Joint Committee On Human Rights

Joint Committee On Human Rights Sixth Report

79. Memorandum from Help the Aged

1. INTRODUCTION

This Memorandum from Help the Aged explores the difference that a Human Rights Commission could make to the lives of older citizens. It sets out some key areas, notably in health and social care, where the human rights of older people are currently at risk.

Action being taken by the Government to promote age equality in employment is very welcome. There are no proposals at present to extend these measures to protection from discrimination with regard to goods, facilities and services. However, even if the proposed equalities legislation were wider in scope, this would still not provide adequate protection for human rights.

The Government has also taken determined action to improve the quality of health and care services for older people and has set new standards, both in the Care Standards Act and in the National Service Framework for Older People. It has also reviewed the inspection and regulation system for these services. These too are welcome steps. However, Help the Aged believes that they need to be complemented by concerted action, not only to ensure that individual rights are protected but also to achieve a change in the underlying culture of the relevant institutions (both public and private) to one that can systematically protect and promote the human rights of older people.

The Memorandum explains that older people whose human rights are violated are often not in a position—or do not choose—to take action themselves. Indeed, the 1998 Human Rights Act[19] has been little used to date in relation to health and care issues affecting older people. We consider how a Human Rights Commission might offer possible remedy.

The Joint Committee on Human Rights has called for evidence of unmet needs in relation to the promotion and protection of human rights in the UK, to which a Human Rights Commission could provide a remedy. It wishes to know what difference a commission could make to the lives of citizens, especially those who do not at present enjoy their full human rights, with an emphasis on the practical benefits that would ensue from the existence of such a commission.

The Memorandum seeks to inform this debate.

2. EQUALITIES PROPOSALS

The EU Equal Treatment Directive requires that all Member States introduce measures to combat discrimination on grounds of age by 2006, alongside (in the UK) the existing grounds of sex, race and disability, and the new grounds of sexual orientation and religion or belief (where measures are due to be in force by the end of 2003). However, this applies only to employment. There are no proposals at present to provide protection from discrimination for older people beyond the field of employment and training.

The UK Government is currently consulting on the establishment of a single equality body to promote equality across all strands affected by discrimination. The aim is "an equal, inclusive society where everyone is treated with respect, and where there is opportunity for all".[20]

Employment

Anti-discrimination measures on age with regard to employment are not due to be introduced until the end of 2006; there is to be a further round of consultation during the spring of 2003.A poll[21] carried out in December 2002 by the MORI Social Research Institute for the Government's Age Positive campaign showed that age was felt to be the most prevalent form of discrimination in the workplace. A third of those who said they had experienced discrimination in the workplace felt that this had been due to their age.

Strong measures will need to be taken to ensure that a hierarchical approach does not develop within a single equality body. The fact that age will be the last strand of the Framework Directive to be implemented through domestic legislation, together with the lack of any existing case law in relation to age, could tend to minimise its impact. It will require determined positive action to offset this tendency. The structure of the proposed single equality body will be significant in ensuring that age is not marginalised. Whether that structure is functional or strand-specialist, expertise and understanding on age issues need to be developed, and the appointment of senior staff with specialist age-related expertise and responsibilities will need to be a priority.

Goods, facilities and services

There is considerable evidence that older people are discriminated against not lust in the workplace but in health, social care, social security, education, insurance and other fields, some of which have a bearing on employment and some of which do not. Much of this evidence is anecdotal as yet, but there is a growing body of research (especially in employment and health) which bears this out. [22]For instance there are significant differences in the average cost of social care to older and younger adults. The average cost of an older person receiving home care is £72 a week, while for younger adults it ranges between £91 and £203 a week With day care, spending on older people averages £50 per person per week, while for younger adults the average ranges between £89 and £203 per person per week Residential and nursing home costs in respect of older people average £338 per week, whereas for younger adults they range between £418 and £663 per week. [23]

These figures are averages only, and might reflect a lesser level of need amongst older people. However, that seems unlikely, as social care for older people is heavily rationed and eligibility criteria have been becoming tighter and tighter year by year. Such differences in expenditure inevitably impact on the availability of help generally (how easy it is to access), the amount of help individuals receive (hours per week), the quality of that help, and the choice available. It seems inevitable that the nature and quality of social care for older people will continue to lag behind that for younger adults while such spending disparities exist.

It is our belief that action on discrimination should be extended beyond employment to goods and services for older people, as it already is for those affected by discrimination on grounds of sex, race or disability. The positive duty on public bodies to promote equality enshrined in the Race Relations (Amendment) Act 2000 should be extended to cover all fields including age, as it is in Northern Ireland, where it is having a significant impact.

Single equality legislation, building on the best and most far-reaching provisions of existing law, is therefore a high priority and would establish greater consistency and a level playing field between the different strands of equality.

Policy initiatives

Even without the benefit of legislation, however, the Government has taken action on age discrimination with regard to health and care services. Standard 1 of the National Service Framework for Older People, published in March 2001, says:

NHS services will be provided, regardless of age, on the basis of clinical need alone. Social care services will not use age in their eligibility criteria or policies, to restrict access to available services. [24]

A series of milestones have been established which require NHS bodies to examine written policies and change any which show evidence of age discrimination; analyse the levels and patterns of services for older people in order to compare them with those in comparable areas; and move towards best practice benchmarks. The extent to which trusts are pursuing anti-discrimination measures varies—there is evidence that in some trusts, this standard is not being pursued as vigorously as other targets set by the National Service Framework for Older People or other priorities. However, there is no statutory requirement on health trusts generally to promote compliance, other than through the clinical governance reviews to be undertaken by the Commission for Health Improvement.

Social care bodies are required to review their eligibility criteria for adult social care to ensure that they do not discriminate against older people. Guidance[25] has been issued under section 7(1) of the Local Authority Social Services Act 1970, which requires local authorities and care trusts[26] to act under the guidance of the Secretary of State and so, in relation to social services authorities, it has some statutory force.

Action is going on nationally and locally to understand and identify both direct and indirect age discrimination in health and care services; to determine when and where distinctions on the basis of age may be justified and when they may not, and to consider where changes in practice and behaviour need to be addressed in order to root out discrimination. No specific resources have been identified for either health or social care to remedy age discrimination where it is found or to bring services for older people up to the expected standard of those for younger adults.

However, it should be noted that even the most extensive application of equality measures will not impact on most situations where older people's human rights are at risk.

3. HUMAN RIGHTS ISSUES

There are a variety of circumstances where older people's human rights are at risk. Those to which we wish to draw attention largely concern the health and social care systems. This is not to say that these systems are particularly at fault, but rather reflects the fact that it is at the point of contact with the health and social care system that older people are most vulnerable and most heavily dependent on others.

The following examples of potential human rights violations are illustrative only, and do not attempt any exhaustive account of the range of such issues affecting older people.

Medical care in care homes

Lack of access to medical care and suitably qualified staff in residential and nursing homes can put the lives of older people at serious risk. An inquest in Eastbourne in October 2002 found that an elderly woman with Alzheimer's Disease died of dehydration after a week in a care home, because no one understood that she needed help with drinking and eating. In another case in north London, a man with mild dementia was taken off medication for his heart condition when he went into a care home, in spite of detailed instructions left by his wife. Instead Temazepam (a short-acting benzodiazepine normally prescribed to prevent insomnia) was administered. His health deteriorated rapidly and he died a few weeks later.

In this second example no inquest took place. There is no available research, but we suspect that deaths in care homes are often assumed to be natural and expected, solely because of the age of the residents, and thus that investigations are rare. The organisation Inquest has been approached by families following care home deaths and has been able to persuade coroners in these cases to carry out an inquest, but shares our concern that these are the exceptions and not the rule. In some circumstances, depending on the level of involvement of the local authority or trust, the failure to investigate such a death adequately would breach the requirements of Article 2 of the Act (the right to life). Whilst these requirements can be satisfied through the inquest system, the right to life of older people in residential care currently appears not to be adequately protected.

Closure of homes

Local authorities and private proprietors not infrequently wish to close a care home because it is no longer financially viable or because it does not meet the required environmental standards. There is strong research evidence to show that when frail older people are moved from a care home in which they are living, there is a significantly increased risk to their health and, indeed, an increased risk of death. "Good practice" standards on the closure of care homes exist which are intended to minimise the risk to residents, but the residents themselves have no say in the matter and good practice is not always followed.

Older people in these circumstances also lose the company of friends amongst the staff and other residents, and the familiarity of a way of life and an environment which has become their home, which seriously affects their quality of life and wellbeing. Home closure is one of the very few areas in which older people's human rights have been considered by the courts. The recent case of R (on the application of Madden) v Bury MBC[27] confirmed that the Human Rights Act requires the local authority explicitly to consider whether Articles 2 and 8 (the right to respect for private and family life) are engaged by any closure decision and, in the case of Article 8(1), whether any likely breach can be justified under Article 8(2). It was not enough for the council to assert that human rights had, in general terms, been considered. However, the courts have not yet developed a systematic approach to dealing with human rights issues in this social and economic sphere.

A telling example is that of the proposed closure of Granby Way, a local authority care home for older people in Plymouth. The Court of Appeal found no point of legal principle to decide in R (on the application of Cowl) v Plymouth City Council[28] and encouraged the parties to resolve matters through an "extraordinary complaints panel" comprising a former judge, a care expert from Help the Aged and a former social services director who is currently chair of a primary care trust.

The findings of the panel were not expressed in the language of the European Convention on Human Rights, but nonetheless in effect upheld the residents' complaints that the decision to close their home did not take account of the threat to their right to life (Article 2), to protection from inhuman and degrading treatment (Article 3) and to respect for private and family life (Article 8).The panel concluded, among other things, that "Growing old is not an illness, and people's age must not be used as a justification for restricting their rights in any way? It appended to its report draft guidelines for local authorities when considering and implementing closure of a care home. These guidelines place responsibility for safeguarding older people's human rights at the heart of the process. This positive recognition of the rights of vulnerable older people goes much further than the courts have gone thus far. Whether the recommendations of the panel will be adopted by way of formal statutory guidance remains to be seen, but the case is illustrative of the sort of work that could be undertaken by a Human Rights Commission.

Family separation

It is not uncommon for older couples to be separated against their will when the local authority says that it cannot provide sufficient care to one of them to enable them to continue living at home, and he or she must instead go into residential care. In a case in Oxfordshire in November 2002, an older couple were placed in two different homes, though the situation was soon rectified after it was exposed in the press. This flagrant disregard for the Article 8 rights of older people indicates the lack of any systematic, conscious application of human rights in this area and underlines the need for a change in the culture of care planning.

Funding panels

Local authorities operate funding panels, through which they attempt to balance demand for care with the resources available. The eligibility criteria applied vary from authority to authority, [29]but are typically strict due to the need for local authorities to manage their resources. Nonetheless, older people who do meet local authority eligibility criteria for support and are thus entitled to services do not necessarily get them. They may be told they will have to wait or pay for services themselves regardless of their income because the local authority has "run out of money".[30]

This unlawful practice is unfortunately commonplace. Individual cases are settled to avoid threatened litigation, but the widespread use of funding panels to ration care continues. Individuals then find themselves unable to access essential services they have been assessed as needing, thus forcing them to live in conditions which, in some cases, may be sufficiently severe as to constitute inhuman and degrading treatment within the meaning of Article 3 and potentially put their lives at risk. There is, as far as we know, no monitoring of how many people die in their homes or following emergency admission to hospital because they have been denied a service they were assessed as needing.

Personal expenditure

The level of the Personal Expenditure Allowance which is intended to meet personal costs over and above care home fees (set to rise to just over £17 in April 2003) is not sufficient to replace clothing or other significant items. Ordinary needs and pleasures, such as a trip out or a bottle of wine or a gift for a relative or friend, have to be carefully budgeted for and many have to be foregone. Furthermore, there is research evidence that, in breach of Article 1 of Protocol 1 (protection of property), some older people do not receive their Personal Expenditure Allowance, because it is being used towards the cost of their care or for other purposes. [31]

Hospital care

There are numerous examples of poor treatment of older people in hospital, ranging from rudeness and lack of attention to downright neglect and abuse. [32]Again, in some cases this attains a level of severity that constitutes inhuman or degrading treatment. The following are quotations from letters received by the Dignity on the Ward campaign. [33]

A nurse unceremoniously lifted her shift garment they had put on her and exposed her completely in front of my son and I. It seemed terrible to me for her to be treated in such an undignified and humiliating manner.

The nurses insisted that he get up and out of bed, and, despite his poorly condition and his helpless protestations, they insisted on ramming him into a wooden "high chair" with a bar across to keep him in position, quite oblivious of the fact that he had a cracked vertebra, in addition to curvature of the spine, and there he had to sit in agony until he was released.

Every day without fail and regardless of my time of arrival I had to change my father as all his clothes were permanently soaked in urine.

She was most upset because she kept on asking for a bedpan and no one arrived, or on many occasions, arrived too late and she wet herself. She was both embarrassed and hurt at the reaction she got to having wet the bed. She ended up with no dignity at all.

There are also particular issues with regard to people with dementia being treated for an acute medical condition on an ordinary hospital ward, and the need for a proper understanding of their care. [34]

With regard to the care required by older people from minority ethnic communities and the protection of their human rights when in hospital, the issues of privacy and dignity raised echoed those above. For instance, one person reported being left "soiled for ages" which made her feel "embarrassed and angry", while others reported having no privacy. However, issues of language, diet and culture, and sometimes racism, created additional problems. Appropriate food remained a big problem, as did a lack of interpreters and the inability to communicate with medical staff. [35]

Restraints

There are areas where the application of human rights is not straightforward and rights may be in conflict. These difficult ethical areas require investigation and clarification. For example, the use of restraints is not uncommon in some care settings. These restraints may be physical, taking the form of locked doors or chairs placed in such a way that the person sitting in them cannot rise or move elsewhere. They may be chemical and take the form of drugs which have a calming or sedative effect. They may be electronic and take the form of "tags" which enable people to be tracked when they leave a particular building or environment. While there are professional guidelines about good practice in the use of restraints (though these may not always be followed), the application of human rights dimensions to these practices requires urgent and independent consideration. [36]

There are other situations where older people face discrimination in relation to enjoyment of a particular human right. One example is the distinction between the scope of disability benefits available as between Disability Living Allowance and Attendance Allowance. However, for the purposes of this Memorandum we have concentrated on highlighting areas where human rights protection is needed in absolute terms, rather than where these rights overlap with equalities issues.

4. PRIVATE OR CHARITABLE PROVIDERS—WHO IS RESPONSIBLE?

Increasingly, the provision of residential and nursing home accommodation for older people is made through contractual arrangements between the local authority and private or charitable providers. This contracting out of service provision leaves older people vulnerable and currently unable to enforce rights under the Human Rights Act since the Court of Appeal confirmed the view of the Administrative Court in R (on the application of Callin and Heather) v The Leonard Cheshire Foundation[37] that the activities carried out by the care provider did not constitute public functions because the local authority's public law duties were not delegated to the Leonard Cheshire Foundation by the arrangement.

Although Lord Woolf expressed the view that "it would arguably be possible for a resident to require the local authority to enter into a contract with its provider which fully protected the residents' Article 8 rights" (to respect for private and family life), this is unrealistic at an individual level. Individuals will not know in advance that they need this protection, nor wilt they be in a position to protect their human rights by way of a contract.

There is an urgent need to safeguard this vulnerable group of older people. It is not, in our view, adequate to leave the responsibility for securing the protection of human rights to individuals to exercise at a time in their lives when they are powerless and facing many difficulties. The necessary safeguarding of human rights, particularly those protected under Articles 2 (the right to life), 3 (to protection from inhuman and degrading treatment) and 8, must be secured by the positive actions of the state if they cannot be protected by individual redress to the Act. This can be achieved through directions or through statutory guidance, but the work of a Human Rights Commission would help to ensure the effectiveness of any such guidance or directions.

"Self funders" (older people who meet the full cost of their care themselves) are particularly vulnerable to human rights abuses. Many people within this group go into care homes without the involvement of the local authority, often because the authority, knowing they will not be responsible for funding, encourages the individual and their family to make their own arrangements, thereby avoiding having to undertake assessments and make the necessary arrangements to accommodate under Part III of the National Assistance Act 1948. In these circumstances, this group would not have the protection of any human rights compliance clauses in the local authority contract with its care providers. This group could be protected, under existing law, if social services authorities were required to assess and to make arrangements to accommodate "self funders" so that they too could benefit from such contract clauses.

However, perhaps a more reliable method of ensuring that human rights are respected by care homes is to require express incorporation of human rights standards and statements on compliance as a pre-condition to registration under the Care Standards Act.

The urgent need for action following the decision in the Leonard Cheshire case is underlined by the alarming findings of the British Institute of Human Rights in gathering evidence of the impact of the Human Rights Act. In relation to older people the report observes that "the interviews conducted . . . suggest that the Human Rights Act has so far made no difference to the quality of care in residential homes." [38]

5. OLDER PEOPLE WILL RARELY COMPLAIN

No matter what their experience, older people who are subjected to abuse will rarely complain. Help the Aged ran a two-year campaign between 1999 and 2001, called Dignity on the Ward, to improve the quality of care given to older people in hospital. Over 1,300 complaints—some of which are quoted above—were received from members of the public. The complaints ranged in severity from dirty wards and lack of respect to abusive treatment and downright neglect However, the great majority of those complaints came from relatives or friends of the abused person, and often only after that person had died. It was very common for the older person not only to remain silent, but to plead with relatives "not to make a fuss", while relatives themselves often felt that complaining would only put the person concerned at even greater risk. [39]This experience is echoed elsewhere:

Many relatives were phoning to discover what could be done to help a victim who could not contact the helpline themselves—for example, because they lived in a care home and had no access (or no private access) to a phone or they had dementia or another disorder which meant that they had communication difficulties. [40]

Action on Elder Abuse, a specialist voluntary organisation, classifies abuse under five headings: physical, psychological, financial, sexual and neglect. In 2000, Action on Elder Abuse published an analysis of 1,421 calls made to its confidential helpline between 1997 and 1999. A quarter of the calls concerned abuse in institutional settings such as hospitals, nursing homes or residential homes; the remaining three-quarters concerned abuse in people's own homes (including sheltered housing). The number of calls concerning abuse in care homes was disproportionately large, given that only around 5 per cent of people over 65 live in such settings. The greatest number of calls reported a care worker as the abuser, with nurses the second largest group.

There are a variety of possible reasons why older people may resist making a complaint:

— Physical reasons include lack of energy and feeling ill: just keeping going from day to day may require all someone's determination and willpower. Some forms of illness, such as a stroke, may restrict the ability to communicate either verbally or in writing, and poor eyesight or hearing can also impede communication. Inability to speak or understand English and lack of literacy are also clearly additional barriers.

— Around two-thirds of older people in care settings have moderate or severe dementia, resulting in increased powerlessness and vulnerability. At times, this may be sufficiently severe to result in mental incapacity. Furthermore, when someone does complain, they may not be believed.

— Psychological reasons contribute to an unwillingness to complain: older people share with other victims of abuse the emotional reactions of depression and shame and may have a desire to keep the abuse hidden. They may fear the consequences of exposing "private" experience to others and setting in motion reactions over which they have no control.

— In some care settings, for example in hospitals or in residential homes, individuals may lack easy access to a telephone or to the necessary privacy to use that phone or talk to visitors in confidence.

— Older people may be uncertain of their rights, lack access to information about these and may not know who to contact. Older people without close relatives may have no visitors concerned about their welfare, and no one in whom they can confide or who is in a position to protect their interests. Advocacy schemes which focus specifically on the needs of older people are scarce, and even where they exist, knowledge about their role and how to contact them may not be available to those who need them most.

— Older people and their relatives may fear retribution or repercussions whether from paid staff or from others, especially in situations where the older person concerned is particularly powerless and dependent on others. This could be either in their own homes, and therefore behind closed doors, or in a communal setting such as a hospital or care home.

In these circumstances, leaving the individual to assert their human rights through the courts is very rarely a realistic option.

6. WHY A HUMAN RIGHTS COMMISSION IS NECESSARY

The evidence above demonstrates that, despite the incorporation of human rights into domestic law, many older people do not have the protection of the law at a point in their lives where they most need it.

In summary:

— To expect human rights law to be enforced by individual action is unrealistic and fails to protect those older people most at risk.

— Moreover, litigation is an inadequate and expensive way of bringing about change. It relates only to specific instances, generally limiting its impact to the facts of the particular case, and is both unpredictable and very slow.

— Some abuses of human rights—for example regarding funding panels or the closure of homes—are "built into the system" and therefore require systemic change. There is an urgent need to ensure that human rights dimensions are incorporated into the policies and practices of health and care service providers.

— The majority of residential and nursing home provision and around half of all domiciliary care is now contracted out to the private or voluntary sectors. However, the human rights of older people are not at present protected under anything other than a public function. There is currently a lacuna in the law that leaves older people in receipt of care from a private or charitable provider exposed to risk and deprives them of the protection of the law.

— There are debatable areas—for example regarding the use of restraints of various kinds—where it is unclear where human rights are at issue and how the Human Rights Act should be interpreted.

— Most of the examples described above would not be remedied by even the most comprehensive equality legislation. We cannot envisage a context in which such legislation could adequately protect the fundamental human rights issues facing older people.

The functions of a Human Rights Commission

A Human Rights Commission is, in our view, essential to developing an effective method of promoting a human rights culture for the benefit of older people and remedying some of the wrongs we have identified. A commission could:

— Assist and support the Joint Committee on Human Rights in advising the Government with regard to the implementation of the Human Rights Act.

— Monitor national policy to ensure that it conforms to the requirements of the Act and maintain a strategic responsibility to identify and investigate areas where further action may be required.

— Provide information, education, guidance and advice to public bodies and private organisations operating in similar fields to enable them to incorporate an understanding of human rights into their policies and practice.

— Promote awareness of human rights amongst the public, and provide education to those organisations offering information, advice and guidance to the public.

— Bring proceedings on behalf of individuals or groups which are unable to take action themselves, referring individual cases, and, in public interest cases, support individuals wishing to take legal action with regard to their rights.

— Undertake public inquiries in areas of doubt or dispute or where it seems that human rights are not being upheld.

At present implementation of human rights depends on older people taking individual action through the courts. This is not a realistic option for many of those most at risk, as we have demonstrated above. Further, it is unlikely that older people themselves will be in a position to take legal action on all the fronts required. At best this would take time and would leave many people at risk while the application of the Act to these situations was established. A Human Rights Commission could short-circuit this process and ensure that the rights of older people established under the Act could be brought into play more quickly and effectively and with less need for recourse to litigation.

There are no alternative ways to ensure that the human rights of older people are upheld and to provide effective remedies where they have been violated. The Local Government and Health Service Ombudsman's jurisdiction does not extend to the investigation of complaints of Human Rights Act abuses.

Voluntary organisations advocating for older people are not allowed to take action on their behalf or in their name as this can be done only by those who are direct victims of the abuse. The potential for voluntary organisations to play a role in public interest litigation in this area by assisting the court as either third party interveners or as amicus curiae only arises if individual cases reach the court in the first place.

The evidence also demonstrates that a human rights culture does not yet exist in those fields where older people's rights are most at risk. Some of the circumstances described above relate not to individual actions but to an abuse of human rights which is built in to the system. Disregard or violation of human rights resulting from the decisions of funding panels or from a public or private provider deciding to close a home are examples of "systemic" problems. It indicates that those responsible for operating the system—devising the policies, managing the services and training and managing staff—do not as yet appear to take the principles of the Act fully into account.

Anti-discrimination measures regarding age are due to be brought in 2006. These will cover only employment. However, even if the law on equality were to be extended to goods, facilities and services, as we would advocate, equality measures alone would not be sufficient to tackle most of the situations described above. A duty on public bodies to promote equality (as in the Race Relations (Amendment) Act 2000) might, if extended to age, go some way further, but would still not cover human rights issues where these do not have an equalities dimension.

The Government has introduced new care standards and inspection arrangements for health and care services, which will undoubtedly improve standards in the longer term. The publication of statutory guidance[41] on protecting vulnerable adults from abuse is another welcome initiative in paving the way for a more positive approach to human rights obligations. However, these need to be backed by an understanding of the human rights dimension and the integration of this into the standards. By promoting a human rights culture and encouraging health trusts and local authorities to integrate a human rights perspective into their practice, a Human Rights Commission would help to ensure that these standards were realised and delivered.

In this Memorandum we have not examined possible institutional arrangements for a Human Rights Commission, nor looked at whether it should be free-standing or included alongside equalities in a single commission to cover both. We will do so in responding to the Government's consultation on a single equality body in February 2003, since the issue is specifically raised there.

However, we believe the case for a commission to ensure the implementation of the 1998 Human Rights Act to be very strong. Indeed, we believe it is essential for the protection of older people at a time in their lives when they may be at serious risk.

January 2003

19 1998 Human Rights Act (1998). London: The Stationery Office Back

20 Office of the Deputy Prime Minister (2002) Equality and diversity: making it happen. London: ODPM Back

21 MORI (2002) Age Discrimination Research. London: MORI Social Research Institute Back

22 Help the Aged (2002) Age discrimination in public policy: a review of evidence. London: Help the Aged Back

23 Table 6 in Department of Health (2002). Personal Social Services Expenditure and Unit Costs: England 2000-01. London: DoH Back

24 Department of Heath (2001) National Service Framework for Older People. London: DoH Back

25 Department of Health (2002) Fair access to care services. London: DoH Back

26 By section 45(10) of the Health and Social Care Act 2001 Back

27 [2002] EWHC 1882 Back

28 [2002] 1 WLR 803 Back

29 Katbamna, S. and G. Parker (2002) Nothing personal: rationing social care for older people, London: Help the Aged Back