Joint Committee On Human Rights Eighteenth Report

8  Empowering older people

234. Throughout the course of our inquiry we have been constantly reminded of the particularly vulnerable situation in which some older people in healthcare find themselves. Of course, it would be wrong to generalise and suggest that this was uniformly the case, in the same way as some of the ill-treatment that we have outlined is not a problem in every healthcare environment in the UK, or that all of the problems are limited to older people. However, it is true that some older people, including those without family or friends, with mental health problems or from black and minority ethnic communities are particularly vulnerable. If the human rights approach is to have any impact, then it needs to reach out first and foremost to those who are the most marginalised and excluded within our society. One of the issues of which witnesses frequently told us, was the difficulties that some older people have in accessing information about their rights and the barriers they face in raising concerns or complaints with the authorities who should be looking after them. We deal with these issues in this Chapter.

Barriers to voicing concerns
    "Older people are often in a situation where they are trying to preserve an ongoing relationship with a care home or long stay hospital and it makes it very difficult for them to have the confidence to complain or assert their rights and they often feel very anxious about their position were they to do so."[312]

    "There are a number of cases, far too many to just be the odd coincidence, where people face eviction from care homes because a relative has complained. There is one case I know of where a relative complained once simply that her mother's bed was very rarely made and her mother faced eviction as a result of that. I have another case here where a caller's mother had been asked to leave her residential care home because she complained about a member of staff who would not attend to her at night. She had wanted to go to the toilet, so she rang the buzzer, but the staff member did not come for half an hour by which time it was too late and the care worker left her in wet nightclothes, took the buzzer from her and threw it across the room."[313]

235. A fundamental issue for older people in healthcare is the relationship that they have with their care provider. A number of submissions[314] described the "power imbalance"[315] which exists between older people and those who care for them. This imbalance is one of the key factors contributing to the poor treatment of some older people in healthcare and one which leads, as many witnesses told us, to a reluctance by older people in healthcare to complain. Other factors include a lack of confidence in asserting their rights; a failure to identify themselves as people with (human) rights; a reluctance to "make a fuss" on their own behalf (not wishing to cause trouble, fear of recriminations); lack of security of tenure and fear of eviction; internalised ageism in the individual him or herself (i.e. lower expectations of what is fair) or lack of family support. The Department of Health agreed that fear of complaining was a problem:

    There is the question of people feeling able to complain without retribution. We are constantly told by people, "I do not like to say anything because maybe they will hold it against me, and anyway the staff are wonderful". It is a sense of feeling that if you can be secure and confident it is perfectly legitimate to register concerns without there being retribution or without suggesting that the whole system is flawed[316].

236. These barriers to raising concerns are present in both hospitals and care homes. The Healthcare Commission bears this out in relation to hospitals. It told us that "our inspections repeatedly highlighted reluctance by older people to complain due to fear that this would affect the treatment that they or their relatives received."[317]

237. As for care homes, it is no wonder that older people in some homes are scared to express concerns. We were shocked by the number of witnesses who told us of people who had faced eviction from care homes because they or their relative or carer had complained.[318] Care home residents, unlike ordinary tenants, do not have security of tenure. This is different from the situation of older people in residential care in Denmark and Sweden, where older people in residential care are accommodated in individual flats and have secure tenancies. As demonstrated by the examples at the beginning of this Chapter, sometimes the complaints can be about very minor things which should be very easily resolved at a local level. Sometimes residents or their relatives will be told that they can no longer be cared for in the home and that they must leave, often at short notice. Whilst this may be true for some people (e.g. where their nursing needs have become too complex for the home to handle), we got the impression that there are likely to be occasions where this excuse was used to get rid of residents who were regarded as too difficult or troublesome. Such residents are usually the most vulnerable and likely to be suffering from dementia or other mental illness which affects their behaviour.

238. During our visit to Sweden and Denmark, we were impressed that people in residential care could continue to be accommodated in the same care homes, and, as their needs increased, so did the care that was provided. This meant that people were not moved around when their needs became more complex and instead received continuity of care, in an environment and with staff with whom they were familiar.

239. The Minister accepted that people should be able to complain without retribution. Dealing with the issue of people being evicted because of making a complaint, he said:

    The commissioning relationship between a local authority and a home or, indeed, a PCT and a home should make that kind of thing impossible because if I was doing business with a private provider who behaved like that I would stop doing business with them.[319]

240. However, whilst this might help residents who are in homes which receive some publicly funded residents, this is of no assistance to self funders. Nor would CSCI intervene (for reasons which we outline further below).

241. We were alarmed and concerned by how little protection care home residents appear to have against eviction, as compared to ordinary tenants in rented accommodation who have the protection of housing legislation, and suggest that rectifying this anomaly be considered as a matter of urgency.

242. In addition, people do not know how to raise their concerns, or doubt that any good will come of it. Help the Aged mentioned institutional and systemic barriers, including there being "no clear or accessible mechanism for raising issues of concern"[320] including about violations of their Convention rights. They pointed out that care home residents have minimal contact with social workers and annual reviews "tend to be a cursory and bureaucratic exercise".[321]

243. In our view, in order to ensure greater protection of an individual's human rights, an individual (or his or her relative or carer) must have a real and effective means of raising concerns with service providers and, if they are not able to deal satisfactorily with the issue, a third party to which he or she can address complaints. We deal with this in more detail below. Such mechanisms go to the very heart of ensuring that the human rights of patients and residents are respected in practice.

244. For people with mental health difficulties or language difficulties, the problem of raising concerns is even more acute.[322] As the Alzheimer's Society said:

    The challenge of promoting human rights for people with dementia is even more pronounced than for older people as a whole. As someone develops symptoms in dementia, their ability to communicate their wishes and challenge human rights violations falls […] This makes people with dementia especially susceptible to abuse […] Reporting of distress is far more likely to happen if the person with dementia has someone such as an articulate relative who can speak out for them and when the care providers encourage feedback.[323]

245. Partly to overcome this problem, the Alzheimer's Society suggests the use of independent advocates and recommends "more emphasis on these types of support".[324] A number of witnesses supported the suggestion that greater use should be made of independent advocates to help older people to express themselves, raise concerns and stand up for their rights.[325]

246. In addition, witnesses suggested that whether or not people had mental health problems, some "older people may need additional support and advocacy to understand the options available to them and to overcome the power imbalance".[326] Recognising how opaque the healthcare system can be, providers also saw the wider benefits of advocates to older people:

    It is incredibly important that people get the right information, but written and conveyed in such a way that it makes common sense, rather than the sort of language that a lot of us in the professions tend to talk; then giving people time to understand it, and to be given some assistance in thinking through some of the choices that might be available to people. Those choices might be limited but they are still choices that people ought to be helped to think through […] In my authority we spend a significant amount of money on advocacy services, because we recognise that, when people need to make important and difficult choices, they should have independent help with that.[327]

And to staff "[…] who find older people having access to advocacy services […] make a real difference to everybody concerned."[328]

247. Some witnesses recommended that consideration should be given to the use of ethnic minority advocates "as a matter of general good practice".[329] In addition, witnesses recognised that, in order for advocates to successfully speak up to protect the rights of older people, the advocates themselves would need to be trained in human rights. However, as BIHR, who have trained advocates of older people, pointed out:

    What [advocates] tell us is this stuff is not complicated but it gives them a language and confidence because what they start from is not the needs of the institution but the human being and the absolute right to be protected from inhumane treatment or the positive right to have a family life. [330]

248. We are pleased to note that the Minister accepted that advocacy had an important part to play saying "you also have to put in place advocacy and other support systems to make control, power and choice a reality."[331]

249. We conclude that older people, especially those who are the most vulnerable, would greatly benefit from the assistance of independent advocates in order to secure their human rights on the same basis as the rest of society. As the Alzheimer's Society Ealing suggests, and we agree, "the key principles of advocacy promote human rights - independence, inclusion, empowerment and citizenship".[332] Advocacy for vulnerable individuals is also required as part of the positive obligations of public authorities to ensure respect for human rights. We welcome the Minister's support for independent advocates and recommend that he ensures that the Department provides sufficient independent advocacy services to older people, with particular priority being given to older people with mental health problems or who are unable to communicate in English. These advocates should have an understanding of human rights principles and the positive duties of service providers towards older people.

    "The caller's mother-in-law had been living in a care home for six years funded by the local authority where she had previously lived. Her daughter first made a mild complaint that her mother's bed was often left unmade late in the day. The care worker's response was to suggest that she might like to move her mother to another home. The daughter made a further complaint about this reaction which was investigated by the manager who wrote to the daughter denying that the home was at fault, claiming they had handled the complaint fairly and gave her mother four weeks notice to quit."[333]

250. The National Minimum Standards for Care Homes for Older People (Standard 17) require that "service users […] are enabled to exercise their legal rights directly". CSCI state that inspectors should assess whether "residents have access to a robust, effective complaints procedure".[334] However, witnesses told us that CSCI's complaints procedure is misleading to users because it suggests that CSCI can help with complaints. In fact, with the exception of severe abuse, which will be referred to the police, CSCI refer complainants back to their care home provider. Alternatively, if residents are publicly funded, CSCI may refer the investigation of their complaint back to the local authority.[335]

251. The Residents & Relatives Association outlined the conundrum:

    In the first instance if a relative or resident complains to the Commission for Social Care Inspection they are advised to go back to the home and resolve it through the home's own complaints procedure and, of course, relatives and residents are loath to do that because of fear of victimisation, they are complaining to a complaints procedure which is run by the very people they are accusing of behaving badly to them [...] [CSCI] are inspecting the quality of the home as a whole and they are not pursuing the interests of individual residents.[336]

252. CSCI noted the practical effect of the problem as follows:

    We do not have the powers to investigate or handle complaints […] each care home has to have a process for handling complaints in place and those procedures have to be exhausted […] When complaints are made to us we do register those […] and we will consider whether we need to go and inspect […] We act on the general issue, although we do not have the powers to deal with the specific issue […] if you are a resident placed in a care home by a local authority, that authority has the duty to investigate concerns and they will also have a contract and commissioning responsibilities for the establishment concerned to ensure good standards are maintained. However, where you are a person who is paying for yourself and you may have placed yourself in a care home, you do not have that protection and you do not have the escalation protection through the local authority or through a different appellate process, nor do you, in those circumstances, have access to an ombudsman. We would say in those circumstances that what we are seeing is two different classes of resident: with one group of residents who may be more exposed because there is no public framework to oversee the placement that they have made […] We would agree [that it is pretty unsatisfactory].[337]

253. The fact that CSCI cannot investigate complaints means, as HTA noted, that individuals do not have "an immediate and accessible remedy".[338] They state that even if an individual complains to CSCI, this may lead to an inspection of the care home, but not investigation of the complaint itself. Whilst publicly funded residents may have their complaint investigated by the local authority, this leaves self-funding individuals in particular without a remedy, as local authorities would not investigate their complaint.

254. The Department of Health's Core Standard C14 requires healthcare organisations to:

  • Have systems in place to ensure that patients, their relatives and carers:
    • Have suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on quality of services;
    • Are not discriminated against when complaints are made;
    • Are assured that organisations act appropriately on any concerns and, where appropriate, make changes to ensure improvements in service delivery.

255. Unlike CSCI, the Healthcare Commission has a duty to investigate individual complaints where a patient is dissatisfied with the response of a trust.[339]

256. ACE suggest that:

    Complaints should operate in such a way that whichever agency receives the complaint has a duty to ensure that there is a response even if they do not regard it as their role to investigate the complaint themselves. Department of Health guidance on NHS and Social Care complaints supports such an approach, but inquiries from relatives and older people received by Age Concern raise doubt as about whether this is happening in practice.[340]

257. The Government's consultation paper on the proposed merger of the inspectorates states "the new regulator will focus on assessing whether organisations have appropriate systems and processes in place, rather than handling individual cases of complaint".[341] The Minister noted that there was a difference in the way that CSCI and the Healthcare Commission dealt with complaints. However, he was not able to guarantee that when the complaints processes were merged, the approach of the Healthcare Commission would prevail (i.e. that it would itself investigate individual complaints rather than refer the matter back to the body being complained about). He said:

    There are two different systems and part of what we have got to decide in terms of merging the systems is where the ultimate right of appeal goes in relation to individual complaints, but we have not made that decision yet […] We have to look at what is the most effective way of ensuring people, first of all, feel able to complain, secondly, feel that their complaint is taken seriously and, third of all, that there is an element of independence and objectivity about the system[342].

258. We welcome the Government's consultation on the merger of the inspectorates, although we are concerned that the consultation suggests that the new inspectorate will not handle individual complaints. We were alarmed that the Minister was unable to guarantee that the new inspectorate would be able to investigate individual complaints at the appropriate point in the process. We are convinced that complaints, including those raising human rights concerns, need to be investigated by an independent third party, rather than by the organisation against which the complaint is made and where the older person may continue to live. We therefore recommend that the newly merged inspectorate be empowered to investigate individual complaints, as the Healthcare Commission is currently able to do.

Low awareness of rights

259. In 2006, the Patients Association conducted a survey among 188 patient/health advocates asking for their views on patients' rights within the NHS, including such issues as the ability of patients to exercise their legal rights within the NHS and how a patients'-rights-based system could be managed and/or enforced. The survey apparently generated one of the best response rates ever attained from a poll of patient/health advocacy groups in the UK, suggesting that the topic of patients' rights is regarded as important by the patient advocacy community in England and Wales.[343] Despite this, witnesses told us that older people generally had a low awareness of their healthcare rights,[344] including how to complain and how to navigate the complaints system.[345]

260. As Age Concern[346] and others noted, this was partly due to a lack of information from the Department of Health and the inspectorates about the standards that people can expect in healthcare. They explained:

    There has been no attempt to publicise the existence of [the health] standards to the public at all. That appears to us to be a huge gap in enabling older people to understand what they and their relatives have the right to expect and to challenge any failure to provide that. It is something that we have consistently challenged the Department of Health on. In setting out these standards, unless you tell people they exist, in effect they do not exist.[347]

261. Noting the gap between rhetoric and reality, the Minister said:

    I also believe that this is not just about the State; I think it is also about the awareness and the confidence of citizens and communities to assert their rights. I think that is why the Government increasingly understands that reforming public services is not just about changing structures; it is also about empowering those people who use services and, more broadly than that, communities and society[348].

262. Whilst we are pleased that the Minister accepts that older people need to be aware of their rights, he misses the point when he says that "this is not just about the State". Given the particular vulnerabilities of people in healthcare, there is an onus on the State to ensure that service users are provided with information about their rights and the standards that they can expect whilst in receipt of healthcare services. Empowering older people relies in part on overcoming some of the barriers to raising concerns which we mentioned above, and in tandem, ensuring that older people, or their carers or advocates, are sufficiently well informed about their rights and the State's responsibilities.

263. According to our witnesses, older people also have a low awareness of their human rights. As one witness put it "human rights are misunderstood, not just by service providers and those who plan services, but also by older people themselves as the end users of those services."[349]

264. As the National Pensioners' Convention said "we are aware that the Human Rights Act has relevance to older people but believe that there is widespread ignorance about exactly how it can be used."[350]

265. This ignorance about human rights should not be confined merely to older people, but is part of the bigger problem of the failure of Government to promote a positive concept of human rights with the general public. Recent research by Age Concern involved researchers meeting with older people to explore their understanding of human rights. Age Concern found that "when exposed to the themes of the HRA, people could see ways in which it might help them, their family or their friends. However, prior to being exposed to the HRA, the tenor of discussion had been very hostile to 'human rights'."[351]

266. This chimes with the findings of the BIHR when healthcare workers received training in human rights (see above). Age Concern found that people did not want information about the different provisions of the HRA, but simply wanted to know that they had a firm legal right to be treated decently and to know how to assert that right. However, poor awareness of human rights is not simply a matter of distrust of the concept of human rights. As Action on Elder Abuse told us, it is also a question of information and terminology:

    What is the point of a human right if I do not know I have got it? That is the first question. The second, what is the point of a human right if I cannot access it? I think we need to address both those things, people need to understand their human rights in whatever terminology we use and wrap it up, that they understand I have a right to be treated with respect and dignity and the right to ask questions and get responses, and if I am not happy, I have a right to complain.[352]

267. The issue of terminology was echoed by the Alzheimer's Society which suggested that human rights were seen as alien and legal:

    Human rights principles do not come easily to older people who often view the Human Rights Act as a legal tool that is used and abused. It is also perceived as being a legalistic approach and this discourages people from making use of human rights arguments. Beyond the populist reaction, human rights also seem alien to people unless particularly violent forms of abuse such as physical or sexual abuse take place.

    A question in this context would be whether it is useful to frame the discussion in terms of "human rights" if seeking to encourage older people to make more use of their rights? Typically the Alzheimer's Society seeks to inform and encourage people to make use of their 'rights', rather than 'human rights'. The term 'rights' seems to have more immediate meaning for people with dementia and their families.[353]

268. In addition to terminological problems, witnesses considered that there might be some "difficulties in communicating information about human rights to the very people who are most vulnerable to human rights abuses"[354] and therefore advocated targeting human rights information to a wider audience beyond older people themselves.

269. There is clearly some important promotional work which needs to be carried out to improve the image of human rights within the population generally, including older people. We commend the former Minister for Human Rights and the former Lord Chancellor for the steps that they have taken, as part of the Government's Common Values, Common Sense campaign. We urge the new members of the Government, in particular the new incumbents in the Ministry of Justice, to be steadfast in their support for the Human Rights Act and its real importance for many ordinary people, including older people receiving health and care services.

How to make rights accessible to older people

270. Despite concerns about terminology, witnesses have nevertheless told us that they see great benefits to older people and their carers or advocates of equipping them with information about human rights principles and their practical application to them. As Age Concern explained, it would be one way of addressing the power imbalance and overcoming the powerlessness that older people complain of when trying to challenge poor treatment.[355] It would also provide them with a new language to help them to "advocate more strongly for themselves".[356] However, the BIHR sounded a note of caution:

    The responsibility for making sure that people's rights are respected should never fall on one frail individual in a residential care home but, at the same time, that frail individual should at least have the opportunity to know what their rights are and for those rights to be respected.[357]

271. Race on the Agenda agreed that consumers of public services need to have enough knowledge to enable them to challenge the system when the service is poor, that they should be consulted to "identify the best methodologies in using the principles underlying the Human Rights Act" but that such a process "should not over-burden individuals".[358]

272. It is important that older people and their advocates or carers have sufficient information about their rights, to ensure that they can claim them from service providers if they wish to do so. However, this should be a matter of last resort. Given the power imbalance between older people and service providers, and their resulting reluctance to complain, we do not consider that it is either realistic or appropriate to expect older people to shoulder the burden for ensuring that service providers treat them with respect for their human rights. The primary responsibility for the protection of human rights, as we have repeatedly said in this Report, falls on providers of public services. We have already recommended in Chapters 4, 5 and 6 what the Department of Health, providers of healthcare services, inspectorates and other healthcare agencies should be doing to ensure that older people's human rights are protected in hospitals and care homes.

273. Witnesses agreed that, in addition to better education of the general public, specific targeted information aimed at older people, their carers and advocates was required. Information needs to be "accessible and meaningful",[359] and staff should be trained to support people in accessing this information. Help the Aged noted the need for independent quality advocacy services to ensure that older people are informed and involved and that "access to qualified legal advice is also essential".[360]

274. Some witnesses commented on the role of voluntary and community organisations in communicating the message of human rights to the public,[361] and they recommended that the new Commission for Equality and Human Rights produce similar general and targeted information.[362] The BIHR told us this about their guide on human rights for older people:

    We produced a plain English guide for older people about human rights and it has flown off our shelves. It has been the most popular guide of the four guides we produce. I think it shows there is an appetite there for information.[363]

275. The National Pensioners Convention told us about their leaflet, Older People and the Human Rights Act.[364] However, Action on Elder Abuse felt that the emphasis should be on changing institutional culture:

    In our opinion, the strategy to move this situation forward is less about producing leaflets or posters telling older people about their human rights, but is more about influencing the institutions that provide health and social care so that a human rights culture is "mainstreamed" into the thinking, planning and delivery; but also to make human rights accessible through mechanisms other than the judicial system.[365]

276. We consider that a dual approach is required: firstly, older people need information about their human rights; and secondly, institutions need to mainstream human rights within their work. We recommend that the Department of Health, the inspectorates, healthcare policy-makers and every provider of healthcare services make a public commitment to: (a) embed a human rights approach in hospitals and care homes across the country and (b) make sure that accessible information on human rights and how to use them are provided to patients, care home residents, relatives, carers and advocates, and the public as a whole.

277. In addition, we recommend that the Commission for Equality and Human Rights, in partnership with organisations representing older people, assesses the quality of the information available to older people, their families and carers on the application of human rights principles to their lives and makes sure that the best information is widely disseminated. Independent advocates and advisors have a crucial role to play in assisting people to understand and apply these concepts.

278. During the evidence session with the Healthcare Commission, it was revealed that although the care standards require hospitals "to respect human rights", this requirement is not made clear to patients:

    Chairman: You do not say to patients and relatives, "Do you realise that human rights include X, Y and Z?"?

    Ms Walker: No, we do not do that. That would be another way of coming at it. Our relationship with the patient fora is in its infancy in the sense that we introduced the annual health check for the first time last year.[366]

279. Under the National Minimum Standards, care homes are required to make the following information available to residents:

    The registered person produces and makes available to service users an up-to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users' guide to the home for current and prospective residents.[367]

    Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately).[368]

280. A number of witnesses, including providers, recommended that older people should be informed about their rights and responsibilities, as well as what the service provider was and was not able to do, when entering the hospital or care home.[369] The Royal College of Nursing suggested that there was work to be done in putting together:

    […] something very simple for patients and for healthcare staff so that they understand what that actually means, so that patients understand what they have a right to expect and so that healthcare staff also have the right in understanding what they have a right to expect and what they should do if they cannot meet those expectations. [370]

281. On our visit to a North London hospital, we were given copies of leaflets provided to patients on admission about the services that they could expect. These included information on care and treatment, how to make a complaint and what happens on discharge. In one of them, Our promise to you, the NHS Trust states "we will deliver our services in a way which is fair and safe, recognising the individual needs of our patients and the potential of our staff".

282. There is no reference to the fact that patients have "rights" as well as "needs" or that the providers have a legal duty under the Human Rights Act. It was thought by those present, however, that a bald reference to "human rights" could be "off-putting" for patients. We recommend that information on human rights be presented by the NHS in an appropriate way to older people.

283. For care homes, information could be provided as part of the information that homes are required, under the national minimum standards, to make available to residents.

284. The Minister agreed that individuals should be informed of their rights and responsibilities when entering healthcare and that ideally this should be done not by giving the older person a document, but by having a conversation with them.[371]

285. Some witnesses advocated a bill of rights for older people in healthcare.[372] This is supported by a survey by the Patients' Association.[373] The British Geriatrics Society suggested that:

Older persons receiving treatment in hospital or in residential care could be better informed about human rights principles […] This could be achieved by a public information campaign and/or a Bill of Rights for older frail persons entering hospital or a care home.[374]

286. As part of its evidence, the British Geriatrics Society appended, as a good practice example, US Federal law requirements for nursing homes which state that "Federal law requires a nursing home to care for its residents in a way that promotes their quality of life."[375]

287. The listed rights under US law are comparable in content to those contained in the Department of Health's national minimum standards but the difference is that they are contained in primary legislation.

288. We recommend that information on the human rights of older people and the duties of service providers as "public authorities" under the HRA be provided to older people, in an accessible form, on entry to the care home or hospital. The applicable care standards for hospitals and care homes should be revised to require that service providers make specific reference to an individual's human rights and the avenue for making a complaint.

312   Q 11. Back

313   Q 12. Back

314   Ev 137, para 4; Ev 140; Ev 172, para 12; Ev 198, para 14; Ev 221. Back

315   See paragraph 59 above. Back

316   Q 379. Back

317   Ev 145, para 2.12. Back

318   E.g. Residents and Relatives Association provide several examples of older people being given notices to quit their care homes after making complaints (Ev 194-196). Back

319   Q 440. Back

320   Ev 164, para 3.7. Back

321   Ev 164, para 3.7. Back

322   Ev 125 & 129, paras 2.4 & 5.1. Back

323   Ev 213 & 215, paras. 10 & 32. Back

324   Ev 217, para 40. Back

325   Ev 125, para 2.6; Ev 135-136 para 2.3; Ev 182-183, paras. 3.6-3.7; Ev 188. Back

326   Ev 137, para 4.1,  Back

327   Q 354 [Ms Owen] & Q 355. Back

328   Q 306. Back

329   Hidden Voices, op cit, paras 4.4 and 9.4. This accords with the recommendation of the Health Committee that "advocates on elder abuse drawn from black and minority ethnic communities should be identified, trained and deployed" (Elder Abuse, op cit, para 10.28). Back

330   Q 274. Back

331   Q 379. Back

332   Ev 142. Back

333   Ev 194, App. 1 para 4. Back

334   Ev 179. Back

335   Qs 12 & 18. Back

336   Qs 18 & 19. Back

337   Qs 148 & 149. Back

338   Q 68. Back

339   Ev 144, footnote 59. Back

340   Ev 130, para 5.1. Back

341   Department of Health, The future regulation of health and adult social care in England, 2006, para 3.24. Back

342   Qs 438 & 439. Back

343   Patients Association, Should the NHS take more account of patients' rights? A survey of health campaigners in England and Wales, November 2006. Back

344   Ev 140. Back

345   Ev 125, para 2.4. Back

346   Ev 125, para 2.4. Back

347   Q 77 [Mr Hurst]. Back

348   Q 406. Back

349   Q 73. Back

350   Ev 103. Back

351   Age Concern, Rights for Real, May 2006, Annex 1. Back

352   Q 237. Back

353   Ev 216, paras 37 & 38. Back

354   Ev 131, para 6.2. Back

355   Ev 131, para 6.1. Back

356   Ev 157, para 8. Back

357   Q 274. Back

358   Ev 200. Back

359   Ev 188. Back

360   Ev 166, paras 4.3-4.5. Back

361   Ev 125, para 2.5. Back

362   Ev 174, para 19. Back

363   Q 274. Back

364   Ev 103. Back

365   Ev 223. Back

366   Q 106. Back

367   National Minimum Standard: Care Homes for Older People (Standard 1). Back

368   National Minimum Standard: Care Homes for Older People (Standard 2). Back

369   Qs 305 [Professor Crome] & 361. Back

370   Q 304. Back

371   Q 437. Back

372   Ev 94; Ev 155; Ev 239. Back

373   Patients Association, Should the NHS take more account of patients' rights? A survey of health campaigners in England and Wales, November 2006. Back

374   Ev 94. Back

375   Ev 95, 42 USC para 1395i-3. Back

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