Joint Committee On Human Rights Eighteenth Report


7  The role of staff in protecting human rights

200. As we have already identified, leaders in healthcare (in the Department of Health and the inspectorates, as well as in service providers) have an influential and important role to play in ensuring that the human rights of older people in healthcare are protected and respected. Without their leadership, the change that we advocate for creating a culture of respect for the human rights of older people will not be achieved. However, the role of staff in achieving this change should not be underestimated. They are the people with whom older patients and residents interact every day and upon whom they rely for their basic care, provided with compassion and skill. They are also the only people who can really bring about this change in culture on the ground, in hospital wards and care homes up and down the country.

201. In this Chapter, we are concerned with clinical and non-clinical staff, as both have a vital role to play in shaping the culture of their working environment and the experiences of older people. Healthcare for older people is sometimes referred to as the "Cinderella" of medicine. When asked about the main practical, management and resource considerations facing those working in healthcare settings, when seeking to protect the human rights of older persons in their care, the British Geriatrics Society forcefully replied:

—  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 10 years.

—  The failure to provide staff with appropriate skills and in sufficient numbers to meet these changes.[265]

202. Often people caring for older people have low status[266] and, particularly in the care sector, are poorly paid. However, whilst witnesses accepted that there were on occasions links between under-resourcing, staffing levels and poor treatment (such as when one care assistant had to choose between helping someone to the toilet, or helping another person to eat), they did not agree that low pay necessarily led to poor performance or abuse. As one witness said "where I would be very wary is to say that abuse is related to somebody's pay or wage, because it is not. We see people very, very poorly paid providing very, very high quality care." [267]

203. Some witnesses referred to the poor morale and high stress levels of staff within the sector.[268] Given the many and competing demands on healthcare staff, if cultural change is to be achieved, it is vitally important not only that staff understand what human rights principles mean and how they apply, but they also recognise and support the positive benefit they can bring to their working lives and to the lives of the patients and residents they serve. Appropriate and accessible training of staff therefore has a vital role to play. We note that the new Prime Minister and the Secretary of State for Health have jointly announced a review of the NHS which will "undertake an unprecedented process of engagement and consultation with NHS staff"[269] and we hope that it will include a review of how a human rights approach can be embedded in the working practices of all NHS staff.

Training

HOSPITAL STAFF

204. The NHS Knowledge and Skills Framework (KSF) is designed to identify the knowledge and skills that all staff working for the NHS[270] need to apply in their post. It is intended to help guide their development and provide a fair and objective framework on which to base review and development for all staff.

205. One of the six "core dimensions" of this framework is "equality and diversity." Staff are assessed as being at level 1 if they "act in ways that support equality and value diversity" and at level 4 if they "develop a culture that promotes equality and values diversity." The term "human rights" is not mentioned in the framework document but the NHS Confederation states that "the current NHS Knowledge and Skills Framework is being further refined and developed and in the process will take human rights principles further into account".[271] They recommend that "the right training needs to be provided for all employees to ensure the Act is part of the way the service thinks and works, rather than being viewed as an issue for the legal department."[272]

CARE HOME STAFF

206. Under the national minimum standards for care homes for older people at least half of the staff providing care services must have qualifications at NVQ level 2 or equivalent.[273] In addition, care home management must ensure that there is a staff training and development programme which meets what is now the Sector Skills Development Agency workforce training targets.[274] In their evidence, ADASS state in general terms "there are many good examples of training programmes to address the key areas of dignity. Some examples are generic through ongoing NVQ training; others are specific which focus upon dignity and equality."[275]

HUMAN RIGHTS TRAINING

207. In its 2003 report on human rights in public services, the Audit Commission recommended that human rights training should be provided for all frontline staff involved in the delivery of services to the public (such as social care, health, education, housing and asylum) and that it should be ongoing and integrated with existing training programmes. [276]

208. Four years on and the verdict from a range of witnesses is that this kind of training has not yet happened or, if it has happened, staff do not know how to apply it in practice. The joint publication of the Healthcare Commission and others, Living Well in Later Life, spoke of there being "little evidence of staff [in acute wards] receiving training to help them challenge ageist attitudes".[277] As one medical witness said "training and knowledge of human rights [by those working in healthcare settings] is poor".[278] This resonated with our experiences at most of the hospitals and care homes that we visited in North London. None of the care home staff we met seemed to have received any human rights training. Some of the hospital staff we met had received training on the duty of care (described by one member of staff as "doing the best for the patient at all times"), whilst others appeared to have some understanding of how human rights related to their work. The Association of Directors of Adult Social Services provided us with examples of training programmes focussing on "dignity".[279] Whilst they are commendable, these programmes do not make an explicit connection with human rights requirements to protect dignity.

209. Further, human rights principles are not included in the criteria for professional training or in codes of practice for health professionals or social care workers such as:

  • The General Medical Council's guidance for Tomorrow's Doctors;[280]
  • The General Medical Council's "Good Medical Practice";[281]
  • The Nursing and Midwifery Council's Code of Conduct;[282]
  • The curriculum for trainees in geriatric medicine;[283]
  • The NHS Knowledge and Skills Framework (which applies to all NHS staff except doctors);
  • The General Social Care Council's Code of Practice for Social Care Workers and Code of Practice for Employers of Social Care Workers (September 2002).

210. Where training has been provided, it has often been a one-off event which has not sufficiently focussed on improving staff understanding of how human rights principles affect what they do on a daily basis.[284] More than one witness spoke of the prevailing idea within healthcare that human rights was something to be confined to the legal department, or concerned simply with damage limitation to avoid the service provider facing a legal challenge.[285] In our view, this focus only on the litigious aspects of human rights risks losing the real benefit that human rights can bring to improving healthcare across the board. Bemoaning the lack of training, Action on Elder Abuse suggested that "this contributes to a cultural approach that denies seeing an older person as an equal within society".[286]

211. Witnesses told us that training needed to "target staff who have direct responsibility for the healthcare of older people"[287] and be supported by managers, including those at the highest level.[288]

212. Ensuring that staff understand human rights principles has benefits at many levels. Firstly, explaining human rights principles and how they relate to the specific work that the staff member does, takes the question of human rights out of the "legal" or "defensive" box and moves it into the mainstream. Witnesses have told us that this resonates with healthcare staff performing many different roles. As BIHR told the Committee:

    What we found was when we took a step back and said, "This is how human rights is relevant to you as a healthcare worker", had a discussion with them, gave them some information and gave them some practical training, they then said, "Hang on, this is what we came to the health service to do. These are the things we care about." And I think that is one of the reasons why we saw such a positive response from the trusts we worked with[289].

213. Witnesses disagreed that human rights would be seen by staff as a chore. Instead, based on her experience as a human rights trainer, one witness observed "I find that rather than seeing human rights as yet another regulatory burden social workers on the ground are enormously excited once they start to see what it could mean. It very much resonates with the care professionals' idea of what their job is all about."[290]

214. Secondly, it provides staff with an opportunity to reflect on the care they provide and its impact from a broader perspective. As the British Geriatrics Society observed "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.[291]

215. Thirdly, it provides a methodology to assist staff in making some of their difficult decisions. The BIHR, which provides training to a range of public sector workers, reports a sea change in the approach of staff following their human rights training sessions "on countless occasions we have facilitated staff to come up with their own human rights based solutions to seemingly intractable problems.[292]

216. In their publication The Human Rights Act - Changing Lives, the BIHR provide the practical example of a carer supervising a man with learning difficulties while he bathed. According to the BIHR, during one of their human rights training sessions, his carer commented "I knew in my heart he was being treated without dignity and now I recognise that his human rights are perhaps being violated".[293]

217. It is right to note that human rights training is not a panacea. Staff do not just need training on human rights, but also require support more generally (for example training on dementia care) and a strong lead from their managers, supervisors and mentors on appropriate caring attitudes. The Royal College of Nursing told us:

    One practical consideration is the need to ensure an appropriate degree of compassion and understanding with those who work with older people in all settings. A need for education and training opportunities is fairly obvious but there is also the need to develop and maintain appropriate attitudes and values when working with older people. Staff working in such environments will need to feel supported in their workplace, care standards can be improved by access to continuing professional development, provision of adequate resources and adequate training for staff about human rights.[294]

218. Organisations may be put off training staff if they do not see the benefit to their core business or if they fear that it will cost too much. However, as the BIHR pointed out:

    Training does cost money but I think you have got to look at the costs of not training people in these matters […] the Committee has heard from previous witnesses just what happens when people are not treated properly, the human cost of that, but also the cost to the organisation in terms of being sued and so on, so we probably need a cost benefit analysis. The early signs we have got are that it does not have to be particularly costly, particularly if you make human rights part of other training which is already going on in the organisation[295].

219. The Minister accepted that the Audit Commission's recommendation had not been effectively implemented, but noted that the Department was looking at how to mainstream "awareness of human rights legislation" as part of staff training.[296] He told us:

    We have to change the way we look at entry level training into some of these jobs, continual professional development, and that has to apply not just to highly skilled, highly paid clinical staff; it also has to apply to all members of staff, and therefore the logic of that statement is that, going forward, awareness of human rights legislation and its implications should have a much greater priority in terms of the way staff are trained. [297]

220. The Minister told us that they were currently looking at "how we are going to embed human rights in the training and induction programmes for staff across health and social care",[298] to include clinical and non-clinical staff. We welcome this development. The Minister also stated that:

    If you are trying to persuade frontline public service professionals of the virtues of human rights, you have to make a correlation between the legislation and what they should want to do in terms of improving the lives of the people they are there to serve. If you do not do that it will just be more guidance and it will be pretty meaningless in terms of transforming either health services or social care services. [299]

221. We can see real benefit for older people in healthcare, especially the most vulnerable, of greater awareness of human rights within the organisations that care for them. Human rights should certainly not remain in the legal department, but instead need to be understood and embedded in the culture of hospitals and care homes. This will only happen if staff throughout the organisation are part of that cultural change. We are pleased to hear the Minister's recent assurance that human rights training of staff should be a priority for the future, and in particular that it will include both clinical and non-clinical staff. However, we are disappointed that, almost seven years after the HRA came into force, such a commitment should still be necessary.

222. In our view, human rights training should have been provided throughout hospitals and care homes and other public service organisations from 2000. We recommend that all staff working in healthcare (both clinical and non-clinical) receive targeted and regular training in human rights principles and positive duties and how they apply to their work. This could be incorporated into existing training programmes (such as ethics or equality and diversity) rather than operate as stand alone sessions.

223. We commend the Department of Health and the BIHR for their pilot[300] on introducing human rights principles in healthcare and have made recommendations on its future development and expansion in Chapter 5. We recommend that the Department of Health review, within three years, the extent to which training has taken place within healthcare and the effects of that training. We also recommend that the Department of Health produce guidance, building on its pilot with the BIHR, including case studies and examples as appropriate, of best practice in training different groups of healthcare staff on human rights principles as they apply to their day to day work.

224. We also recommend that the reports on individual healthcare providers by the newly merged health and social care inspectorate should include details of the human rights training that has been provided to staff. Further, we recommend that the Commission on Equality and Human Rights monitors the extent to which hospitals and care homes include human rights principles in their staff training.

QUALIFICATIONS

225. Some witnesses, including the representative bodies of nurses and doctors working with older people, have also suggested to us that human rights principles should be included in qualifications, accreditation and re-licensing for health professionals.[301] The Royal College of Nursing saw a wider imperative:

    I think there is clearly a need to ensure that all nurses are educated around the implications of human rights […] The reason why I think we do need to work with the Human Rights Act and to use it as a lever is because we have decades of examples of challenges in terms of trying to get society in the UK to view aging in a positive way […] the first thing is legitimising speaking out when things are not right. There is something relatively straightforward that could be done around nurse education, pre-registration and post-registration, in terms of an introduction to the essential aspects of human rights. [302]

226. Not only would a greater understanding of human rights help to overcome "ageist attitudes", it would also provide healthcare workers with ammunition to persuade their managers of a need to change working practices or obtain more resources if they saw that they were unable to properly respect the rights of the older people in their care. We recommend that a basic understanding of how the Human Rights Act requires the protection of basic principles such as dignity, fairness, respect and equality be included in qualifications, accreditation and re-licensing for health professionals.

Reporting abuse

227. We accept that training only goes so far to improving the care and experience of older people in healthcare. Whilst the majority of people working in healthcare are dedicated professionals, striving to provide the best service to all those within the care, there will inevitably be those who cannot or do not meet acceptable standards of care. On our visit to Sweden, we were informed about Lex Maria and Lex Sarah, two laws which require all employees in residential care settings or hospitals to report suspected abuse.

228. We were told in evidence that, in the UK, doctors and nurses are already under a professional duty to report poor treatment.[303] The issue is whether such a duty should be extended by legislation to everyone caring for older people in healthcare institutions. Several witnesses[304] have supported the introduction of such a law. For example, the Alzheimer's Society saw it as a way of raising the debate about abuse and neglect "if you introduce that type of obligation then necessarily you […] expand people's knowledge about what abuse is and not just […] violent, aggressive forms of abuse which people might talk about but also the neglect, so that would be incredibly helpful.[305]

229. Witnesses noted the difficulties faced by whistle-blowers[306] and suggested that staff, whilst protected by the Public Interest Disclosure Act 1998, needed to know that it was legitimate to speak out when things were not right.[307] Further, some witnesses, such as Action on Elder Abuse, whilst supporting the proposal, offered a word of caution about how effective such a duty would be "the caution I would give […] is mandatory reporting exists in America and the best estimate is one in five cases is actually reported and we need to be aware that there are limitations of that.[308]

230. From the provider side, ADASS noted that staff had a moral obligation to report abuse and agreed that this duty should also form part of an employee's contract of employment. However, a key issue for staff would be to see that effective action was taken at a management level when suspicions were brought to their attention:

From a social services' perspective, our view is that there is a moral duty and it should be custom and practice that that is the case. The key thing, though, is that, if we are to ensure that it is a moral duty and it is custom and practice, that requires strong leadership and it requires people like ourselves sitting around this table and others to make sure that we can demonstrate that we take action against those perpetrators, particularly of abuse.[309]

231. The Minister was not sure whether a statutory duty was required, although he stated "I am not saying I would rule it out forever".[310] He pointed to existing professional standards and registration, stating:

    Every professional who works in health and, as we register the social care workforce, in social care will have professional standards that are non-negotiable, and part of those professional standards, as well as the guidance that will operate in any care setting in any part of the country, will be that if somebody is being abused you have a responsibility as part of your professional code of practice, as part of the policies that apply in your workplace to report that […] we have recently gone through a process of registering social workers. We are moving on to domiciliary care staff and we are moving ultimately to people working in residential and nursing care settings, and as part of that registration they have to meet certain professional standards, including reporting abuse, so we are on a journey in that respect in terms of those who work in residential and nursing homes. I am not sure that the Chairman's fears would be allayed as a consequence of having a law. [311]

232. Whilst we do not want to increase the burdens on healthcare staff, we are conscious that they have a vital role to play in ensuring that all patients and residents with whom they come into contact are treated with dignity and respect and are not subjected to abuse. They do this in two ways. Firstly, they are responsible for their own conduct and ensuring that they act in accordance with human rights principles and their positive duties. Secondly, they are the eyes and ears of the outside world. They will be the first to notice if someone is being ill-treated. Older people with mental health problems or who do not have visitors are especially vulnerable. A duty to report suspected abuse is more than merely a moral duty and we consider that such a duty should be a requirement for all staff working in the NHS and in care homes. We therefore recommend that the Government include a requirement in both the Care Standards for Better Health and the National Minimum Standards for Care Homes for Older People (or, as we have already recommended, preferably in one set of integrated care standards) that hospitals and care homes should have a policy requiring all healthcare workers to report abuse or suspected abuse, with protection for whistle-blowing and confidentiality.

233. We now go on to consider whether older people, their relatives, advocates or carers, have sufficient information to safeguard their rights and ensure that service providers meet their responsibilities, and the difficulties they encounter in raising concerns and complaints.


265   Ev 94. Back

266   Ev 94. Back

267   Q 225. Back

268   Ev 87, para 4(a). Back

269   Department of Health press release, 4 July 2007. Back

270   Except doctors, dentists and some senior managers who are subject to separate review arrangements. Back

271   Ev 232. Back

272   Ev 230. Back

273   Department of Health, National Minimum Standard 28. Back

274   Department of Health, National Minimum Standard 30. Back

275   Ev 227. Back

276   Human Rights: Improving Public Service Delivery, op cit, para 19. Back

277   Living Well in Later Life, op cit, p 26. Back

278   Ev 101. Back

279   Ev 228-229. Back

280   Q 305 [Professor Crome]. Back

281   Although it requires doctors to "show respect for human life" and "treat patients as individuals and respect their dignity". Back

282   The Code is currently under consultation. It states that registered nurses, midwives or specialist community public health nurses "are personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs", p 5. Back

283   Q 305 [Professor Crome]. Back

284   Q 282. Back

285   Ev 171-2. Back

286   Ev 221. Back

287   Ev 186, para 8.4. Back

288   Qs 258 & 259. Back

289   Q 252. Back

290   Q 81 [Ms Gould]. Back

291   Ev 94. Back

292   Ev 172, para 10. Back

293   British Institute of Human Rights, The Human Rights Act-Changing Lives, April 2007, p 7. Back

294   Ev 189. Back

295   Q 262. Back

296   Q 421. Back

297   Q 422. Back

298   Q 399. Back

299   Q 429. Back

300   Human Rights in Healthcare - A Framework for Local Action, op citBack

301   Q 291. Back

302   Qs 294 & 304. Back

303   Q 358. Back

304   Action on Elder Abuse (Q 243), NHS Confederation (Q 358), ADASS (Qs 357 & 358), Royal College of Nursing (Q 299), and British Geriatrics Society (Q 300). Back

305   Q 243. Back

306   Q 300. Back

307   Q 304. Back

308   Q 243 [Mr FitzGerald]. Back

309   Q 357. Back

310   Q 385. Back

311   Qs 380 & 384. Back


 
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