Download MSWord document

Following this submission, evidence was given to the Joint Committee on Human Rights by the RCN, BGS, NHS Confederation and Association of Directors of Adult Social SErvices on older persons in health care.

Other Links: RCN response
US Federal Law - Rights of people entering nursing homes
Age Concern's Submission

The Society is delighted to be given the opportunity to contribute to this debate and despite many old people getting imaginative and appropriate care in hospitals and care homes would comment as follows:

1. What are the main challenges to the Human Rights of older persons to receiving treatment in hospital and residential care homes? Do the same problems arise in both settings?

The main challenges in hospital are the perceptions that:

• Older persons do not respond to treatment as well as younger persons do.
• It is acceptable to deny dignity and privacy to older persons in a mixed ward.
• Ill health is part of ageing and that frailty secondary to chronic disease is not treatable.
• It is acceptable to use the toilet in a mixed ward next to a person of the opposite sex separated by an insubstantial curtain.
• It is acceptable to move an older person to another ward without advanced warning because of bed pressures.

In both settings:

• Older persons, who have difficulty feeding them selves, may not receive adequate nutrition as there are not sufficient staff numbers identified to feed them.
• Older persons may be left soiled in their beds or chairs.
• Older persons may be told “ Do it in your pants, I do not have time to change you and I will come back later”
• Older persons may be publicly reprimanded for soiling themselves.
• Older persons visual and hearing problems may not be identified, treated or managed.
• An assumption may therefore be made that they are either stupid or lacking in capacity.

In addition older persons in care homes have their human rights infringed for the following reasons:

• They may be placed in care homes without adequate opportunities for assessment and rehabilitation to maximise their function. This raises issues under Article s 8 (right to respect for private life).
• Some older persons go into long-term care without receiving a comprehensive assessment of their needs. This raises issues under Articles 8 and, in extreme cases, 2 (right to life).
• Their conditions may be left untreated until crises arise, as it is perceived that they are in a place of safety. This raises issues under Article 2.
•  There is a delay in the medical information about new residents being sent to the homes’ GP S. This causes problems with continuity of care and a failure to understand the unique health needs of each resident. This raises issues under Articles 8 and 2.
• Older persons in care homes may be given sedatives, tranquillisers and restrained physically. This can arise as a result of inadequate levels of staff, skills and training. This raises issues under Articles 8 and 3 (prohibition of inhuman and degrading treatment).
•  Ambiguity in the case law means that the extent to which the Human Rights Act applies to the voluntary and private care home sector is currently unclear. (The Committee is concurrently exploring issues relating to the definition of ‘public authority’ in the Human Rights Act despite 60% of older residents receiving public funding for their care in these homes).
•  The population of care homes has become increasing frail and dependant over the last 20 years. There is very little difference between those receiving NHS Continuing Care and care home residents. There has been no shift of resources from the NHS to the community to care for this increasingly dependant group of the population. This raises issues under Article 8 and, in extreme cases, Article 2.
• General Practitioners (GPs) and District Nurses regard their responsibilities in care homes as additional to their normal workload and an area for which they have not received any specialist training.
• Only 40% of the GPs will have received any postgraduate training in the care of frail older persons with multiple pathology. This results in older frail persons in care homes receiving sub-standard treatment.
• Nearly half of care homes are failing to meet national minimum standards for how they give persons their medication, prescribed by their doctors, to treat their medical conditions. This raises issues under Articles 8 and, in extreme cases, 2.
• Older persons can be given the wrong medication, someone else’s medication, medication in the wrong doses or no medication at all. This raises issues under Articles 8 and, in extreme cases, 2.
• Many older persons, in care homes that would benefit from multi-disciplinary rehabilitation and medical treatment for their chronic diseases cannot access it. This raises issues under Article 8.
• Reversible mental health conditions such as depression are not diagnosed and are not treated. This raises issues under Articles 8 and, in extreme cases, 2.

2. Are there discriminatory restrictions of the rights of older persons to access health care without justification, for example in relation to criteria used for sharing or rationing finite health resources?

•  Older persons, admitted with trauma and fractures, which require surgery, may have their operation delayed, as younger patients with or without trauma may take precedence.
• Older persons, who suffer delays for operations for fractured neck of femur, have been found to have a worse outcome in terms of morbidity and morality.
• In some units older persons may be refused surgery as their outcomes may be perceived as poor and this may effect affect the surgeons’ outcome figures.
• This approach will deny older persons access to successful interventions.
• In some units they may have greater difficulty accessing investigations because of their age. Examples include access to 24-hour tapes for identification of cardiac arrhythmias.
•  
• Older persons often have their medical complaints put down to old age with phrases like “social admission”, “acopia”, “inappropriate admission” or “bed blocker” used when they have perfectly treatable illnesses which would benefit from intervention
• Older persons with delirium are not identified and thus are not perceived as suffering from a treatable medical condition.
• Medical conditions in older persons suffering from dementia are considered not to be worth treating
• Most older persons with advanced dementia do not receive appropriate palliative care
• Older persons are no longer wage earners and thus less important to treat.
• Women over 70 are not entitled to breast screening.
• Many older persons in the UK cannot get help with podiatry (foot care) from the NHS, leaving them in pain, housebound and at increased risk of falls and in extreme cases unable to mobilise

3. What barriers face older persons, and their families, seeking to voice their concerns about possible abuse, neglect or discrimination in healthcare?

• Staff are too busy to set aside a specific time to listen to concerns.
• Older persons tend to face barriers such as an assumption that they are too confused to be able to be an accurate observer.
• Disabled older persons are seen as less worthy of equitable healthcare than younger persons with a single pathology.
• An older person may feel less confident about speaking out as they fear there may be reprisals. Similarly their families will be concerned that if they voice their concerns, their relatives’ care may suffer
• Elder abuse does not have the same high profile as child abuse and as a consequence may be missed or mishandled

4. Could older persons receiving treatment in hospital, or in residential care, be better informed about human rights principles? If so, how could better information and involvement be achieved?

•  Older persons receiving treatment in hospital or in residential care could be better informed about Human Rights principles.
• Older persons, or their surrogates, on entering hospital and care homes should be informed about their Rights and responsibilities
• Nurses, doctors and care staff should be educated about the importance of older persons’ Human Rights
• This could be achieved by a public information campaign and or a bill of Rights for older frail persons entering hospital or a care home.
• Staff taught about Human Rights were able to look at things differently and stopped thinking just about protecting themselves but about care from the resident’s as well as the families’ perspective.

5. What examples are there of health care professionals or other workers, or advocates for older persons using human rights principles to secure the dignity of older persons undergoing treatment for physical or mental illness?

• The British Geriatrics Society in partnership with Age Concern England, the Department of Geriatric Medicine, Cardiff University, Carers UK, the Continence Foundation, Help the Aged, Incontact, the Royal College of Nursing have developed a Dignity toolkit, Behind Closed Doors, based on the principles of Human Rights.
• Age Concern (in partnership with the Chair of the BGS Policy Committee) are running the “Hungry to be Heard campaign” on malnutrition in older people.

6. What are the main practical, management and resource considerations facing those working in healthcare settings, including residential homes, when seeking to protect the human rights of older persons in their care?

• Meeting NHS targets is used as an excuse to sacrifice the older person’s dignity and Human Rights
• Senior managers have been heard to defend mixed sex wards on the grounds of safety and health care delivery. The consequences of this approach were not appreciated.
• Providing safe health care is used as an excuse to sacrifice the older person’s dignity and Human Rights.
•  
• The main considerations facing those working in health care settings are those of time, money and human resources.
• The needs of younger persons with a single pathology take priority.
• The availability of beds in either setting.
• The need to make beds available for emergencies and thus to transfer a patient from one setting to another in the middle of the night.
• Freeing up an A& E trolley to prevent longer than 4-hour trolley waits
• The failure to recognise the increasing complexity, frailty and dependency of older persons in the hospital and care home settings over the last five to ten years
• The failure to provide staff with appropriate skills and in sufficient numbers to meet these changes
• Ageist attitudes still persist as well as low status for those caring for older patients

(Real life examples of Human Rights abuses in both settings can be provided)

7. Do Nice and the Healthcare Commission take sufficient account of the human rights of older persons in their work?

8. The Committee would welcome detailed views on practical means of securing the human rights of older persons and positive examples of good practice in the treatment of the human rights of older persons in hospital and in residential care including by reference to the approach of other countries:

We enclose an example from the United States from the residential care sector, which succinctly states the Rights of the individual entering a care home.