This blog really started two years ago and was revived by the report from the “Commission on Improving Dignity in Care of Older People”.  (Click on “Dignity be Damned” in the TAG CLOUD).

The report was co-authorised by the Local Government Association, the NHS Confederation and AGE UK.  It is well argued and makes a lot of common sense recommendations.

Few would argue with their aspiration to provide better care for the elderly.  However, I am not sure they have fulfilled their stated ambition to “identify the underlying causes of these persistent failings”.  I have commented on what I think should be a more strategic response on my previous blog on this subject.

Meanwhile, here are my comments on their 48 recommendations:-  (Click on the following link www.nhsconfed.org/Documents/Delivering%20Dignity.pdf  if you want to read the full report).

1. Deliver care at home in the community
   • Absolutely, but you will have to get GPs out and about first, and build shop window style health centres
2. Make independence at admission and discharge a key measure
   • Good idea – why not pay a bonus for health improvement
3. Ban patronising language
   • Yes but it’s hardly a top priority so let’s not get all P.C. about it
4. Comprehensive geriatric assessment
   • It is wishful thinking in these express service NHS days
5. Nutritional needs
   • A critical failing that will only be solved with more staff, volunteers and relatives
6. Families, friends and carers
   • Agreed and see above
7. ‘This is me record’
   • Nice idea so long as it is not turned into a blizzard of paper
8. Feedback
   • Needs to be monitored by a panel of independent elderly people with a direct reporting line to health boards
9. Staff take personal responsibility
   • A platitude
10. Practiced based development
    • Should lead to a new NVQ/Nurse for the elderly qualification
11. Recruit compassionate staff
    • Another platitude.  Most staff are compassionate, it is the system that needs changing
12. Dementia training
    • This is essential, there should be dementia nurses at ward sister level on all elderly wards
13. Devolved leadership
    • This will never happen inside the NHS.  It is a command and control model and probably should stay that way for short-term acute care
14. Board leadership
    • It is called “walking the floor” but right now they could well get lynched if they ventured onto elderly wards
15. Ward leadership
    • Will only happen if you reduce paperwork, give them enough staff and empower them to discipline poor performance
16. Patient/family feedback
    • Who can disagree
17. Staff reflection time
    • Ditto
18. Professional duty of care
    • Motherhood and apple pie
19. Protection of vulnerable adults
    • A toothless, ineffective process that has nothing to do with leadership
20. Discharge from hospital
    • Should be controlled by community based staff, otherwise the rush to empty beds takes priority
21. Care home values
    • Not at all clear what this is about
22. Care Quality Forum
    • If the Nursing Quality Forum has not worked for older people, why would another forum for care work?
23. A rating scheme for care homes
    • CQC has only just abandoned one
24. My home life
    • A good process that should be used more widely
25. Care plans
    • This is already mandatory but too often its use is limited to basic care tasks by pressure of time
26. Buildings fit for purpose
    • There needs to be massive capital investment to build new accommodation and thereby eliminate old out-of-date residential care homes
27. Family and friends, carers as partners
    • Of course
28. Volunteers in care homes
    • Residents themselves are the most valuable and reliable volunteers
29. More use of technology
    • Yes in principle, but it all needs to be more “elder-friendly”.  SKYPE could open a window way beyond contact with relatives, so could web cams and CCTV
30. 360° staff appraisal
    • If it is done constructively
31. Personal responsibility
    • Motherhood and apple pie again
32. Access to medical care
    • Of course but it only works if doctors will come out of their surgeries
33. End of life care
    • Agreed
34. Board role
    • See answer 14
35. Non Executive Directors
    • Agreed.  It should be routine and regular, not just ceremonial
36. Invest in training
    • 5% of staff time should be spent on training
37. Residents’ charter
    • Rarely worth the paper it is printed on
38. Feedback
    • See answer 8 and also consider suggestion schemes, resident forums and comprehensive annual surveys of residents, relatives, volunteers and staff.  The results and improvement plans should be published.
39. NHS Commissioning
    • Cost drives their decisions.  I have little confidence they can put a price on dignity
40. Ditto
41. NICE
    • All hot air
42. More fine words
43. Local advocacy groups
    • A good idea in principle but toothless in practice
44. Health Watch
    • Community health councils did not work so what will change this time
45. Universities and professional bodies
    • They already have this responsibility but are ineffective at guaranteeing good performance or compassion
46. Regulation
    • This has singularly failed to deliver better care and I have long argued that the DoH should refocus CQC’s remit to focus on best practice and training for improvement rather than ineffective policing.
47. Healthcare Assistant
    • I think there should be a new qualification of second level, mainly practice base ‘nurse for the elderly’, as already operated in Holland.
48. Care Quality Commission
    • See point 45.  They should also conduct regular customer satisfaction surveys with residents and their relatives

As I said at the beginning, there is nothing much to disagree with here.  It is mainly good practice that is already implemented in the best care homes and hospitals.  The key question is why is it not done everywhere and that will not be answered by greater exhortation.

Who was it who said “two priorities are no priority at all”?  48 recommendations may be a direction of travel but they are a long way from a road map.

The second stage of the Commission’s work needs to start further back at the root causes of the problem.