Wednesday, 28 July 2010

Kathleen Jones
Emeritus Professor of Social Policy, University of York

Frail Elderly People and Human Rights: the distortion of Human Rights in the National Health Service

Many very old people are unsteady on their feet. Offering a helping hand is a natural courtesy in most civilised societies. We nearly all help our older relations or our neighbours when necessary. Strangers and passers-by often offer help in the streets; but most care staff in hospitals, residential Homes and sheltered flats and the community services are now under instructions not to lift residents. They send for an ambulance on the grounds of HEALTH AND SAFETY. The ambulance crew routinely takes the old person to hospital, also in the interests of ‘health and safety’. Tests are carried out, and in most cases, the patient is discharged on the following morning. Failure to meet the needs of the very frail is often justified on the grounds of the EQUALITY of all patients. Enquiries from concerned relatives may be met by evasion and denial on the grounds of
This policy is often very distressing to the patient, and makes unnecessary demands on expensive ambulance and hospital admission facilities


Surely this sort of thing does not happen very often? According to a report published recently by the Nuffield Trust* there are now 4.9 million unplanned hospital admissions a year – a rise of some 12 per cent since 2004-5, costing the NHS £11 billion a year. Most of these patients spend less than a day in hospital. The main causes of these admissions are ‘an ageing population’ and the hospitals’ readiness to accept emergency admissions in their attempt to reach the unrealisable target of 100 per cent bed occupancy. The authors recommend ‘better out of hospital care and better preventive care to reduce the risk to patients of admission, and to enable expensive hospital beds to be closed’.

Can you give an example of what is happening?

A frail lady of 94 well known to me has been taken to hospital three times in three months despite her very determined objections, and in each case discharged on the following morning. She now lives surrounded by with red alarm buttons, and is frightened to press any of them in case it happens again.

Mrs C. is intelligent and humorous, a former civil servant. When she got to eighty-five, she sold her house, and rented an expensive sheltered flat. She has relatives living close at hand, and sees them several times a week, but she values her independence. Recently, her legs have begun to fail her. On three separate occasions, she has landed quite gently on the floor, but has been unable to get up again. She wears an alarm pendant round her neck, and has others within reach, but she hesitates to press any of them because she knows that when she does, the care staff will appear promptly enough, but they will tell her that they have instructions not to help her get up again. They cite ‘HEALTH AND SAFETY’ (their health and safety, not hers) as the reason.

The staff have no idea whether ‘Health and Safety’ is European law or English law or simply a directive from their managers. They are simply told never to lift residents, but to call an ambulance instead. When the ambulance crew finally arrive, they do not put Mrs. C. back in her chair. ‘Health and Safety’ are cited again. She is carefully rolled on a stretcher and taken off hospital. There she has a long and uncomfortable wait before receiving medical and nursing attention at the hospital. Eventually she is allocated a bed, and tests are carried out. By that time, her blood pressure has soared, and her blood sugar (she is diabetic) is alarmingly high. Her hearing is not as good as it used to be, and her sight is a bit blurred. She cannot find her handbag or her spectacles. She wants to see her daughter, who lives only a couple of miles from her flat, but she does not know how to get in touch with her. She hesitates to call a nurse because everybody ‘seems to be very busy’, with set tasks involving clip-boards and trolleys. She does not want to cause trouble.


For their part, the ward staff assume that the test results are prima facie evidence that hospital admission was the correct course of action - though they could equally well indicate Mrs C’s distress and frustration at the upheaval. By the following morning, more test results are available. Blood pressure and blood sugar have returned to normal. A doctor nods: the bed is needed for more urgent cases. Mrs C. is put in an ambulance with several people she does not know, and eventually finds herself back in her own flat; and her own chair - until the next time.

Surely this is not standard procedure? It seems that it is in many areas. The health service unions, including the Royal College of Nursing, are strongly opposed to their members lifting patients manually, and the subject is frequently brought up at annual conferences.

What is Department of Health policy? Basic policy documents state that ‘the design of local services is the responsibility of the responsible NHS Trust or local authority. The Department of Health does not indicate how organisations should best meet the needs of their local populations’. However, DH advice on patient lifting has followed the views of the health care unions, and has been decidedly negative. Training courses are listed, but with strong warnings about the risks to staff.

Of course DH should not dictate to local agencies; but it might provide some guidelines? And some public education? DH has considerable resources in audio-visual aids, and unrivalled access to the media. It uses these resources brilliantly to provide information about bird ‘flu or MMR vaccines or sexually transmitted diseases, and in early 2010 in a public campaign to improve recognition of the symptoms presented by stroke victims. There seems to be no reason why it should not provide comparable short TV documentaries for the general public on the precautions to be observed before lifting a patient, and simple lifting techniques. The subject is not that complicated.

Are the training courses useful? There are many good training courses and documentaries on the subject, all advertised on the internet. Some are open to the general public, some are designed for particular professions. They are all run by private fee-paying agencies and the fees are usually quite high, so they seldom reach the patients in private homes or in small residential homes.

So what does DH contribute? DH publishes the Manual Handling Regulations, 1992. These reulations appear to have been designed to protect workers required to lift heavy crates of machinery, not patients, as they refer throughout to the ‘the load’. The 1992 revision appears to have been cursory. Only in the final section is there mention of workers being ‘required to handle a person’. In this case, they are recommended to ‘communicate’ with the person. (Nobody communicated with Mrs C). It is recommended that ‘loads’, whether animate or inanimate, should be handled by mechanical means wherever possible.

But most private homes and small residential homes do not have a mechanical hoist? Precisely. It is fifty years since community care was launched, and much of the care of sick and disabled people moved from the hospital into the home. The regulations do not deal with this major change of focus. General practitioners and other community care staff often recommend calling an ambulance to deal with lifting a patient, but it seems that they seldom consult the ambulance service before doing so. Ambulance staff, for their part, frequently do not regard lifting as part of their responsibility. Many are dedicated to the crisis aspect of their work: they rescue sick or injured people, usually from accidents, and convey them to hospital for expert diagnosis and care, sirens blaring. Some of them are quite indignant about being called out to lift patients, considering it a waste of their specialist skills.

Surely nurses are taught lifting techniques? Why don’t they teach care staff and patients’ relatives? The Royal College of Nursing advises its members not to lift patients manually ‘in all but exceptional circumstances’. Not all nurses are taught the techniques in time to save their own back muscles; and many of those who ‘do their backs’ are the most active in wanting to ban patient lifting. Also, most practice nurses are not teachers. Some tend to treat safe lifting as a trade secret. It is much easier to say ‘Health and Safety’, and not get involved.

There must be some cases in which lifting is not advisable? If the patient is injured or unconscious, the ambulance staff will take extra care and use a stretcher. If the patient is very heavy, the BMA and the health care unions are usually ready enough to publicise the cases, and to say that they should not be the responsibility of their members. In Scotland, the Fire Service has been called upon to lift ‘obese’ patients because the ambulance staff refuse to do so. (Note that such cases are frequently referred to as ‘obese’, which implies that the problem is the patient’s own fault for over-eating); but Mrs C. was not ‘obese’, injured or unconscious. Staff caution often goes much further than the Regulations suggest.

Why are staff over-cautious? Because we live in a compensation culture, where TV advertisements continually urge viewers to apply for ‘No Win – No Fee’ compensation for injury. The fear of litigation motivates many staff and many staff organisations. Mrs. C. might possibly have cracked a bone or strained a ligament in the fall. She might then have claimed to have sustained an injury while being helped to her feet, and sue the helpers. In a litigious society where beaming clients wave their cheques on television, a kindly gesture could mean financial ruin for the helper - or, of course the organisation in the case of a residential Home. It is not really surprising that all the professionals are against manual lifting.

Can’t anything be done about this? A Bill on Personal Care for the Elderly which was before Parliament at the time when the General Election was called in May 2010 included clauses limiting the solicitors’ fees on ‘No Win – No Fee’ cases. It had passed the Commons, but fell in the Lords on objections to other clauses that were related to financial provision.

So the professionals are playing safe? Yes, and for other reasons as well. Mrs C. is very old indeed. With the best of care, she will not live much longer; but if she dies during one of these episodes, questions will be asked. There may be an inquest. Somebody may be blamed. Somebody may be sacked. It is safer to observe the protocol, follow the instructions, stick to the rules. No one wants a death on their hands. That’s another excuse for citing ‘Health and Safety’.

This discussion has been confined to the responsibilities of health care staff; but can Mrs C. not speak for herself? I think you are forgetting that this lady is 94 years old. She doesn’t see very well, she doesn’t hear very well, her bones ache, and she forgets things. Her views have been ignored, and she is desperately weak and tired. Nobody notices her distress, because here another Human Rights principle comes into play: EQUALITY. We no longer have separate geriatric hospitals, and we do not call old ladies ‘Dear’ or ‘Gran’ any more. The very old are treated just like other patients, without reference to their age. Discrimination is rightly frowned upon; but surely that principle should not be taken to the lengths where frail old people are expected to function like healthy teenagers, so that their distress is not even noticed. Nurses and doctors still need to look at the individual patient, not just at the records.

Well, has Mrs. C. no relatives to speak for her? Indeed she has. Her daughter and son-in-law live within a couple of miles of her flat, visit her several times a week, and are deeply concerned for her; but they were not informed by the staff of the sheltered flats when she was taken into hospital. On the most recent occasion, they found this out only when they telephoned her flat that evening, failed to get an answer and contacted the duty worker. They immediately drove to the hospital, but had great difficulty in finding out what was happening to Mrs. C. The responsible doctor had gone off duty. The nurses were engaged in a shift handover. The only information they were given was ‘She’ll have to see doctor in the morning’. When her daughter returned on the following morning, she was informed that Mrs. C. had already been sent home by ambulance.

Surely hospital staff work with and advise patients’ relatives? Much less than they used to. Much less than most of us assume. Hospital staff are very nervous about patients’ complaints and the threat of litigation, and many ward staff seem to have concluded that the less contact they have with relatives, and the less the relatives know about treatment and hospital procedures, the better. This policy has a Human Rights name, too. It is called PATIENT PRIVACY.

But what happens when the patient is discharged? Surely the relatives are advised about medication and care at home? A formal note about medication will be sent to the GP, but it is now quite common for medication to be handed over to the patient – even in circumstances where the patient is clearly unable to retain the information. No one has the right to divulge medical information to a third party unless that person shares the same accommodation or is designated on official records as Personal Carers. Needless to say, neither Mrs. C. nor her daughter is aware of this.

So what can be done? The difficulty is that community care – the ‘better out of hospital care’ recommended in the Nuffield paper quoted - is not a matter for hospital managers. It involves many agencies and individuals, and it is obvious that there is a serious mismatch between need and service. The need is growing all the time as the baby boomers of the late 1940s reach their frail years.

We need public recognition that Human Rights principles are being badly distorted:
  • ‘Health and Safety’ now refers to the worker’s health and safety, rarely to the patient’s.
  • ‘Equality ‘ has come to mean ‘Don’t make any concessions for age or infirmity’.
  • ‘Personal Privacy’ too often means ‘Don’t give the relatives any information, they might sue’.
There are many excellent staff now working desperately hard in the Hospital and Community Services. They deserve a better framework than these cynical and shabby compromises. And so do their patients.

  • The Department of Health should take responsibility for national public education campaigns to ensure that frail elderly people who are conscious and not in pain can be lifted manually, without fuss. Trusts and local authorities should be encouraged to promote participation in more advanced courses on lifting techniques by both professionals and the general public.
  • A Bill to limit solicitors’ fees in ‘No Win – No Fee’ cases should be reintroduced in Parliament as soon as possible – and preferably not linked to other, more controversial provisions.
  • Legal opinion might be sought on a) whether an intention to help a frail old person is a defence in law aginst tendentious claims for damages; and b) forcible removal to hospital of a quiet and sober patioent aginst his/her will constitutes a common assault.
  • The Manual Handling Regulations 1992 should be rewritten in two distinct sections: one for the automatic handling of inanimate (and heavy) objects in hospitals, and the other for the manual handling of frail or sick human beings, including those living in community settings, where automatic lifting machinery is unlikely to be available.
  • The health care professions in the community (district nurses, social workers, residential care workers, the ambulance service) should revise their training programmes to ensure that they have a common level of knowledge about community care, and that they can work together when necessary. Good visual aids would be of considerable value. Where the patient’s relatives are co-operative (and most are) they should be regarded as part of the team, not as potentially hostile witnesses.
  • Hospital staff should be taught that, while all patients are equal, some need a little more help than others. That is not discrimination, it is common sense.

Above all, we need a new perspective. The frail elderly are not ‘a social problem’. They are evidence of years of successful health and welfare policies that have given them – and all of us – a greater expectation of active life. If this is to be a blessing and not a burden, we had better start looking seriously at solutions to the difficulties. One in four children born in 2010 is likely to live to be 100 years old. Are they to be left lying on the floor and in the streets in their last years because nobody has the nerve to pick them up?

* Ian Blunt, Martin Beardsley and Jennifer Dixon,
Trends in Emergency Admissions in England, 2004-2009: is greater efficiency breeding inefficiency?
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