2 Treatment of older people in hospitals
and care homes |
"The home always looked attractive with flowers and pictures in the foyer but this masked the quality of the care."
9. The care of the elderly, frail and sick can be immensely demanding
both physically and mentally. At the outset of our Report
we pay tribute to the many private individuals and professional
staff who do this with dedication, setting high challenges and
standards for the rest of us. They deserve the full support
of society as a whole, not least in ensuring that the necessary
resources are available. Our Report is highly critical
of where in institutional care things go wrong. We seek
to point no fingers of blame. Our analysis and recommendations,
although sometimes hard hitting, are made in the hope that they
will help to strengthen best performance. As we explain,
a recognition of the significance of human rights is a vital way
of underpinning that performance. We emphasise that ensuring
the dignity and self-respect of the vulnerable, which is central
to the fulfilment of human rights, is a task for us all.
10. In this Chapter, we set out the evidence we received
of the quality of treatment that older people receive in hospitals
and residential care homes.
Scale of the problem
11. During the course of our inquiry, we received
a considerable volume of evidence about the quality of treatment
that older people receive in hospitals and residential care homes.
We have heard examples of both good and bad practice. Witnesses
stressed that some older people received an excellent service
in hospitals and residential care. Comments included
There are many residential and nursing home environments
out there that are providing very good quality care.
We do not see systematic problems across the
whole of the NHS. In fact, what we see is a lot of very,
very caring activity going on. There are patches of problems
and when those come to light they really are a betrayal of values
so that you do need the reserve for when that happens.
We will always in our society hear the bad news,
the bad stories, the evidence of bad practice and often will not
hear about some fantastic practice that takes place. There
is far more good practice than there is bad.
12. However, many witnesses, including the inspectorates,
providers and organisations supporting older people, expressed
concern about continuing poor treatment of older people in healthcare.
Their principal concerns related to:
- Malnutrition and dehydration
(Articles 2, 3 and 8 ECHR)
and rough treatment (Articles 3 and 8)
- Lack of privacy in mixed sex wards (Article 8)
- Lack of dignity especially for personal care
needs (Article 8)
- Insufficient attention paid to confidentiality
- Neglect, carelessness and poor hygiene (Articles
3 and 8)
- Inappropriate medication and use of physical
restraint (Article 8)
- Inadequate assessment of a person's needs (Articles
2, 3 and 8)
- Too hasty discharge from hospital (Article 8)
- Bullying, patronising, and infantilising attitudes
towards older people (Articles 3 and 8)
- Discriminatory treatment of patients and care
home residents on grounds of age, disability and race (Article
- Communication difficulties, particularly for
people with dementia or people who cannot speak English (Articles
8 and 14)
- Fear among older people of making complaints
- Eviction from care homes (Article 8).
13. Below we explore in more detail some of the recurring
issues which emerged in our inquiry. Difficulties experienced
by older people in making complaints are dealt with in Chapter
8. Many of the concerns are overlapping and inter-related.
Whilst some of these issues may not appear, at first glance,
to be obvious healthcare issues, all of the problems, in our view,
seriously affect people's experiences of the overall care that
they received in hospitals or care homes.
14. According to the Commission for Social Care Inspection
(CSCI), since the introduction of the National Minimum Standards
in 2002-03, the percentage of social care services meeting the
standards for privacy and dignity has increased from 82% to 91%.
CSCI also reports that residential services for older people
met 79% of the National Minimum Standards in 2006, compared with
59% in 2003. Nevertheless,
we note that this means that, more than three years after the
standards were introduced, 21% of care homes are still failing
to meet the minimum standards required of them.
15. The Department of Health, in its written evidence
to our inquiry, does not explicitly acknowledge any of the problems
identified by other witnesses, but instead focuses rather defensively
on the financial investment made into the NHS and the many initiatives
launched by government in relation to older people.
These include the Dignity in Care campaign
and, as recently announced by Ivan Lewis MP, the Minister for
Care Services, a national action plan to tackle the issue of older
people and nutrition which will be published in the summer.
"An 80 year old woman [
] was seriously sexually assaulted by another resident in 2004. It was reported in the log book but no action taken [...] It was only reported to the resident's daughter in July 2005. She reported the matter to the police."
16. According to Department of Health guidance, "Abuse is
a violation of an individual's human and civil rights by any other
person or persons".
17. More particularly, elder abuse has been defined
as, "A single or repeated act or lack of appropriate action
occurring within any relationship where there is an expectation
of trust, which causes harm or distress to an older person".
18. According to Age Concern, 500,000 older people
are subject to abuse at any one time in the UK, although not all
of this abuse occurs in healthcare. Almost four-fifths
of the abuse is perpetrated against people over the age of 70,
and 16% affects people over 90.
Based on telephone calls to their helpline, Action on Elder
Abuse identifies five categories of abuse: physical (19%
of calls), psychological (34%), financial (20%), sexual (3%) and
neglect (12%). It highlights the high number of allegations
of multiple abuses (44% of callers report more than one type of
abuse occurring simultaneously). The majority of abusers
are related to their victim (46%).
The next highest category of abusers is paid workers (34%).
Of the one third of abuse which is perpetrated by two or more
people acting together, 62% is perpetrated by paid staff "that
is, through abusive practices that are institutional and passed
from one worker to another".
23% of reports to the helpline concern care homes (where less
than 5% of the older population live) and 5% concern hospital
19. Reporting on elder abuse in 2004, the House of
Commons Health Committee found that abuse of older people was
a hidden, and often ignored, problem in society, and was a violation
of their human rights.
It concluded that, unlike child abuse, whose profile had been
dramatically raised in the past few years, abuse of older people
remained hidden. Witnesses to our inquiry agreed
and suggested that it was difficult to determine the scale of
abuse due to under-reporting
and the lack of resources focused on the issue,
although some suggested that there was now greater awareness of
20. In our view, elder abuse is a serious and
severe human rights abuse which is perpetrated on vulnerable older
people who often depend on their abusers to provide them with
care. Not only is it a betrayal of trust, it would also,
in certain circumstances, amount to a criminal offence.
NEGLECT OR CARELESSNESS
"A lady of 89 had been in a care home for 18 months as a self-funder. She was taken to hospital with severe pressure sores and dehydration. The hospital criticised the quality of care she had been receiving and said that she should have been receiving nursing care. On discharge she returned to the care home and was placed in the nursing wing.
When the lady's son asked staff in the residential section (where she had been living before) why she had been allowed to deteriorate prior to her admission to hospital, why the pressure sores and dehydration had been allowed to develop and why her needs had not been reassessed, they replied that it was not their job to do that and that the district nurse should have been informed and called upon to do it. They did not acknowledge that it should have been their responsibility (or at least the home's) to call her in if this was the case."
21. Witnesses complained that older people in healthcare were
sometimes neglected and that staff failed to show them appropriate
and adequate care. Neglect is one aspect of elder abuse.
By "carelessness", we mean treatment that is less
severe than neglect, but which implies a lack of thought by staff
about the effect of their actions on patients and residents.
Examples of neglect or carelessness that we heard of included:
- Lack of hygiene, which at its most severe led to ill health
and death such as the outbreak of clostridium difficile
in Stoke Mandeville Hospital which, according to the Healthcare
Commission resulted in the "avoidable deaths in hospital
of at least 33 patients, who were mainly elderly people".
- Problems with personal care, including people
being left in their own waste.
This not only causes distress to individuals, but may also
lead to health problems such as the development of bedsores.
- Rough handling of patients and residents by staff,
for example when changing their clothes.
- Older people being left with their spectacles,
hearing aids or false teeth out of reach.
- Patients being repeatedly moved from one ward
to another for non-clinical reasons, sometimes at night.
- Hearing and visual problems not being addressed,
and conditions remaining undiagnosed and untreated until they
- Patients being left for hours in hospital reception
without medication, food or water whilst awaiting transfer to
another hospital or residential care.
22. It is now a criminal offence for a person providing
care to someone who lacks capacity to ill-treat or wilfully neglect
them. A similar
offence, of longer standing, exists for anyone being treated for
mental disorder in a hospital, mental nursing home, independent
hospital or care home.
DEHYDRATION AND MALNUTRITION
"She grew very thin and it was obvious to visitors that, although she has always had an excellent appetite, she found great physical difficulty in feeding herself and using a cup. Visitors would have been only too willing to help her but they were discouraged from staying during meal times. She appeared to be slowly starving to death."
"A woman reported that her mother, Dorothy, who is 92 and suffers from dementia, was admitted to hospital but not given the help she needed to eat. On many occasions Dorothy's food was left untouched on her bedside table and taken away at the end of mealtimes by the catering staff. Her food also needed to be pureed but often this was not done."
"Often nurses firstly do not have the time to be able to do this type of work well, but I think we are also seeing no clear understanding of whose job it is. Typically, what a carer will report to us is 'I asked the nurse if she would be able to help my mother with eating her dinner' and she said, 'Ah, no, that is really the job of a care assistant, find a care assistant'."
23. A number of witnesses expressed concern about malnutrition
and dehydration of older people in healthcare.
In 2006, Age Concern reported that 60% of older people in
hospital were at risk of malnourishment or of their situation
getting worse during their hospital stay.
Hospital meals may be taken away before patients can eat them
and insufficient help is given with eating and drinking. On
occasion this can lead to preventable deaths.
The same year, the Healthcare Commission published a survey
of 80,000 adult inpatients. Of those needing
help to eat mealsa fifth of those surveyedalmost
40% said that they either never (18%) or only sometimes (21%)
received help. On 7 March 2007, the Healthcare Commission
announced that it would be investigating and reporting on dignity
in the care of older people in hospitals. 
24. The Minister accepted that there was a problem
of malnutrition in some healthcare settings but stated:
We talk sometimes about the way that nutrition
is organised in hospitals we end up with the Daily Mail
saying thousands of people are being starved in this country.
They are not, but are we satisfied with the way that nutrition
and people's access to food is dealt with in hospitals and care
homes? Often we are not.
25. Some good practice exists. For example,
some organisations use red trays to identify patients who have
difficulty eating without assistance.
Others ensure that meal times are not interrupted. These
practices help to preserve the dignity of older people and are
examples of positive steps that organisations can take to ensure
that the rights of older people to life and not to suffer ill-treatment
"[The caller's] mother suffers from mild dementia and in recent months had tended to wake at night. At the new home, the staff who sleep in overnight did not like being disturbed during the night because, the manager said, they had day jobs elsewhere to go to during the day. She (the manager) said she had to pay them extra each time they had to get up. The manager suggested that the daughter would have to cover these extra costs.
The home thought that sleeping medication might solve the problem of her wakefulness and the GP prescribed this without seeing the lady or her daughter."
26. A number of witnesses expressed concern about the inappropriate
use of medication on older people, including the over or under-use
of medication and the use of medication as a means of controlling
patients and residents. Action on Elder Abuse cited the
misuse of medication as one type of abuse which frequently comes
to its attention.
This is a particular issue in care homes.
27. Again, witnesses accepted that there was good
practice in this area,
but that this was not universally implemented. Witnesses
raised a particular issue of medication being inappropriately
used to keep residents docile.
As the Alzheimer's Society's said:
The response to aggression in dementia is often
to prescribe powerful sedative neuroleptic drugs that can help
to calm the person However, these treatments have very
damaging side effects. Medications such Haliperidol, Risperidone
and Olanzipine are being routinely prescribed to people with dementia
in hospitals and care homes. A recent study found that
40% of people with dementia in care homes are being prescribed
Neuroleptics are not licensed for use in dementia care but
have become a convenient staple as part of routine treatment,
despite known evidence on the risks which such 'treatments' pose
to quality of life and the increased risk of death.
28. The concerns of witnesses accord with the findings
of the Health Committee that medication was "in many cases,
being used simply as a tool for the easier management of residents".
The National Service Framework for Older People requires that
all people over 75 years should normally have their medicines
reviewed at least annually and those taking four or more medicines
should have a review every six months.
In 2006, Living Well in Later Life noted that "the
management of medicines needs to be addressed, as many older people
taking more than four medications are still not receiving a review
every six months".
CSCI found that, in 2005-06, only 59% of care homes met the
National Minimum Standard (Standard 9) for medication.
The Alzheimer's Society agreed that there is a very poor record
of medication in care homes.
LACK OF PRIVACY, DIGNITY AND CONFIDENTIALITY
"I went to visit my husband on the first day and he is a very private person, he doesn't like anything to embarrass him and when I went in he was almost in tears which is not my husband. He said 'please, please go and get a bottle I am nearly wetting myself'. I rushed out I got a bottle and I said to him 'Well why didn't you just ring the nurse', in my innocence. 'I have for an hour and a half I've been asking for a bottle'. Well when I went out [and] told the nurse she said 'Oh don't worry we would have changed the sheets'. Now his dignity at that stage would have gone out of the window. There was no dignity." (Older person)
] there are two reception desks side by side, two lines of patients having discussions about the nature of their medical condition. There cannot be confidentiality in that." (British Geriatrics Society)
"I don't know whether people get almost blasé about the fact that they are dealing with people in a vulnerable state all the time and they forget how that person may be feeling about it." (Physio assistant)
"I think that healthcare staff have become so required to focus on technology and targets that they have lost sight of the humanistic aspects of caring." (Royal College of Nursing)
"We have reached the stage where we value care far less than we value cure." (NHS Confederation)
29. Witnesses told us of the lack of privacy, dignity and respect
for confidentiality afforded to older people in hospitals and
care homes. Examples included:
- The continuing use of mixed sex wards.
Whilst some witnesses felt that there were advantages to mixed
sex wards (such as companionship),
others noted the problems they raised for privacy, particularly
when people were partially clothed or naked.
- Sensitive confidential medical advice being given
to a patient on a ward, where other patients could overhear.
- Problems with personal care such as "neglect
of proper hygiene care or continence care resulting in individuals
left lying in their own urine or excrement",
people not being allowed to use the toilet in private
and care home residents being fed whilst on the commode.
- Healthcare staff having conversations between
themselves, whilst attending to the intimate care needs of older
30. Witnesses complained that some hospitals and
care homes appeared to be planned around the staff rather than
service users. For example "the elderly are not treated
like individuals; they become just another part of the hospital
or care home routine".
The rights of patients are affected by both clinical and non-clinical
staff. We heard one example of an elderly woman who was
being discharged from an acute to an intermediate care hospital
who had to sit and wait for 5 hours in the non-medical discharge
lounge without food or water.
31. In a public survey conducted by the Department
of Health, respondents stated that one of the characteristics
of ensuring that services provided for dignity in care was "respecting
basic human rights, such as giving people privacy and encouraging
The Minister told us that they were focussing on "the
centrality of dignity and respect of older people in a variety
of care settings, again both NHS and social care".
Recognising the right of older people to privacy, he noted
Every individual has a different story, a different
background, a different set of life experiences, a different set
of fears maybe. None of us is the same, so the ability
of the system or of staff to treat people in a very individualised
or personalised way is something that is raised with us.
32. The Healthcare Commission Core Standard C13(c)
requires that providers of healthcare services "have systems
in place to ensure that staff treat patient information confidentially,
except where authorised by legislation to the contrary".
However, Help the Aged commented that the duty to maintain
confidentiality could pose risks for a patient or resident who
did not have capacity:
The issue of confidentiality is often misunderstood
by health staff, particularly in relation to patients who lack
the capacity to consent to disclosure of information, such as
many dementia patients. As a result, the principle of confidentiality
is applied in a very over-restrictive way (Articles 6 and 8) [
This is a practical problem for carers. We are concerned
particularly with older carers, typically the spouse or partner
of a person who has lost capacity. This can leave carers
deprived of vital healthcare information, including information
about effects of medication, which exposes both carer and cared
for to unnecessary risks.
] the husband was in hospital, the wife had died, and the individual social worker was told that she had to get the son to go and visit a care home the following day, and he said he could not do that because he was attending his mother's funeral. The discharge went ahead on the day of this man's wife's funeral, which seems to me grotesque, grotesquely inhuman."
33. Regulations made under the Community Care (Delayed Discharges
etc) Act 2003 require social services to arrange a discharge placement
within two working days of notification by the NHS Trust that
an acute patient is clinically ready for discharge. If
the patient cannot be discharged within this time, the local authority
may be required to make payments to the NHS Trust.
34. The Department of Health informed us that it
is committed to reducing the number of people whose discharge
from hospital is delayed. Figures provided by the
Department show that between September 2001 and December 2006:
number of people over the age of 75 delayed in hospital reduced
from 5,673 to 1,651, a reduction of 71%
Total delays for the same period were
reduced from 7,065 to 2,190, a reduction of 69%.
35. In 2006, Professor Ian Philp, National Director
for Older People's Services, in his report on progress in implementing
the National Service Framework for Older People noted, amongst
other things, that "delayed discharge from acute hospitals
has been reduced by more than twothirds".
According to the Department of Health's own statistics, about
16% of patients over 75 years of age are re-admitted to hospitals
within 28 days of discharge compared with about 10% of patients
36. Although witnesses saw the merit in ensuring
that patients did not stay longer in hospital than was necessary,
a number of witnesses expressed real concern about the operation
of the Delayed Discharge Regulations, particularly regarding the
short timescale permitted to arrange a placement, and the implications
that this had for an individual's right to respect for his private
and family life. Witnesses told us that the application
of the current Regulations leads to older people:
- Having no choice on discharge.
- Being put into placements that do not meet their
- Having no chance to come to terms with a momentous
life changing event (i.e. the possible move for the first time
from independent living to residential care).
- Being discharged to care homes instead of receiving
returning to their homes with community support.
- Being discharged to care that is miles away from
friends and family.
- Being discharged without adequate care in place
or when they are still unwell.
In addition, we were told that Department of Health
guidance that no one should be discharged from an acute hospital
bed directly to a care home was "routinely ignored"
by people applying delayed discharge criteria.
37. The British Geriatrics Society stated "what
we do as geriatricians is to try and thwart some of the attempts
to discharge people prematurely"
and "I do not have the words for how stupid and how wrong
such a policy is".
Similarly, the Royal College of Nursing said "it is clearly
harmful to discharge someone who is not ready to be discharged
and to discharge them before services have been put in place.
That is something that concerns us a lot".
Help the Aged were concerned that the Regulations currently
"have the balance wrong"
and create a situation that is "so abusive of individual
38. We were pleased to hear the Minister's assurance
that "nobody should be discharged from hospital without appropriate
arrangements being put in place for their care"
and his acknowledgement that the operation of the Regulations
could have human rights implications. However, although
Department of Health guidance sets out a number of principles
which it suggests should be applied, including that discharge
should be "planned for at the earliest opportunity across
the primary, hospital and social care services",
we are concerned that, for a number of reasons, this is simply
not happening in practice. We are also concerned that the
premature or inappropriate discharge of older people could lead
to their readmission shortly afterwards.
39. When we asked the Minister about this, he stated
that "there are lots of reasons and causes for readmission,
a lot of which are absolutely nothing to do with the 48 hour part
of the guidance".
However, he added:
On the question of the data that has come to
light on the readmissions, I do not think we would want to be
defensive about it, we would want to be frank about it, and we
need to go away, reflect on it, do more work on it, and if we
find that this is an unintended consequence of policy then we
ought to do something to address it. Personally, I would
regret it if we were to move away from a system where we took
the pressure away, as was the case at one stage, and as a result
of that people ended up languishing in inappropriate hospital
beds for weeks, months and in some cases years. 
40. Some witnesses recommended that greater flexibility
should be introduced into the Regulations to ensure that the rights
of older people were respected when discharge was being considered.
Suggestions for amending the Regulations included that the
time period should be extended from two days to about a week
or a little longer.
One witness described the operation of the Regulations as
leading to a "chaotic scramble"
to find appropriate care for an individual whether in intermediate
care, in a care home or supported within their own home. From
the evidence that we heard, we agree that this can sometimes be
the case. We recommend the Government amend the Delayed
Discharge Regulations to allow for flexibility in applying the
time period so as to ensure that the Article 8 ECHR rights of
older people are respected. We also recommend that the Government
issue guidance for hospitals and local authorities on the application
of the Regulations to ensure respect for the Article 8 rights
of older people.
41. As we have already highlighted, older people
in healthcare are especially vulnerable to ill-treatment because
of their dependency on others for their basic needs. The
question is whether they receive this poor treatment because of
their age and if so in what situations. Some witnesses
have suggested that age discrimination still exists in the provision
of healthcare in both hospitals and residential care homes.
We have also heard evidence that some older people experience
discrimination in addition to their age, due to their race
or disability. However, we note that it is incorrect to
talk about older people as one homogeneous group. As one
This [susceptibility of older people to human
rights abuses] is not actually a problem of age by itself because
older people are very diverse. It is by no means all older
people who are vulnerable to human rights abuses, but some groups
are more vulnerable than others because of ill-health, disability
] an older person in a care home who is expressing difficulty with breathing where the care home response is to ignore it or say, "She will be okay" or "he will be okay", and there is absolutely no access to a GP for three, four or five days and then the care home will present it as being a sudden deterioration. But it is not a sudden deterioration, it is a denial of access to a GP that would not happen if that was a younger person."
42. The National Service Framework for Older People states that
"NHS services will be provided, regardless of age, on the
basis of clinical need alone".
43. Witnesses tended to agree that explicit direct
age discrimination has become less common since the introduction
of the National Service Framework for Older People.
Living Well in Later Life put this improvement down to NHS
trusts auditing their policies on access to services and social
services reviewing their criteria for eligibility.
One example of improved practice is that access to cardiac
procedures and hip and knee replacements have improved since the
NSF was published.
44. However, some witnesses told us that direct discrimination
has not ceased altogether. We were alerted to a recent
study which found
that almost half of a sample of 85 GPs, cardiologists and specialists
in old age are influenced by age in deciding whether or not to
carry out tests. Patients over 65 are less likely to be referred
to a cardiologist, given an angiogram (artery scan) or given a
heart stress test. Cardiologists are also less likely to recommend
operations to open up blocked coronary arteries for older patients,
and they are less likely to be prescribed statins to reduce cholesterol.
They are, however, more likely to be offered a follow-up appointment
and more likely to have existing drugs reviewed.
45. In Age Concern's recent report on age discrimination,
it concluded that age discrimination existed in healthcare.
Examples cited included:
- Treatment for minor strokes
is covertly rationed for people over 80 years of age.
- Doctors are less likely to refer angina sufferers
to see a specialist or to have tests if they are over 65.
- National priorities for health and social care
restrict targets for reducing heart disease, strokes and cancer
to people under 75.
- Invitations to breast screening stop for women
- Older people tend to be excluded from drug trials.
46. In addition, particular concern was expressed
by Age Concern and others about the poor provision of mental health
services to older, compared with younger, people. We consider
this issue in greater detail below.
47. What became clear to us from the evidence
is that an older person's age is much less likely to be directly
taken into account when decisions are taken about his or her healthcare
than in the past. However, age discrimination in both hospitals
and care homes is now more subtle and indirect. As
one witness told us, "the majority of policies that directly
discriminated on the basis of age have now been eradicated, although
it has proved harder to challenge embedded ageist attitudes on
the part of NHS staff".
This accords with the findings of the National Director for
Older People's Services, who has said "although overt age
discrimination is now uncommon in our care system, there are still
deep-rooted negative attitudes and behaviours towards older people"
and "our existing services were not designed with older people's
needs in mind".
The Royal College of Physicians of Edinburgh said that there
is "'structural ageism' in the NHS [
] which biases
against the multiple pathology of older persons".
Given that, according to the NHS Confederation, "the
NHS spends 80% of its resources and 80% of its time on people
over the age of 65",
we find it surprising that this bias against services for older
people continues to exist. Examples include:
- Local authorities have lower
budgets for their older people's teams than for teams dealing
with younger people.
- There is a lower financial cut-off point for
care packages for older people compared with equivalently disabled
- Decisions about whether to refer or treat are
made on the basis of "deep seated, underlying attitudes and
beliefs about older people".
DISCRIMINATION AGAINST VULNERABLE
48. The most vulnerable older people are particularly
susceptible to poor treatment. Older people may face poor
treatment not just because of their age, but also for other reasons
such as disability or race. We consider two particular
People with mental health needs
49. According to the Alzheimer's Society, there are
currently 700,000 people with dementia in the UK.
With an ageing population, these numbers are set to rise steeply
in the future.
People with dementia are significant users of social and health
care services. A recent report found that direct costs
to the NHS and social care of dementia are currently at least
£3.3 billion a year in England, although the overall economic
burden is estimated at £14.3 billion.
One third of people with dementia live in care homes. Two
thirds of care home residents have some form of dementia. Approximately
one quarter of hospital beds are being used by people with dementia
at any one time.
50. The National Service Framework for Older People
requires that "older people who have mental health problems
[should] have access to integrated mental health services, provided
by the NHS and councils to ensure effective diagnosis, treatment
and support, for them and their carers".
51. However, the National Service Framework for Mental
excluded older people from its reach as it only focussed on adults
of "working age". As reported in Living Well
in Later Life:
] the organisational division between
mental health services for adults of working age and older people
has resulted in the development of an unfair system, as the range
of services available differs for each of these groups [
Older people who have made the transition between these services
when they reached 65 have said that there were noticeable differences
in the quality and range of services available. 
52. A number of witnesses criticised the poor provision
for the mental health of older people, for example:
- Older people do not have access
to the range of specialist mental health services, such as talking
treatments, available to younger adults despite having the same,
and often greater, need.
This inevitably restricts their choice of treatment options.
- Younger people receive higher levels of community
services than older people. Older people are moved into
residential care even though "a small amount of additional
support at home could help someone to maintain their independence
in the community for far longer".
- Some care homes will refuse to take older people
with dementia, even though the majority of people living in care
homes have a form of dementia.
- Mental health services are not tailored to the
needs of older people.
- Staff have insufficient training on the specific
needs of people with dementia or other mental health problems.
53. A recent report on dementia concluded that:
People with dementia have not benefited from
the developments in mental health services seen for working age
] Overall [
] services are not currently delivering
value for money to taxpayers or people with dementia and their
] The rapid ageing of the population means
costs will rise and services are likely to become increasingly
inconsistent and unsustainable without redesign.
54. As Mind said:
Despite the high prevalence of mental health
problems in older people, too often services fail to provide for
this group [
] Mind is concerned that as the population
gets older, the service people receive for mental distress in
older age will get worse unless discrimination in the system is
Black and minority ethnic older people
55. Surveys show that black and ethnic-minority people
are high users of healthcare services for conditions that may
or may not be present in old age such as heart disease,
stroke and diabetes.
In addition, it is suggested
that black and ethnic minority
people, and African Caribbean people
in particular, fare worse under the mental
health system than other people.
56. Several witnesses told us that black and ethnic
minority older people may be especially vulnerable to poor treatment.
As Mind put it:
Many services have a poor record on engaging
with older people from black and minority ethnic (BME) communities.
The way that mental health services are organised and delivered
creates cultural norms and practices different to those of older
BME communities, many of whom spent their formative years outside
of Britain. Barriers may include language issues, knowledge
of what is available, and attitudes and practices of service providers.
A lack of translated information about mental health issues
and services often results in isolation for individuals and the
delivery of inappropriate care or no care at all [
older people from different communities may share similar experiences
of racism and ageism, but the circumstances of (for example) Chinese,
African-Caribbean or Asian older people may require very different
57. As we note below, older people face particular
barriers in making their voices heard and raising complaints.
This is even more acute for people who are not able to communicate
with the authorities because they do not speak English or understand
to whom to turn. Witnesses told us that language barriers
for older people in accessing healthcare are of real concern.
As Race on the Agenda said, "it is unrealistic
to imagine that people who have reached a certain level of maturity
can learn a new language".
58. The Healthcare Commission highlights a number
of common themes in the treatment of older people in healthcare
which resonate with the evidence of other witnesses, including
"deeply rooted ageist attitudes [
] Standards of nursing
care that fall below expected levels [
] A focus on high
profile targets [
] Shortcomings in leadership, management,
accountability and governance [
] A poor and institutionalised
59. In our view, these are symptomatic of wider and
more general issues of concern for the protection and respect
for the human rights of older people. These include, at
a very basic level, a lack of sufficient "protection from
dignity, respect, confidentiality, independence and autonomy (or
as the British Geriatrics Society put it, a "lack of encouragement
to older people to make their wishes and desires known to the
staff looking after them").
We consider that the power imbalance between service providers
and service users and the strong evidence that we have received
of historic and embedded ageism within healthcare for older people
are important factors in the failure to respect and protect the
human rights of older people. These problems require more
than simply action at the local level, but an entire culture change
in the way that healthcare services for older people are run,
as well as strong leadership from the top. The Human Rights
Act has an important role to play in moving the culture to one
where the needs of the individual older person are at the heart
of healthcare services. We discuss this more fully
in the next Chapter.
60. We have heard some valuable and useful suggestions
on how the deeply unsatisfactory situation we have outlined can
be improved, including a new statutory duty on public services
to promote age equality (similar to the race, disability and gender
Concern recommend that an age equality duty would be beneficial
It would have a very powerful influence in transforming
public services and achieving a culture change [
would end up getting far more voice and choice in relation to
the services that they needed and involvement in decisions as
to how these services were planned [
] not only would all
existing policies and services be assessed for their impact on
agethey would be age proofedbut also all new policies
and initiatives would be assessed for the impact they made on
age as well.
61. We note that the Minister for Work and Pensions,
Barbara Follett MP said the following during the recent Commons
debate on age equality:
A positive duty could be particularly effective
in ensuring that public service providers take the needs of people
of all ages into account when planning and commissioning services
and providing staff training. That could play quite a part
in the cultural shift that we need to bring in.
62. Help the Aged
and others also recommend that the existing prohibition on age
discrimination in the workplace be extended to the provision of
goods, facilities and services.
The Discrimination Law Review Green Paper on the need for
a single equalities Actstates "we are considering whether
legislation to prohibit negative age discrimination beyond the
workplace would help to ensure that people are always treated
with respect in our society, whatever their age." 
63. We will consider these proposals for law reform
in due course. In the interim, we consider, based on the
evidence that we have received, the case in favour of these two
legislative changes to be made.
64. We are convinced that the existing legislation
does not sufficiently protect and promote the rights of older
people in healthcare. We recommend that there should be
a positive duty on providers of health and residential care to
promote equality for older people. We also recommend that
the current prohibition on age discrimination in the workplace
be extended to the provision of goods, facilities and services,
so as to encompass (amongst other activities) the provision of
65. The new Commission for Equality and Human Rights
(CEHR), which opens its doors in October 2007, has a significant
role to play in ensuring that older people's rights are promoted
The CEHR has a duty to "monitor the effectiveness of
the equality and human rights enactments"
and to publish periodic reports.
We therefore recommend that the CEHR monitors the implementation
of human rights and equality legislation in healthcare for older
people and reports on this in its State of the Nation report.
66. In the next Chapter, we consider how the application
of human rights principles could make a difference in practice
to the problems we have identified above.
5 Ev 194, para 2. Back
Q 211. Back
Q 140. Back
Q 285. Back
See definitions of "elder abuse" at paragraphs 16 and
Commission for Social Care Inspection, State of Social Care
Report 2005/06 (December 2006), p 140. Back
Ibid, p X. Back
Ev 105-122. Back
Launched 14 November 2006. Back
Launched 13 February 2007. Back
Ev 194, para 3. Back
Department of Health, No Secrets - Guidance on developing and
implementing multi-agency policies and procedures to protect vulnerable
adults from abuse, March 2000, para 2.5. Back
on Elder Abuse, Hidden Voices: Older People's Experience of
Abuse (September 2004), p 2. Back
Age Concern, Rights for Real, May 2006, p 35. Back
Hidden Voices, op cit, pp 2-5. Back
Hidden Voices, op cit, p 3. Back
Hidden Voices, op cit, pp 4-5. Back
Health Committee, Elder Abuse, Second Report of Session
2003-04, paras 13 and 107. Back
Ev 155. Back
Q 7. Back
Qs 4-7. Back
Q 213. Back
Ev 195, para 6. Back
Ev 144, para 2.3. Back
Ev 144, para 2.3; Ev 160, para 1.2. Back
Ev 195, para 7. Back
Ev 104, para 1(e). Back
Ev 98; Ev 143, para 2.2. Back
Ev 92; Ev 153. Back
Committee visit. Back
Section 44 Mental Capacity Act 2005. Back
Section 127 Mental Health Act 1983 as amended by the Care Standards
Act 2002, section 116, Sch 4, para 9. Back
Ev 104, para 1(c). Back
Age Concern, Age of equality? Outlawing age discrimination
beyond the workplace (2007), p 23. Back
Q 214. Back
Ev 85, para 1(i); Ev 122-123. Back
Age Concern England, Hungry to be Heard: the scandal of malnourished
older people in hospital (2006) referred to in Ev 130. Back
Ev 163, para 1.25 , Ev 144, para 2.3. Back
Healthcare Commission press release, 7 March 2007. Back
Q 379. Back
Ev 163, para 2.6. Back
Ev 195, para 8. Back
Ev 222. Back
Q 219. Back
Ev 195, para 8; Ev 173, para 16. Back
Margallo-Lana, M et al, (2001) Management of behavioural and
psychiatric symptoms amongst dementia sufferers living in care
environment. International Journal of Geriatric Psychiatry. Back
Ev 214, paras 22-23. Back
Health Committee, Elder Abuse, Second Report of Session
2003-04, para 65. Back
This milestone was set in April 2002. Back
Living Well in Later Life, p 9. Back
State of Social Care 2005-6, op cit. Back
Q 219. Back
Ev 97. Back
Q 291. Back
Ev 97. Back
Q 285. Back
Q 336. Back
Ev 123. Back
Ev 90. Back
Ev 160, para 1.5. Back
Q 287. Back
Ev 160, para 1.2. Back
British Geriatrics Society, Behind closed doors - Using the
toilet in private. Back
Ev 160, para 1.5. Back
Ev 160, para 1.5. Back
Ev 140. Back
Department of Health, Dignity in Care public survey
- Report of the Survey, October 2006, p 5. Back
Q 373. Back
Q 379. Back
Ev 162, para 1.20-1.21. S v Plymouth City Council 
EWCA Civ 388 - Article 8 ECHR (right to respect for private life)
includes a procedural requirement to be involved in decision making
processes, including on behalf of a family member who lacks capacity
(para 40). Back
Q 23. Back
Ev 113, para 75. Back
Ev 108, para 17. Back
Ev 116-121. Back
Ev 161, para 1.11; Qs 23 & 281 [Dr Dalley]. Back
Ev 160, para 1.9; Q 27. Back
Q 227. Back
Q 23. Back
Ev 101; Ev 126, para 2.7; Ev 141. Back
Ev 214, para 19. Back
Q 227. Back
Ev 174, para 17. Back
Q 27 [Mr Hurst]. Back
Q 287. Back
Q 311. Back
Q 281. Back
Q 23. Back
Q 25. Back
Q 446. Back
Department of Health, Discharge from hospital: pathway, process
and practice, January 2003, p 3. Back
Q 448. Back
Q 460. Back
Q 23. Back
Q 230. Back
Ev 214, para 19. Back
Ev 125, para 2.3. Back
Ev 197, para 13. Back
Q 11. Back
Q 244 [Mr FitzGerald]. Back
Standard One, 27 March 2001. Back
Ev 215, para 27; Q 44 [Mr Hurst]. Back
CSCI, Audit Commission and the Healthcare Commission, Living
Well in Later Life, March 2006, pp 6-7. See also Ev
108, para 16. Back
Ibid, Living Well in Later Life, p 7. Back
Harries, C., Forrest, D., Harvey, N., McClelland, A. and Bowling,
A., Which doctors are influenced by a patient's age? A multi-method
study of angina treatment in general practice, cardiology and
gerontology, Quality and Safety in Healthcare 2007;16:23-27.
See also Young, J., Ageism in services for transient ischaemic
attack and stroke, British Medical Journal, 9 September
2006; 333; 508-9: "whenever a clinical stone is turned over,
ageism is revealed". Back
Age Concern, Age of Equality? Outlawing age discrimination
beyond the workplace, May 2007. Back
Ibid, May 2007, p 22. Back
Ev 128, para 4.1. Back
Department of Health, A New Ambition for Old Age, 19 April
2006, p 2. Back
Department of Health, A Recipe for Care - Not a Single Ingredient,
2007, p 1. Back
Ev 153. Back
Q 336. Back
Q 58. Back
Q 58. Back
Q 46. Back
Ev 212, para 3. Back
National Audit Office, Session 2006-2007, Improving services
and support for people with dementia, HC 604, p 6. Back
This figure includes both formal and informal costs (i.e. carers'
time). National Audit Office, Session 2006-2007, Improving
services and support for people with dementia, HC 604, 4 July
2007, p 4. The Alzheimer's Society estimate that the total
economic burden in the UK is £17 billion, which includes
£6 billion of care provided by families (Ev 212, para 3). Back
Ev 212, paras. 4-5. Back
Standard 7. Back
Department of Health, September 1999. Back
Living Well in Later Life, p 7. Back
Q 44 [Mr Hurst]; Ev 212, para 6; Ev 134, para 1. Back
Ev 100; Ev 163, para 2.7. Back
Ev 135, paras. 1.2-1.3. Back
Ev 215, para 28. Back
Ev 214, para 20. Back
Ev 135, para 1.2. Back
Ev 217, para 41. Back
Improving services and support for people with dementia,
op cit, paras. 34-36. Back
Ev 135, paras. 1.2-1.3. Back
South Asian people are 50% more likely to die prematurely from
coronary heart disease than the general population. Delivering
the National Service Framework for Coronary Heart Disease,
NHS, 2004. Back
Amongst African-Caribbean and South Asian men the prevalence of
stroke was between about 40% and 70% higher than that of the general
population respectively after adjusting for age. National
Statistics, Health Survey for England 2003. Back
Men and women of Pakistani and Bangladeshi origin are more than
6 times as likely as the general population to have diabetes,
and Indian men and women are almost 3 times as likely. Rates of
diabetes among Black Caribbeans were also significantly higher
than in the general population. The Health of Minority
Ethnic Groups, Health Survey for England, 1999, National
African-Caribbean people are much less likely to be referred by
their GP to mental health services but twice as likely to be referred
by the police and the courts. Healthcare Commission, 2005,
Count me in - results of a national census of inpatients in
mental health hospitals and facilities in England and Wales, London.
Black and ethnic minority groups are more likely to be misunderstood
and misdiagnosed, have more ECT (electro-convulsive therapy) rather
than 'talking treatments', are more likely to stay in hospital
longer and less likely to have their psychological needs addressed.
Mind, The Mental Health of the African Caribbean Community
in Britain. Back
Ev 197, para 13; Ev 101. Back
Ev 138, para 5.6. Back
Ev 198, para 14. Back
Ev 144, para 2.6. Back
Q 281. Back
Q 280. Back
Race Relations (Amendment) Act 2000; Disability Discrimination
Act 2005 and Equality Act 2006. Back
Q 61. Back
10 July 2007, Column 412WH. Back
Q 62. Back
Ev 163, para 2.8. Back
Discrimination Law Review - A Framework for Fairness, op
cit, para 9.4. Back
Here we agree with the Health Committee, Second Report of Session
2003-04, Elder Abuse, HC 111-1, para 13. Back
Equality Act 2006, Section 11(1). Back
Equality Act 2006, Section 12(4)(a). Back