilled at playing the game, rather than protecting the weak.

We want to be wrong.

In the last twelve months we have experienced at least one of their Senior Board members  threatening us to 'toe the line' on personalisation or suffer the consequences. We're big enough to shrug that off, as long as they are delivering protection for vulnerable people.

Which is why the evidence given on Monday by Amanda Pollard and Kay Sheldon to the Mid Staffs inquiry is so damning, so painful, so pathetic and so frightening.

CQC can argue that the Mid Staffs Inquiry is the wrong place to consider these matters. They can produce Board minutes, strategy papers, and a multitude of explanations to argue that these people are wrong. They can claim that these two 'whistleblowers' are anything they like - misled, confused, ignorant or whatever.

But. Those of us who have been around long enough recognise the smell of decay, will ultimately know. 

Everything we have feared is seemingly confirmed in the evidence given last Monday. Everything we have tried to 'bottom out' has been described in detail by these two CQC insiders, and we're still working our way through their evidence.

We will be analysing this in more detail shortly. But the questions are now out there for answering. No-one in their right mind would want yet another new regulatory body to be created. But this one is dead in the water, discredited by care providers, anti-abuse organisations, and by the public. It cannot continue. The question now is only one of time; when will Government Ministers recognise that this is a liability that is incapable of delivering public confidence? When will they cut their losses?

If the evidence of the whistleblowers has any validity then the only other question of time, in reality, is when will there will be another Castlebeck or similar? And no politician will want to front that one out.

A new Board. A new image. A fresh start. Nothing else will work.

Because this is no joke, however farcical it might seem.

It's time to call 'time out' on CQC

According to the CQC, regulation and inspection of social and healthcare is intended to ‘put people first, stand up for their rights, and act quickly to remedy bad practice’. But analysis of the DANI inspection reports (which CQC summarised on Thursday) questions these assertions.

While inspectors witnessed practices that were variously illegal, cruel or heartless, they took no immediate action to guarantee the safety of the patients affected. Instead, the hospitals with the poorest record of care were often given 28 days to devise a plan, and then were not monitored until many months later.

Unlike the response to nursing and care home abuse, there were no immediate protection plans, suspension of admissions, or ongoing monitoring to ensure immediate patient safety. And, as Paget Hospital recently demonstrated, leaving it to the Trusts gave no certainty of improvement.

During the visits, inspectors recorded health staff falsifying food and drink records to give the impression that uneaten meals had been consumed, a patient left for 30 hours without sustenance because medical notes had been ‘misread’, barrier nursing of an isolation ward ignored, patients being squeezed into extra beds without the necessary equipment to allow adequate nursing, high risk patients without nutrition plans implemented, and patients with their genitals, underwear or incontinence pads exposed.  Inspectors even described some patients as being ‘at risk’, but still the deemed the hospitals compliant with the standards.

Despite this, the CQC did not make a single adult safeguarding referral or refer any staff member to their professional body or to the Independent Safeguarding Authority.

We are all rightly concerned about the sub-standard care provided on some of these wards, which degraded older people and put a number of them at obvious risk. But we also need to consider what the regulator did, or rather did not, do in response. A large number of these hospitals were deemed ‘compliant’, but had requirements placed on them which meant that they were in fact not compliant at all. This misleads the public. And the CQC have proclaimed the fact that no hospital had a ‘major’ concern around dignity. But, the definition they used made it impossible to record such a ‘major concern’, so this too misleads the public.

Of particular concern was the casual disregard of the national guidance on ‘Do Not Attempt Resuscitation Notices’.  In some cases these were routinely inserted into patient files on admission. In others the decision was left to junior doctors, who never consulted the patients or their families. In one case Inspectors found a notice from a previous admission, still wrongly active in a patient’s files. This is a dangerous situation, as evidenced by the case of Peter Carter who died in 2010 when a nurse assumed a blank DNAR notice meant he should not be revived. Inspectors noted these issues in hospital reports but the regulator then took no further action.

The quality of care is obviously the responsibility of the hospitals and the Trusts. But the public expect a regulator to take immediate action when it discovers neglect or abuse, and to ensure that patients or residents are immediately safe and protected, today and tomorrow. The CQC did not do this. This leaves the unpalatable question as to how many older patients continue to be neglected and abused in these 100 hospitals, and others throughout the NHS. We need better quality NHS care, and we need better regulation too.

But, we also need a sense of urgency injected into safeguarding of older people. There is currently an almost surreal approach to instances of institutional abuse, with commissions being established to inquire into dignity, planning groups to feed into the development of the White Paper, and the continuing work around the No Secrets Advisory Board. All of these are worthwhile ventures, but what is missing is the here and now. We need a 'right now' strategy to run alongside the more long term planning that seems to dominate the current agenda. We need some action to match the words. 

Otherwise, we might be forgiven for the analogy of deck chairs and the titanic. Only, in this case, the people going under the water are frail, old and vulnerable. And the people with the deck chairs should really know better!

What is the definition of 'immediate'?

CQC have announced today that a warning notice has been served on James Paget University Hospital as a result of the Trust's failure to protect service users from the risks of inadequate nutrition and dehydration.

They have said, "Concerns around nutrition were originally identified when the Trust was inspected as part of the DANI programme. Following this inspection, the Trust provided an action plan outlining what improvements would be made. However, when CQC inspectors returned to the Trust on 1 September, they observed incidences of people not being given appropriate support to eat and drink, and that people in need of intravenous fluids did not have infusions. The Trust is now required to become compliant with Regulation 14 (meeting nutritional needs) by 26 September (today) or face further action, which might include prosecution or suspension of services."

So, should we feel reassured by this action?  Should we feel that the same urgency that has manifested in response to Winterbourne has now been applied to the care of very vulnerable older people? Umm, I wonder.

The Hospital was visited by Inspectors on 5 April 2011 (yes, that is nearly six months ago), and the care that was witnessed could charitably be described as poor. People were moved around in full view of the ward, wearing the open backed gowns that cause such distress, had dentures removed from them in public, and one was sat on a commode in view of others with no means of calling for assistance - call bells were not accessible to all people; they were spoken to in a patronising manner, and recording systems were described as 'inconsistent'. Staff said that the number of people with dementia who required support 'adversely impacts on care delivery'.

And that's just the start. The hospital could not say what was in the food, so patients who had allergies had to 'manage their own diet' by omitting foods they thought might harm them. No handwashing facilities were available, and patients had to wipe their soiled hands on bedsheets or clothing. People struggled to eat because they weren't positioned to do so, and the 'red tray' system (used to identify people who needed help to eat) was useless, people who needed help weren't given it while others who could eat unaided were given a red tray(?) Assistance was sporadic when it was given, and someone who complained of nausea was given a bowl next to their meal and 'wretched a number of times in full view of others eating their meals'.

Recording was so poor that food and fluid charts were not completed or not accurately completed - one person with dementia was not given enough assistance to eat and so had the meal removed untouched, but the records were completed to indicate the full meal was taken i.e. the record was falsified! This was noted in a second record too:

‘We closely observed two people being assisted with their meals, one person identified as having dementia received assistance to dine for a few minutes before being put back into bed. We saw the meal removed from the table almost untouched. When we looked at the records of food intake the member of staff had recorded that the person had eaten the meal. We found similar inaccuracies in the second person’s records when we also observed the meal had not been eaten.’

The Trust was required to send a report to CQC, within 28 days of receiving the inspection conclusions, indicating what actions they proposed to take to achieve compliance.

There was no Adult Safeguarding referral. There was no 'blanket ban' on admissions. The requirements of the Mental Capacity Act 2005 (MCA) were not applied. There was no immediate protection plan, leaving us to fear what happened to all the old people who passed through that hospital in the last six months. What sort of care did they receive, if CQC now feel the need to take 'further' action?

This was observed SIX MONTHS AGO, and the response after five months was to give the Trust yet another month to become compliant. And still no Adult Safeguarding referal, or action under the MCA!

It seems very hard not to question the inconsistent approach between this, and the actions taken in response to care home or nursing home neglect and abuse. It seems very hard not to question the inconsistent approach between this, and the actions taken in response to Winterbourne. Is this because the victims are old, frail, vulnerable people, and we're witnessing the same age discrimination as we were challenging ten years ago?

Since June we have been asking the Department of Health (DH) what response was made to the November 2010 report on deaths of older people in hospital 'An Age Old Problem'  and the Health Service Ombudsman's report 'Care and Compassion' (you can get a summaries from AEA). And we have just been told that (a) Professor Oliver attended the launch of the  'An Age Old Problem'  report and gave a presentation; and (b) the Department highlighted the Ombudsman's report to Health Boards and SHA Directors of Nursing. They also referred to the DANI inspections as being in response to the Ombudsman's report, but CQC do not agree with this point. But, even if this is true, is this really a sufficient response to such serious reports?

A number of years ago AEA felt it necessary to stimulate undercover reporting of the care of older people in order to generate an appropriate statutory response to the neglect and abuse that we knew was happening, but which was being denied. Perhaps we need to start doing this again, although this time the neglect and abuse is not being denied. It's being carefully recorded in CQC inspection reports, or being circulated by the DH.

I wonder if that's progress?

Where now for CQC?

I must admit to finding the article by Jo Williams in today's Guardian (there may never be a rational explanation) very difficult to read in quite the balanced way that Jo would clearly like.

I totally agree with her observation that (a) the responsibility for quality of care must rest with the provider (most of the time) (b) that adult safeguarding in South Gloucester have some serious questions to address (and incidentally they were the only LA in the UK who refused to answer most of our FOI questions on safeguarding earlier this year, indicating they wanted £1800 to respond to questions that other LA's answered for free!) and (c) commissioning has a crucial role in this (hence why there are occasions when the quality of care might rest more with the commissioner than the provider). However, I think that CQC is in a slightly different category for a number of reasons.

Firstly, I'm not so sure that CQC inspectors might be quite as shocked as Jo has been. Those who have interacted with us over the last 12 months have expressed growing alarm at the gap between what they see as effective inspection (ie. face to face inspection), as opposed to the new regime of self assessment by providers and what might be better described as a paper process of inspection (the QRP approach). It is hard not to see this approach as a cost saving one, rather than a tried and tested model which is better than face to face inspection, and Jo has of course been chair during that process. Certainly there have been reports in the last twelve months, quoting trade unions, to suggest morale has been low for quite some time in CQC.

Secondly, there has been a dramatic drop in inspections - from 10,856 in 2010 to 3805 in 2011 (with only 774 undertaken in the six months to March 2011) - a total drop of nearly 65%. I believe this was to enable inspectors to be diverted onto what seems to have been a very cumbersome re-registration process. That may not have been the wisest use of resources for a regulator under pressure, and it would certainly seem to be an argument for suggesting that there is a need for more resources if one task has resulted in the loss of a second (and some might suggest more important) task.

And thirdly, CQC does not monitor improvement against requirements at a central level, and therefore has no way of establishing centrally whether or not the inspection process is effective. Nor do they centrally monitor the number of inspections that are triggered as a consequence of a public complaint.

All in all it is a worrying situation.

However, from my perspective what is equally worrying is the sudden 'hierarchy of vulnerabilty' implied by their current strategy. What the Panorama programme showed was indeed appalling and needs urgent action, which is why we so strongly support Mencap's approach to this issue. But, is it any more appalling than some of what is being uncovered by the CQC investigation into nutrition on hospital wards? Or the content of the (fairly recent) Health Ombudsman's report into the care of older people, or the equally damning report last November by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)? This is about adults who are in very vulnerable situations, whether through age, learning disability, disabilty or mental health. And CQC should play a crucial role in protecting those people, maintaining and driving up standards, and ensuring public confidence in health and care services. To do that they must be effective. and to do that they must react to situations on their merits and not because they were splashed across our TV screens. Regulation by media cannot be the way forward.

Perhaps the current situation is best summed up by a number of care providers who are beginning to question whether CQC is actually fit for purpose. Admittedly, they are still angry at being given only three days notice of the new, increased registration fees, but it is still a good question, and to answer it I think we need to be very clear about the standards against which we measure not only CQC's performance, but also the decisions they have taken since inception. Because, from an abuse perspective, we are worried in case those standards have slipped.

And perhaps, in addition to having an internal investigation into why a whistleblower may have been ignored, CQC should also see the Panorama programme as a cautionery indicator that they might need to reconsider some of their wider current strategies? Public confidence after all is quite a fickle thing!

Media investigation - the new regulator?

The Panorama programme last night was harrowing to watch (and I get a sense of deja vu as I type those words). The scenes were more akin to watching a horror movie than witnessing anything remotely connected with care, and yet once again they took place in 21st century Britain in a regulatory system that is 'designed to enable us to spot warning signs that might indicate an emerging problem' (see Cynthia Bower's letter to the Guardian). So, how and why does this keep happening? Why is it that we have systems in which such abuse can go unnoticed and unchecked, with very vulnerable people suffering dreadfully, and yet no-one notices or 'blows the whistle'?

But this is a key point that emerged from the programme. Panorama had focused on Winterbourne View after being approached by Terry Bryan, a former senior nurse at the unit who had tried and failed to raise his concerns within Castlebeck and with the CQC. The regulator said it recognised that "there were indications of problems at this hospital which should have led us to taking action sooner". So, why didn't they?

And this is an important question which cannot be simply relegated to 'hindsight vision', because the regulator is required to make these judgements every day of the week. And it goes to the heart of the policy which implies that 'the regulator doesn't investigate individual complaints'. Given that Mr Bryan had enough information to trigger the interest of Panorama, it must beg the question as to why it didn't trigger the interest of CQC who are the supposed experts in this area? It is certainly a question that justifies a formal inquiry and a public explanation, and not just an apology.

Perhaps, in the interim, care providers should pay their registration fee to a reputable media company. Because, if you consider the recent 'Which magazine' report, and some of the regional broadcasts about quality of care, the media seems to be doing a better job at focusing upon standards at the moment than CQC.

England puts Adult Safeguarding Boards onto a statutory footing

We have had the best piece of good news for many a year (well, at least since 2007) with the announcement today by the Minister for Social Care, Paul Burstow, that Adult Safeguarding Boards are to be made mandatory. While the details are yet to become fully apparent, this is the first major step taken by a Westminster Government since the 2000 launch of No Secrets.

Not surprisingly we have strongly welcomed this news - we've been campaigning for this since 2007 - and we're looking forward to understanding how the decision will be implemented on the ground. The news is coupled to a statement of outcomes that local safeguarding agencies should seek to achieve in their work. All good stuff.

Law Commission delivers on Adult Safeguarding

The Law Commission today underlined the need for adult safeguarding legislation, reinforcing and reiterating the message already given by the vast majority of those people and organisations who made contributions to the No Secrets Review two years ago.

Almost as they were switching the lights out and departing the scene, the last Labour administration promised that they would bring forward such legislation but never said when. And anyway, it took so long for them to reach that decision that we were all in General Election fever by the time the commitment was given. Which means that it fell with the last Labour Government, and has yet to be picked up by the current one. And the consequence of this is that, for far longer than has ever been necessary, too many older and other vulnerable adults have been forced to continue relying on a post code lottery for their protection.

But now, the Commission's recommendations provide the opportunity to finally bring this situation to an end if, and it is an important if, the Coalition Government agree to introduce them into law. And this is a political decision, not one based upon fact. Because the fact is that we need systems that are consistent and can guarantee adequate protection if we are to adequately challenge the horrendous abuses and neglect that happen on a daily basis. This is known by the overwhelming majority of people who work in adult safeguarding, and many who experience the process, and was stated by multiple contributors to the No Secrets Review. And yet we still await legislation, as though there was all the time in the world to get to it, which of course is not the case for many older victims of elder abuse.

The Commission's recommendations include a duty on social services to investigate or cause an investigation into adult protection cases; a duty on Government to prescribe the process for such investigations; a new definition of people at risk of abuse and of harm in order to ensure those in need receive adequate protection; a statutory basis for adult safeguarding boards which should as a minimum comprise local social services, police and health; the legal requirement to establish serious case reviews; and an enhanced duty to cooperate between relevant organisations.

These are of course excellent recommendations but, despite the comprehensive nature of the Report, there are still a number of crucial issues that have yet to be addressed, including adequate funding of adult safeguarding in a time of cutbacks, and also what powers of intervention might be needed to ensure adequate safeguarding. The Law Commission unnecessarily sidestepped these matters and yet establishing the framework for adequate safeguarding will be insufficient if investigators lack the necessary powers to gain entry and intervene. So, we now need the Government to consult upon and then introduce appropriate powers in any new legislation. But the question is, will they?

What the Commission has successfully done is place this issue back into the hands of Government, who have been publicly very quiet over the last year about No Secrets, the messages that came out of that Review, and what they planned to do to address the inadequacies of the current situation. There is no doubt that there are some policy challenges ahead as they seek to reconcile Big Society and Localism on one hand with the need to structure adult safeguarding on the other. But older victims of elder abuse do not enjoy the luxury of time to mull over and debate the finer points of political dogma. They need effective protection right now. Will they get it?

That silence you can hear is our bated breath as we all await that response...

The return of ghosts and mirrors?

Just what is the role of CQC these days, I am prompted to ask?

I have been pondering over the weekend the rather odd interview given by Jo Williams, Chair of the Care Quality Commission, to the Independent newspaper last Thursday (Dire state of care homes for the elderly is only going to get worse, says top inspector).

Linking public sector cuts with quality of care, she made the argument that care providers will be asking themselves ‘what can I do to cut corners’ - in the statutory sector that’s called making efficiency savings - while she simultaneously confirmed that more needed to be done to train staff in nursing homes, that the workforce is patchy, with many staff on the minimum wage, and that there was a need to repair dilapidated buildings. She painted a pretty frightening picture of a care sector that is poised to ‘slash costs as a result of the public sector cuts.’

Now, in terms of what care providers will do to survive, I don’t know if she is right or not. I know care providers are worried. I know budgets are being squeezed. I know they don’t have many options. But I don’t know how this will all translate ‘on the ground’. I’ve seen no research or empirical evidence that allows me to draw any conclusions (yet), although I am naturally concerned. And more so, now that the Chair of CQC has implied that this is a likely scenario. Which is a key message, isn’t it? Because it is one thing for a charity, or indeed a care provider body, to make such statements, but it is quite another when it comes from the Head of the CQC.

But then we get to the second half of the article, which perhaps explains why anxiety levels are being raised. Because, Jo tells us, ‘it is against this background that the Commission is signalling that it will take an increasingly tough line to ensure that ‘essential standards’ are met – even when budgets are cut.’

So, care providers equal bad. Regulator equals good. And we are really expected to believe it is that simple.

The fact is that local authorities are decimating services for older people. ADASS says that funding of nursing home places will fall in real terms by 3% each year for the next three years, but no-one questions or challenges this bald statement, least of all CQC. After the Spending Review last October the Minister for Social Care, Paul Burstow, clearly stated that “There is no justification for local authorities to slash and burn or for local authorities to tighten eligibility as far as the settlement goes….the extra money would provide councils with "the wherewithal to meet the demographic pressures.” So, why are we seeing local authority care homes being closed at an unprecedented rate across the country, and ADASS making statements of intent about underfunding care provision? Is anyone watching how this is playing out on the ground, because the impact on vulnerable on older people is profound?

But Dame Jo does not appear to recognise this cause and effect, instead choosing to concentrate on the sector with least options of response. She continues by reassuring people that, to counter the ‘threat’, the Commission is looking at ways to identify failing care homes, including software used by the security services to identify suicide bombers. “What we are looking to do,” she says, “is use an organisation which currently does a lot of work for the security services by scanning what’s out there – either in newspapers or on the net – and identifying risk.” Apparently, this system will be used to trigger unannounced visits by inspectors.

This is the system that I mentioned in a previous blog, as reported by the Nursing Times. Their 'web crawling systems would produce a real time feed for the CQC of comments left with local media, blogs and social networking sites.' And their spokesperson at that time indicated that the scheme was being appraised by the Department of Health now and if approved, a pilot would start before April. Which is interesting because, according to a letter from Paul Burstow (in response to that blog), this has not actually been approved by DH, “I am aware that the CQC is looking at how it might best gather and analyse information in the future.” He told us. “I have been clear that any proposals will need to go through the appropriate approval channels within my Department. No proposals have been received to date.”

There are of course two key concerns about this. The first is that not everything published in newspapers, in blogs or on Facebook, about care providers is necessarily true. The complexities of providing care often means that it can be difficult to separate reality from perception, or reasonable expectations of care from unreasonable ones. Which is why we need regular unannounced inspections of care providers that involves talking face to face with service users/residents and staff. And this is the second point. Because there are fewer and fewer of these inspections taking place, as the regulator switches to paper based systems and the Quality Risk profile. Jo apparently admitted that the Commission ‘would have’ a smaller budget than the combined total of its predecessors, £164m compared to £250m. She obviously got her ‘tense’ wrong here however, because the Commission has had that budget reduction since day one and its impact on their social care work seems obvious!

And this brings me right back to the beginning. This was an odd interview that might have had some resonance (in parts) if it had been given within three months of the formation of CQC. Because there was a huge chunk of CQC responsibility that Dame Jo appears not to have mentioned, and which has a major relevance here.

Not only has the regulator been responsible for inspecting care services (so do consider her comments about training etc in that context) but they had also been responsible for reviewing the performance of local authority commissioning too. So isn’t there something they should have been doing before now to validate statutory decisions that involved cutting funding to care providers? Something about duty of care, adult safeguarding, or vicarious liability would have worked nicely for me in this regard.

I use the past tense here because of course that responsibility was removed from CQC last November by the Minister, to be replaced by “a more proportionate and constructive system built around local accountability, driven by sector-led, mutual support, not the unhelpful stigma of priority for improvement status”.

There is no doubt that everyone is being squeezed as Government cuts play out. And there is no doubt that AEA will challenge and address any consequences that are abusive to older people. But, we cannot simply focus on one part of the equation and not recognise the bigger picture here. If the Minister is right, and there are no grounds for cutting social care services to older people then he must demand explanations and accountability from local authorities in terms of what they are doing. And, if local authorities are right, that they have no choice but to make these cuts, then they should transparently explain how and why the weight of this seems to be falling so harshly on older people. What are their priorities? What and who is being protected in such prioritization? Because, ultimately, the Government and local authorities hold the purse strings that dictate what social care will actually look like for thousands of older people. And it is Government and local authorities that are ultimately responsible and accountable for what happens.

So I do hope Dame Jo recognises that bigger picture.

Balanced Safeguarding

Having just published a report on the Vetting and Barring system entitled 'Striking the Balance' it is somewhat ironic that we need to so quickly return to that very question of balance. There is no doubt that AEA is one of the strongest supporters of adult safeguarding systems in the UK, but we do try to do so in a measured way, hence our view that we should not present all care providers as automatic or inherent abusers and that often they should be at the heart of safeguarding actions and inquiries.

But, if this is important when we think of organisations, it is equally so when we consider the impact of allegations on individual workers, and the equally grave impact of poorly thought out actions in response to allegations. Not every allegation is true and, while it is important to protect the vulnerable adult who has raised the concern, it must be equally important to be proportionate in how the member of staff is addressed. For example, not every allegation warrants suspension or a police inquiry and, unfortunately, sometimes it's difficult not to form the conclusion that an action by an employer has more to do with protecting the organisation than anyone else.

Why am I prompted to say that?

Because this week a coroner in Flintshire considered the death of Beverley Marie Kelly, who hanged herself six weeks after being suspended from her job as officer in charge in a care home. She had been laying out patients’ medication for the next day while on shift on July 16 last year and had dropped some tablets. One of the residents stood on them, forcing her to flush some of the medication down the toilet, so she had left a note on the pot of medication in question to make staff on duty the next day aware of what had happened. According to the the media, the next day she was called into the office and was asked by the owners of the home what had happened to the medication. She told them what she had done but they said they had not seen any note, so she was told to leave the premises and was suspended from her job. She went home and (unsuccessfully) took an overdose. She was subsequently interviewed by the police and a blood sample taken which, after her death, cleared her name.

On 26 August she had been asked to go into the care home for a meeting with senior management, and family members said she was terrified at the prospect. Her mother said she "was being sick and said she couldn’t face going there." Beverley’s body was discovered that night, hanging in the shed of a house on Chemistry Lane, which she owned with fiancé Lee Hill.

I have no doubt that no-one forsaw the implications of what was probably considered no more than routine good practice by the home, an action that is happening up and down the UK every day of the week. But it should cause a pause for reflection - on whether suspension was necessary, on whether some support at the time of suspension would have been sensible if not kinder, on why her first suicide attempt did not set alarm bells ringing. And of course, on balance and a proportionate response to such situations. It may well be that Beverley's actions that July were somewhat foolish, but that was all. Adult protection is about human beings and it requires the application of intelligence and common sense, not procedures by themselves, to work effectively.

My thoughts are with Beverley who died a needless death, her family who will be grieving greatly, and all those involved who must have thought they were doing the right thing but forgot to see the individuals concerned. Because this just wasn't worth it.

The need for Vetting and Barring

A new report from AEA, published today, proposes a more focused and effective Vetting and Barring system. In recent years that system, and criminal records checks, have been variously described as intrusive and excessive by various groups and individuals, leading to a Government Review of both schemes. The review includes the option of scrapping the Vetting and Barring Scheme altogether.

However, the voices of vulnerable adults have so far been missing to a large degree from the public debate around what is needed, and yet they sit at the heart of this issue. While we accept the need to reform these systems to ensure they protect individual rights, we must have a balanced debate that also recognises the need to protect adults at risk of abuse. Clearly, the complete removal of these schemes would result in increased access by abusers to vulnerable adults and a consequent increase in abuse.

Consequently, our Report (Striking the Balance) argues that there are justifiable grounds for reviewing the scope and operation of the schemes, but that this is different from suggesting that CRB or vetting and barring is not needed, or that such systems have no role within the concepts of a ‘Big Society’. Our view is that society expects certain standards of behaviour within designated working roles, and that society already accepts that people can be excluded from withholding information relating to criminal convictions when applying for designated jobs, or from undertaking certain roles (through the use of either a blanket ban or a register) for similar reasons.

The charity is seeking a scheme that is: focused on a much smaller number of workers and volunteers, has closer links between regulatory bodes to avoid duplication, has a one-time entry with more cost-effective access by employers to information, has clearly defined circumstances for barring, has portability between jobs for workers etc., and only uses ‘soft intelligence’ if it has been validated and risk assessed.

Ultimately, people do not want unnecessary intrusion in their lives. But they do want a reasonable level of protection if they are in vulnerable situations, and it is that balance that we must seek to achieve.

A copy of the Report is available from our website at www.elderabuse.org.uk

Inspection and Regulation - a question of ghosts and mirrors?

Last month the BBC told us that all was not quite right with some of the more robust news releases put out by the Care Quality Commission in recent days, in fact some appear to have been downright misleading!

Apparently, according to the BBC, the CQC claim that 93 homes and agencies had been shut in the past year due to poor ratings was somewhat generous with the truth. The regulator had announced the closures in September, claiming the figures demonstrated a new determination to "get tougher", and asserted that 42 providers had shut because of enforcement action, with the rest closing voluntarily after receiving poor reports. Uh, not quite!

The BBC found some were 'actually allowed to remain open despite concerns about standards, while others had never been rated "poor" at all. In some cases the regulator had allowed homes to close and then reopen on the same day, if the home applied to do so, which they can under the current rules. Damning reports about their past records were then removed from the CQC's website, so potential residents and their relatives could no longer read them'.

It's hard to imagine that such a shambolic situation would ever have arisen with CSCI, but then they understood social care and had sufficient staff and resources to do the job adequately. And they didn't mask cuts under an illusion of adopting a light touch to regulation, which means its hard not to reach the conclusion that the 'robust' news releases were no more than a cover to hide very little action by them in this area. Unlike their predecessor, who regularly brought out a range of comprehensive reports on social care provision, it's hard to spot one emanating from this body (Has anybody seen any?) And its hard to believe the line that the use of self-assessment forms and other paper-based evidence can ever be an improvement to actually going out and visiting providers. Sadly I have to say that some of our departed CSCI colleagues warned of this office based approach to inspection as they refused, one by one, to join the new regulator. The view expressed by one retiring manager was that such an approach was dangerous, had no basis in evidence to support it, and would place people at risk

But they are being creative, I heard one person mutter the other day. They've found some technology used by the security services to identify and trace terrorist extremists online, and they plan to use it (now wait for this) to monitor social networking sites such as Facebook for complaints about care homes and healthcare providers. Yes, that's right. They won't go and visit and talk to staff and residents. And they won't investigate complaints made by individuals (unless they have a more corporate slant). But they'll follow what you say on Facebook and MySpace instead. Apparently, according to the Nursing Times, their 'web crawling systems would produce a real time feed for the CQC of comments left with local media, blogs and social networking sites.' Apparently, the work is being appraised by the Department of Health now and if approved, a pilot will start before April.

A CQC spokesman apparently explained that the spur to consider a new system came from the challenge posed by the large number of social care facilities the CQC must regulate. “There’s something about the nature of the care you get with social care." he said, "which also makes it suited to this kind of information-gathering.”

Yes, it's not being inspected!

Perhaps I should have called this blog, 'From the sublime to the ridiculous'? Except of course, the implications are too serious for that, aren't they!

Mid Staffordshire

A public Inquiry begins today into the care and health failings of the mid Staffordshire NHS Foundation Trust between 2005 and 2009. A previous independent inquiry published its findings in February and indicated 'systemic failings at the hospital, where managers were preoccupied with cost-cutting and government targets'. The previous Labour Government however refused to hold a public inquiry and this remained the case until June when Andrew Lansley announced a change of direction in order to 'discuss conclusions, rather than questions'. He rightly suggested that there was a need to combat 'a culture of secrecy' and restore public confidence in the NHS.

Of course you could argue that inquiries come and go, so does this really matter? And the simple answer is, yes it does. For too long we have had inquiries into one scandal of care after another, and usually involving either older people or those with learning disabilities, and no-one is ever held accountable. It is always put down to systemic failings and we are always told lessons have been learned. Until the next one. So a public inquiry for the first time in decades introduces an element of accountability into the process.

But perhaps John Burton, Head of The Association of Care Managers, summed it all up best in a recent hard hitting observation on the state of the Care Quality Commission, when he drew attention to the subject of Mid Staffs, "Cynthia Bowyer, the £200k+ p.a. boss of CQC, was Chief Executive of the West Midlands NHS Strategic Health Authority (“strategically” responsible and most definitely accountable for Stafford Hospital). Speaking about the Public Inquiry, Ken Lownds of the Stafford campaign group ‘Cure the NHS’ told the Conservative Party Conference "We need to understand how we can possibly have got to a situation, in a civilised society, in which demeaning vulnerable patients was considered something to be tolerated in the interests of efficiency targets - leaving them without water, crying for painkillers, and telling them to relieve themselves in their own beds."

I really couldn't have made that point any better myself. Because we really do need to understand that!

Market Forces

Buried in the news this week are reports that Southern Care Homes, which has homes in Conwy, Denbighshire, Flintshire and Wrexham, employ 270 people and care for up to 300 elderly people, has gone into receivership. And the following day came the news that a similar fate has befallen Middlesex-based firm Charlton Care Homes, which owns three care homes in North Lincolnshire and four other sites across Leeds and Bristol. Low occupancy levels led to cash flow issues.

PKF, which is working with care home management firm Healthcare Management Solutions, said it expected "substantial interest" in Southern Care Homes. The administrator said it had assured staff, residents and relatives that there was "absolutely no cause for alarm" and are working with social services officials to ensure the homes operate normally. Manchester-based PKF said: "Once the financial position is stabilised, the administrators intend to offer the businesses for sale.

In relation to Charlton Care Homes, KPMG has been appointed administrator and the firm is in talks with the same Birmingham-based care home management firm, Healthcare Management Solutions, to keep the homes trading as normal until a buyer is found. KPMG said, “All the care homes will be trading as usual while we market the businesses for sale. “The administrators will explore any form of sale that will maximise the return to creditors so we will look at expressions of interest for the full portfolio of homes or individual homes,” he added.

Isn't there something wrong with this picture? How would you feel right now if your mortgage provider went into receivership and you were told that your home was now for sale to the highest bidder? It's a strange world we now live in, isn't it!

This week will probably be the most immediately momentous for quite some time, as the implications of the Comprehensive Spending Review begin to sink in and then take effect. The Government is giving out very clear messages that the impact will be spread over at least four years and let’s hope that this proves to be the case.

In particular Local Government needs to hold its collective nerve and not make rash decisions about care services or about adult safeguarding services. There are just too many people in very vulnerable situations that can be badly hurt by any short term or knee-jerk reactions to what is announced on Wednesday, so Council responses need to be measured and perhaps different from previous years. Certainly, we would be a little bit more reassured if ADASS had been prepared to give a public commitment to maintaining adult protection/safeguarding, but they did not respond to our calls in this regard and it would seem that their new rallying call these days is around ‘affordability’.

Now, dare we wonder who could possibly consider stopping elder abuse to be unaffordable? Is there a community in the UK who would really agree that abuse of old people, or other adults, should continue because councillors have decided that there is something else more important to spend the money upon? And this is essentially what it will come down to. Whether people choose to argue that, ultimately, it is all the fault of George Osborne and the Coalition Government for making cuts, the reality is that the pain, the suffering, and the final accountability will rest at local level. Some may argue that this is unfair, but it is nevertheless the reality of life!

Which perhaps brings me to what has been happening since the beginning of October. A callous daughter stole £60,000 from her frail mother’s bank account and blew the lot on luxury holidays around the world as the Alzheimer’s suffer lay dying in a care home. A 30-year-old care worker was accused of stealing £10,000 from one of the residents at Hagan Hall sheltered complex in Jarrow and £2,000 from another. She got 10 months' imprisonment, suspended for two years, with supervision and 250 hours' unpaid work. Another carer elsewhere was convicted of stealing £700. A Care home project manager from Birmingham “plundered” more than £6,000 from a vulnerable woman in her care but escaped going to jail, while another was jailed for stealing £7500 from three elderly residents. However, the retired bank manager who swindled more than £47,000 from a vulnerable care home resident got two years probation and was ordered to repay the money within nine months. And that’s just this month. So far!

But perhaps the worst report was on 6 October when the Northampton Serious Case Review report confirmed that five elderly people who died within two weeks of each other at a care home in the county suffered "severe neglect". They were aged from 83 to 100, and died between 22 July and 6 August 2009. The case review found standards at the home had declined since previous inspections and that, by July 2009, the home "simply could not manage". The home was rated "adequate" in November 2008, and was due to be inspected again within a year, but CSCI was alerted in July by Northampton General Hospital.

Contrast that with the Press Release by CQC on 11 October (five days later) which said that around 1,000 care homes across the country have no registered manager. But, according to CQC, this does not mean there is a direct risk to residents. They said that the only problem that could arise without a registered head in place was that problems may take longer to spot.

What, like Northampton?

Slow and steady

Any immediate developments in adult protection systems in England will very much rest on the outcome of the work being undertaken to redesign No Secrets into a new guidance document. Perhaps more long term we can reasonably expect safeguarding legislation in some form or another to emerge from the Law Commission work, but any improvements in the short term will only be gained from a new version of No Secrets. Which makes the work of the Advisory Group convened by the Department of Health so important.

There was a time, prior to the May elections, when we would have been really quite depressed by this reality, but things have changed. The Advisory Group is now addressing some very important and critical issues associated with Safeguarding and the quality of the debate and considerations are really quite significant. Yesterday's meeting, for example, sought to encapsulate not only what should be the formal 'Aim' of safeguarding in its widest sense, but also the Principles under which safeguarding and protection should operate (in a similar sense to the Mental Capacity Act Principles). This is challenging stuff and, if it reaches a logical conclusion, will establish the parameters within which Safeguarding will operate for the foreseeable future.

I guess, not surprisingly, we are doing everything we can to facilitate this process and make it happen, notwithstanding our much reduced resources. For example, we are currently exploring with the DH the possibility of hosting of some workshops to consider safeguarding and personalisation, empowerment, and of course powers of intervention. We are also looking to begin a debate around localism and the Big Society, and how these concepts may be used to enhance Safeguarding.

None of this is simple stuff. But, if we don't get it right at this stage, we will weaken rather than improve the potential of Adult Protection to make a difference in the lives of people in very vulnerable situations. And, as Adult safeguarding/Protection has no legislative basis at the moment it must be at risk from the October Spending Review and potential cuts. And that would not be a good thing!

Changes

Well, the last few weeks have certainly seen the Coalition Government begin the process of dismantling and re-arranging some of the structures left by Labour, with a firm emphasis on less regulation and fewer bodies.

Perhaps somewhat surprisingly the Care Quality Commission (CQC) appears to be emerging relatively unscathed, possibly due in part to the imminent confirmation of Jo Williams as Chair of that body. But others have not fared so well, with the Vetting and Barring scheme almost certainly being scaled back considerably, the General Social Care Council disappearing entirely (with much of its functions transferring to the National Institute for Health and Clinical Excellence (NICE), and the Social Care Institute for Excellence (SCIE) also losing its role in promoting social care excellence to NICE. There is understandably some concerns that these particular moves may further undermine the uniqueness of social care in comparison with health, an anxiety perhaps borne out of the experiences with the CQC over the last eighteen months. However, whether things will prove different this time around, with a new Minister for Social Care and a different set of priorities, time will tell.

There is of course little argument that the complexity and multitude of the regulatory/advisory system was and to some extent continues to be, a mess. It was placing increasing cost and resource expectations on (mainly) social care providers and individual workers with an increasing uncertainty about whether or not we were seeing a consequent return in terms of quality of care. To some extent process was taking precedence over outcome - although it's a real pity that the new Chief Exec at the GSCC, Penny Thompson, didn't get a greater time to influence that body. But, in our view, the only question that will need to be answered in terms of the current, and no doubt continuing future, changes, is one which gauges their success in improving matters.

Change by itself can be reinvigorating,but only for a little while. Thereafter, it gets judged by what it delivers!

Moving forward

We've been involved in a couple of meetings at the Department of Health in recent weeks, and both have helped give us a sense of direction in terms of the Coalition Government and their approach toward Safeguarding.

The first was the Social Care Reference Group which was chaired by the new Minister for Social Care, Paul Burstow, and which generally looks at a wide range of policy initiatives associated with social care provision. It was a useful meeting on a number of fronts, but not least because the Minister made some important statements on the direction of travel that is being mapped out for Adult Safeguarding. This was then built upon at the No Secrets Advisory Group, which took place this week.

So, what's our estimate of what's likely to happen over the next twelve months?

Well, the dubious commitment given by Phil Hope that he would bring forward adult safeguarding legislation at a time unspecified is clearly dead. It was never a runner, and our assessment from the start was that this was no more than a cynical political ploy to get us off his back on the issue. Instead, the focus is on the work of the Law Commission which will make recommendations in April next year, with social care legislation coming forward for the next Parliamentary cycle. We anticipate this will include adult safeguarding legislation. (You can read our submission to the Law Commission (here)

What we did get wrong in our predictions was the inter-Departmental Ministerial Group on Adult Safeguarding, proposed by Phil Hope in January. This has not died in the transition as we anticipated, but has been re-instated by Paul Burstow and, we're told, has already had its first meeting! Which is good news in terms of the status and priority potentially being given to the issue.

And No Secrets version 2 is going ahead, but this time we are seeing a greater degree of interaction and consultation tasking place, unlike the previous situation where key issues were not being considered and where contributions were being ignored if they did not 'fit' with what was considered popular. In terms of our 're-set' button, this is one of the most important immediate elements of the Review, and we're throwing a lot of what's left of our resources into this activity.

But, in terms of its implications, one of the most important messages we have heard recently relates to the Personalisation drive, which to date has effectively ignored safeguarding, treated the issues of elder abuse with contempt, and operated as though it was the one and only solution to everything and everybody. As we anticipated, personalisation is here to stay and in fact is likely to see the pace of implementation quicken. But in a safeguarding context it has a new perspective, with the Minister indicating that there needs to be an adult debate about the line between individual user choice and the need for protection, but that the State did have a role in protection. That is not to say that people must be wrapped in cotton wool or have the quality of their lives adversely affected by protective rules and systems, but we never proposed that in the first place. But it does mean that we finally have a Minister who understands that the current strategy is likely to place some people unnecessarily at greater risk of abuse. Which is what we have been saying for more than two years!

Of course, none of the above gets us away from the fact that it is set against a backdrop of major financial reductions and cuts, with adult social care at risk of taking a disproportionate share of those cuts - local government doesn't have a good track record of protecting such services. And it doesn't mean life is going to be easy for any of us, although it would be very naive to think cuts were not inevitable regardless of which party won the General Election (and Lord Mandelson's revelations this week make sober reading in that regard). But it does mean that we have a chance of coming out of this with the potential for some solid foundations finally laid on adult safeguarding. And we have no confidence that we would have been able to say that if Phil Hope had continued in office.

So, we plan to push forward with some significant level of caution, and a certain degree of hard won cynicism. The last two years have left us with no illusions about how easily policies can be disregarded if they no longer match immediate political priorities, but we would be failing in our duty to adults at risk of abuse if we didn't give this our best shot. And that includes giving the new administration the chance to prove that they mean what they say on this issue.

As we ended our last blog, watch this space!

Reset button

The issue of safeguarding adults at risk of abuse has gone very quiet over the last month, partly because we have been keeping our collective mouths shut and partly because other issues have dominated the wider political agenda. Silence however hasn't been through any sudden lack of interest on our part, but because we were assessing the impact of the change of Government and where adult safeguarding fits into the new scheme of things,

Of course, it would be easy to say that things could not have become any worse with a new Government than we experienced under the previous administration. The last eighteen months for adult safeguarding, and for us as the primary Third Sector voice on the subject, were not easy. Our written submissions to DH were invariably marginalised - we submitted one of the most comprehensive documents possible to the No Secrets Review and it was very obviously ignored - and our contributions to meetings were often treated with disinterest, to the point where it became pointless to attend events other than to keep the flag flying. And, of course, a major hit for AEA was when DH refused to provide any further funding for the charity, presumably on the basis that, if they couldn't shut us up, they certainly weren't going to give us funding to effectively subsidise what we were saying. We have no doubt that the decision had nothing to do with the quality or content of our proposals and everything to do with what had gone wrong with the Government, and perhaps with a civil service who had stopped giving the Government any advice that they (the civil servants) judged might not 'fit' with what Ministers wanted to hear.

How far Labour had traveled, and what a sad route they had taken, from the days when they published the elder abuse prevalence study and committed to the Review of No Secrets, a document that they had originally introduced back in 2000. And there is no doubt that we might have held a very different view on their ultimate track record if Ivan Lewis had not been replaced by Phil Hope - one of the many actions taken by Gorden Brown for what seems to have been personal rather than sound political reasons. And we could no doubt be forgiven for viewing somewhat cynically the observations of one ex-Labour Minister at last months National Pensioner's Convention who agreed that what was needed was Adult Protection legislation. Yeah, right! Perhaps she should have said that two months ago to her (now unemployed) former colleague when he was Minister of State for social care.

So, where do we go from here? Well, someone who we trust significantly on this matter suggested recently to us that the General Election should be considered a 're-set button' when it comes to safeguarding in general, and also to the debate on safeguarding and personalisation.

We agree. And we're pushing that button because, for adult safeguarding and elder abuse, and despite the dire financial challenges facing the country, the Coalition Government still offers a much better chance to have grown-up discussions on these matters, and achieve strong foundations for adult protection, than was ever likely to be the case with the Brown Government and Phil Hope. And we look forward to that.

So, as is often said within AEA, watch this space!

In six days time we vote...

Well, the last of the three Prime Ministerial debates are over and, apart from the fact that they were staged as though the UK comprised of England alone, they have proved a powerful force to upset the comfortable status quo that has existed for so many generations. The expected battle between the two 'big boys' of Westminster has been clearly disrupted by the unexpected impact of the Lib-Dems, whose leader has very calmly established three-party politics back into the British psyche. Of course, there was only ever one outcome for the General Election debates themselves, and that was to enshrine them for evermore into the political arena. There is now no way back.

So, where does that leave us in terms of adult safeguarding?

Well, it can't do us any harm. Phil Hope, as Labour Minister for Social Care, has hardly been a champion for the protection of vulnerable adults. The No Secrets review was a disaster, leaving huge questions over how we successfully protect some of the most vulnerable people in our society. He refuses to listen to any concerns about the safeguarding implications of the personalisation agenda. And, in the same period as he published the White Paper on Social Care, which advocates a better trained and quality workforce, his department declined to continue funding AEA because they didn't consider workforce development as one of their stated preferences. Hardly a consistent approach.

But then, we don't really know where the Conservatives will run with any of this either. The concept of a Big Society is a good one in principle, but getting it to work is going to be quite a challenge. And, they have a view on regulation and quangos that does rather suggest quite a change for organisations like the Care Councils and care regulators etc if they gain power. Some (perhaps many) might argue that would be a good thing.

Which keeps bringing us back to the conclusion that, for adult protection, a hung parliament might not be such a bad idea. The Lib Dem strategies of emphasising change, of fairness, of honesty in politics, all lend themselves to a very strong argument that these should be applied to the process of protecting adults at risk of abuse. And they do have a good track record of supporting issues to do with elder abuse in particular and adult safeguarding in general. So, perhaps a bit of haggling between parties in Westminster, that forces them to work together and that forces out some of the more extreme policies, might not be bad thing.

Of course, that pre-supposes that a hung parliament wouldn't simply paralyse the whole process of Government. And I'm sure that's giving some Civil Servants a few sleepless nights. Ah well, six days to go...

General Election

Well, the General Election is finally starting to roll onto fairly safe territory with the publication of a manifesto by each of the three main Westminster political parties. Of course these documents don't really mean a great deal in the long term in that they are often ignored once the Election is finally over, but they usually provide material for the battle ground over which the Election is fought. And they usually give some insight into what the leading politicans consider to be the primary issues of the day.

Which means we can be fairly sure that the safeguarding and protection of older people and other adults at risk of abuse scores a huge zero on the political interest charts. And we can also be pretty sure that adequate funding of social care and the provision of quality and safety within the personalisation agenda is also a non-runner.

There is no doubt that the next Parliament will need to reach concensus on how the long term care of older people is funded. And there is also no doubt that we need to see care and health provision more reflective of individual choice and control. But the devil has been in the detail for too long, and there have been too many 'special interests' able to ride rough-shod over the implications of both these issues at the expense of very vulnerable people. Martin Green, from the English Community Care Association, put it very succinctly in a news release yesterday when he said,

“Yet again, social care has been relegated to the margins within party manifestos. It is interesting to note that good quality social care is equally important as education as a foundation for economic recovery and social renewal, but politicians are obsessed with one and tend to ignore the other. At a time when the debate has to centre on the budget, we need an approach to social care that recognises its economic and social importance for a civilised society. We need politicians to do what we expect of them, which is to lead the agenda and deliver tangible benefits, rather than endless discussion.

Too true Martin. Too true!

Can we Hope for change?

With the General Election finally called it is difficult not to speculate on what it will mean for the future protection of adults who are at risk of abuse. By their very nature Elections feed on special interests and it's always a challenge to get an issue heard above the din, particularly if the issue has never achieved a high profile.

But of course the abuse of older people did achieve such a profile, with the launch in 2007 of the Comic Relief/DH funded study into the prevalence of elder abuse, and which indicated that 4% of older people (342,000) were experiencing abuse in the UK. We now know from further research that the figure is nearer 8.6%, but the point is that the prevalence report resulted in Ivan Lewis, then Minister for Social Care, announcing the review of adult protection systems in England. So, how is it that just a few years later it all seems to have fallen apart, leaving so many vulnerable people in limbo?

The issue naturally boils down to the importance that politicians place upon protecting old people and people with learning disabilities. If they have a personal interest and commitment then things happen, but if they don't...well, then it becomes just another issue that has to compete with all the other issues. And that can be translated into whether or not there are votes in it. So, where will those votes finally go?

Well, the pundits suggest we'll either have another Labour Government, or a Conservative one, or more likely a hung Parliament with the power potentially held by the Lib Dems. But will any of that be good news for vulnerable adults?

Possibly. We know that the most vociferous and consistent advocate in Parliament for the protection of older people has been Paul Burstow, a Liberal Democrat MP (and Chief Whip) who has an unrivaled record of raising this issue and supporting our work. So, assuming that he remains influential within his party (and is re-elected), any control that the Lib Dems can achieve might well be of some assistance. And that rather suggests a hung Parliament might be in our/the vulnerable adult's favour. Which means that's a 'maybe', then.

We don't know (yet) what the Conservative position will be, so we're actively pursuing that to see if we can get some clarity on what the adult protection world might look like if it suddenly turned blue in the House of Commons. Certainly, Stephen O'Brien has been supportive of our helpline work with Southern Cross Healthcare and clearly perceives such collaboration to be a positive way forward. But, would that translate into Adult Protection legislation? The truth is we just don't know.

So that leaves Labour.

On current track record, with Phil Hope, we can presumably expect a continuation of the current situation, and that cannot be good news if you are at risk of being abused. Under his stewardship we believe the review of adult protection systems became heavily influenced by a political agenda that was far removed from its original intent. It looks like the Code of Practice on consultations was ignored. And then, despite being told by the police, by local authorities, by adult protection staff, and by charities such as mine, that the only effective way forward was to introduce adult protection legislation - it took Mr Hope almost twelve months to the day to make an announcement. (To put that in context, our helpline took nearly 9000 calls on elder abuse during that year). And still no-one can actually tell us what that announcement meant in terms of legislation; there's a growing belief that it actually meant nothing, that it was just to stall things until after the election. And, we certainly won't be able to find out 'from the horse's mouth' because, unlike his predecessors who regularly met with us to discuss adult abuse, Mr Hope refuses our requests for a meeting. Even the Social Care Reference Group, of which he is chair, consistently ignores the issue unless we raise it. Adult Protection just isn't a high profile issue any more. It's dead, and in the last eighteen months or so, we think it's gone backwards instead of forwards. Which is very bad news if you're being assaulted, or coerced, or neglected, or you're having money or property stolen from you, and you're just too vulnerable to defend yourself.

So, what do you think? Labour, the Conservatives or a hung Parliament? A topic to which I shall no doubt return in the coming weeks.

Everything has a cost

As of today AEA no longer receives any Government funding.

The charity has consistently maintained very close working relationships with successive Ministers of Social Care over the last decade, and this was particularly so with Ivan Lewis who preceded our current incumbent.

Ivan demonstrated what we believed was a very real commitment to the issues of elder abuse and safeguarding, and we had a confidence that the case for vulnerable adults was being heard and understood. Not that all civil servants appreciated his interaction with us and I recall one in particular telling me that 'Ministers come and go' and that sooner or later we would have to deal with them instead. If it wasn't a threat it was difficult to perceive it in any other way, and I mentioned it to Ivan at the time.

Times of course have changed. We no longer enjoy the same relationship with the current Minister, and nor does adult safeguarding or elder abuse feature as key aspects of social care strategy. The Minister has declined our request to meet and discuss the issues, and the last two meetings of the Social Care Reference Group didn't even have safeguarding as an agenda item. While we asked for it to be tabled for the first meeting the ensuing contribution was such that we felt it pointless to ask again when it once more failed to appear on the agenda of the second meeting. Such is the importance now given to the abuse of vulnerable people.

This change of approach was obvious at the outset of the review of No Secrets, the guidance under which adult protection systems are established. And, while we did our best to maintain our role of 'critical friend' to the Government during this process, what became quickly apparent was that the DH no longer wanted such friends. We hadn't changed, but they had. And consequently we had a choice to make: be quiet and protect our funding, or speak out on behalf of our constituency i.e. all those adults who experience abuse and who do not have a voice. No contest, but definitely a cost.

And so today we find ourselves with no Government funding. Which is exactly what we anticipated would happen, and exactly why we reconfigured our budgets in anticipation. So, we won't be going away. Or changing our strategies. Or shutting up. Where politicians or statutory agencies put forward coherent policies or reports we will continue to support them, as we did yesterday with regard to the CSSIW report on Welsh safeguarding. But where they put forward policies or reports which fall short, we will continue to question, probe and advocate. Because that's why we are here and that's what breathes life into democracy.

Hopefully the General Election will re-invigorate Central Government. Because on the issue of adult protection it has lost its way. And when Government's can no longer appreciate the suffering of their people, they must surely have lost their mandate too.

The good and the ... what?

The Welsh regulator, CSSIW, published a very insightful report this week into the state of adult protection within the nation and it makes interesting reading. Last year we felt it necessary to be generally critical of the state of play in terms of regulation and adult protection in Wales, and this report identifies and addresses some of those issues as well as many others. And it suggests some positive next steps.

An obvious challenge within Wales, which is identified in the report, is the need to establish a common understanding of thresholds for intervention, particularly as there are some significant variations in terms of who is perceived as being eligible for protective intervention and how that is established. And an obvious positive in the report (which would be worth exporting to the other nations) is the very real work being undertaken to link contracting/commissioning and adult protection. All of which provides a positive direction for the future, and perhaps an air of optimism within Wales. Do get hold of a copy of the Report and have a read!

Which brings us to consider the White Paper which was published by the Government yesterday. It clearly contains many statements of general principle that are to be welcomed and supported, including the commitments to a national system of assessment and eligibility for care, free personal care at home for people with high needs, and an element of free personal care for people in residential care. And it puts all of this in the context of increased information for users, workforce development, and user empowerment and control. Which is probably why it has been so well received by many organisations in the Third Sector,

But there are obvious questions hanging over this process, and it is understandable that many care providers should be unhappy. Referring the funding debate to a commission instead of biting the bullet now is a questionable move, particularly given the fact that there was a Royal Commission on the Long Term Care of the Elderly back in 2000 which made recommendations that the Government ignored. So there isn't exactly a confidence that they will listen this time either.

And there are a lot of unexplained decisions too. After carrying out a review of the General Social Care Council, the Social Care Institute for Excellence and Skills for Care, the White Paper announces that the GSCC is to be split into two, with one new body focusing on social workers and the other addressing everyone else. But it really isn't clear as to why, or what the benefits will be? The results of the review have never been published, and there are little explanations of this decision to be found in the White Paper so we are all left a little bemused.

And proposing a voluntary system of licensing (and do notice that this is no longer called registration) for social care staff is just silly. If the purpose of registration is to regulate the workforce, in a similar manner to the NMC role with nurses, then this new decision really cannot take us anywhere. The White Paper would have been better off redesigning the GSCC to focus on 'fitness to practice' (which is currently not within its remit) than to undertake this split. But it means we have now seen contradictory decisions within regulation in the space of a year; three regulators have been merged to form one super-regulator in CQC (justified by all the arguments around consistency, cost-benefits etc), while another regulator finds itself split into two. Most odd.

But perhaps what is the most confusing is the funding approach now being adopted. If we link the White Paper and the Personal Care At Home Bill, we can envisage a situation in which someone who has a high level of care need at home can get support for free, but if they deteriorate and need support within residential care then they must begin to pay. And then if they survive for two years it all becomes free again. I'm still trying to get my head around the logic of that one...and it has crossed my mind to check on the average length of stay in residential care before people die (of natural causes I hasten to add).

Didn't someone say it was about two years..(do let me know if I'm wrong)?

It's all about perception

Having been 'off the scene' for at least a couple of weeks - either preparing for our two day National Conference, delivering the event, or simply recovering from it - I find myself trying to pick up again on all the issues that are current. (And of course, also prepare for the year long campaign on elder abuse which we are launching with 3 Counties radio on Monday).

But what is particularly on my mind is the imminent publication by the Government of the White Paper on Social Care, and presumably the next stage of the Free Personal Care at Home Bill. Both should be positive measures for older people but somehow I can't help feeling anxious about them, and one of our conference speakers earlier this week helped me realise why. He was discussing the way in which older people are perceived by our society, and challenged why the concept of the 'demographic timebomb' is more acceptable (which is a negative perception of a massive part of our communities) as opposed to celebrating the fact that our health service has successfully extended life - a success that should be capitalised on in terms of the knowledge, experience and skills that are retained by older people and could still be put to good use.

Of course, despite our views and those of the National Pensioner's Convention, it seems unlikely that the Government will consider a care service that is fully paid for by taxation, they have already argued that this would place an unfair burden on those still at work. But that seems to simply maintain the concept that anyone over 65 years of age is non-productive and dependent, and can therefore be forcibly retired. Once upon a time, the argument was that the old should give way to the young, but if there are fewer and fewer of the 'young' it does seem illogical that we still have enforced retirement based on age alone. Isn't that somewhat counter-productive?

But then again, if the Dispatches TV programme earlier this week is accurate, a number of our MPs are demonstrating their belief that retirement should not be the end of someone's working life. Their philosophy clearly is that if you retain the knowledge, the skills and the contacts you should put them to use.

I wonder if Geoff Hoon, Stephen Byers, Patricia Hewitt and Sir John Butterfill realised that the older retiring population might end up perceiving them as champions for 'the right to work for as long as they want'?

It's been a long week, so maybe that's just one thought too far!!