The hardness of COVID ethical choice

Nelson Mandela in a speech in 1998 stated:

“A society that does not value its older people denies its roots and endangers its future. Let us strive to enhance their capacity to support themselves for as long as possible and when they cannot do so anymore, to care for them.”

Like many others I have been waiting with interest for sight of the ethical guidance which would be made available to our frontline clinicians who are engaged in the struggles against the Coronavirus epidemic. I read the ‘COVID-19 Guidance: Ethical Advice and Support Framework’ with considerable expectation and hope for a clear grounding for hard decision making. When I finished I was left with more questions than answers and no small sense of disappointment.

The reason for such a document is self-evident. Despite all the best efforts of planners and politicians we may get to situation where there is insufficiency of resource to be able to provide the optimum clinical care and treatment to every citizen.  As the document itself states;

‘if immediate need exceeds what is required and there is no additional capacity, changes to healthcare delivery and scope may be necessary.’

It is in this context when we are clearly not in ‘normal times’ that we need to be able to give our frontline clinicians the ethical, moral and rights-based tools to allow them to do their harrowing job with dignity and authority. I am afraid this document fails to give that sense of grounding and raises fear and concern for many of us. It fails to live up to its declared self confidence that ‘This guidance is considered both clinically sound and on firm moral ground.’

Some of my concerns include:

The Guidance describes the role of Ethical and Advice Support Groups at both a national and local level. Whilst the membership is delineated as including clinical professionals, academics, lawyers, religious groups, social workers and lay persons, it does not describe for us HOW these individuals will make their decisions. What will be the moral and ethical boundaries, principles and framework which will guide them? What will be the clinical criteria to enable them to make impossibly hard recommendations? Will these be based on utilitarian views? How will we be assured that their decisions and advice will be non-discriminatory and based on a robust human rights critique? To what extent will characteristics of age, co-morbidity and frailty influence decision criteria? What indeed will be considered the interests and obligations that this decision-making has to the ‘wider population.’

Secondly, the Guidance uses a lot of ‘feel good’ language but does not illustrate how that assurance is going to be played out in reality. It states that:

‘Everyone matters…

Everyone matters equally…

the interests of each .. are a concern for all of us

Harm suffered by every person matters…’

All undeniably laudable aspirations and statements but how are these fulfilled in practice in an emergency, resource constrained environment?

The Guidance describes the principles of Respect, Fairness, Minimising Harm, Working Together, Flexibility and Reciprocity, but again one is left asking what it means to state that

‘Patients should be treated as individuals, and not discriminated against.’

Perhaps more challenging is the statement:

‘No active steps should be taken to shorten or end the life of an individual, however the appropriate clinical decision may be to withdraw life prolonging or life sustaining treatment or change management to deliver end of life care.’

Thirdly the use of certain phrases beg more questions than they deliver answers:

‘Where there are resource constraints, patients should receive the best care possible, while recognising that there may be a competing obligation to the wider population.’

‘Under normal circumstances, these decisions would be made of the basis of patient choice and anticipated clinical benefit to the patient. In the context of increased demand, it may also be important to consider fairness of healthcare distribution within the wider population.’

What in this context is meant by the ‘competing obligation of the wider population’? If we are to supplant patient choice and anticipated benefit for an individual what does ‘fairness of healthcare distribution’ actually mean not just at a theoretical level but in raw reality for individual citizens? Care is to be rationed- I can understand – but ethically what does the needs of the majority mean for the care of the vulnerable minority?

Fourthly, I am really concerned that issues of equality and human rights are mentioned explicitly only in two footnotes. I have stated before that Scotland should be rightly proud of its articulate defence of the human rights which have framed both our legal and parliamentary process, not least since Devolution. To present a document which articulates some of the most challenging ethical choices of our generation, perhaps of any time since the Second World War, and to have that devoid of a robust human rights articulation is wholly inadequate. How are we going to make an ethical decision which upholds the right to life and the right not to be subject to inhumane and degrading treatment? How is the State going to fulfil its duties to the Human Rights Act or the European Convention of Human Rights? I see no robust articulation of this within this document. If human rights are to be more than rhetoric in easy times they have to be real in hard times.

All this matters a great deal and it matters now.

Already we have stepped into questionable territory.

I can fully understand that for many frail and older people who develop Covid19 in a care home that the best place for them to be supported is within the care home, that transfer to an acute setting is likely to be over traumatic and result in little effective clinical outcome.

I can accept and know at first hand the astonishing professionalism around palliative and end of life care delivered in Scotland’s care homes which makes them in ordinary time hospices in the heart of our communities.

What I am deeply uncomfortable with is a blanket presumption that there will be no transfer of any individual (except in the instance of large-scale fractures) from a care home into the acute context. This leaves me disquieted because it presumes that all individuals within a care home are old and frail and it assumes a sufficiency of resource in care homes which would potentially enable some individuals who have a severe infection to respond well.

What I am equally appalled by in the last few days is the numerous instances of DNACPR being demanded as routine and automatic from care home residents by some general practitioners up and down Scotland. Quite rightly the Chief Medical Officer has robustly challenged this.

I am equally dismayed at the number of GPs who have in recent days intimated that they will not visit care homes. I fully understand that the risk of infection has to be taken into account but a presumption of non-attendance to meet the needs of individuals, even with the best use of video diagnostics, is wholly unacceptable.

If equality of access and treatment mean anything then we must not abandon our care homes, their residents and staff to an unequal level of clinical support.

The next few days and weeks must surely be those where both the clinical community and wider Scottish society needs to have a proper debate about ethical treatment and care in the face of reduced resources. It is simply too important a set of decisions to be left to a document which though it tries hard is too subjective, too generalist and lacking in a foundation of human rights and equality.

The way we respond to harrowing issues of choice will determine the society we will be as a nation after Covid-19. In Mandela’s terms decisions which are potentially based upon an over-reliance upon age and do so in a discriminatory manner endanger the rootedness and the future of the whole of our society. I trust that over the coming weeks by our actions and decisions we will all create a future we will be proud of.

Dr Donald Macaskill

Criminal record checks for coronavirus (Covid-19) response workers

Disclosure Scotland will prioritise checks for the workers Scotland needs to deal with the coronavirus, they will prioritise roles in the sectors:

  • Healthcare
  • Phamaceutical
  • Childcare
  • Social work
  • Social care
  • Prisons and justice

Urgent applications for priority roles

Ministers have suspended fees for urgent disclosures. You do not have to pay for forms emailed before midnight on 11 May 2020. 

Use these forms to apply for urgent disclosures in the priority sectors:

Organisations must have their countersignatory send applications. You cannot apply by email on behalf of a countersignatory.

They are not taking any paper applications. Email completed forms with the cover sheet to [email protected].

You can follow this website for more updates: https://www.mygov.scot/coronavirus-disclosure/

 

Disclosure Scotland helpline update – 27 March

Unfortunately due to the impact the COVID-19 situation has had on the business and the high volume of priority applications for critical sectors, we made the decision to temporarily close the helplines in order to maximize the number of staff processing applications.

You can prioritise any critical role applications already submitted by emailing the details, including barcode & ‘role applied for’ to our COVID Priority mailbox; [email protected]. NB General enquiries and application updates will not be handled via this channel.

Any other enquiries can be sent our normal enquiry mailbox; [email protected].”

Whilst we anticipate this situation temporary it is the channel we are signposting customers to at this time. We thank our customers for their patience during this on-going difficult situation.

Regards

Jillian [Customer Engagement Manager]

Disclosure Scotland applications update – 27 March

Scottish Care has received the following letter from Disclosure Scotland with a Covid-19 update on PVG applications.


Disclosure Scotland is making a temporary change to how applications are processed.

We have been working closely with the Scottish Government and key stakeholders on our response to coronavirus (COVID-19).

In addition to our prioritisation of checks for those who have the most vital roles supporting the country during this time, as of Monday we will no longer be accepting paper applications.

On Monday (30 March) a new page will go live on our website with all the materials you need to continue to submit applications.

Please note; this process should only be completed by countersignatories.

  • you can submit an application via email using the template on our website
      • electronic signatures (typewritten or scanned) from the applicant and countersignatory will be accepted
  • we will process the application through a priority service
  • where possible we will email you a notification of the outcome, prior to receiving the paper certificate in an expedited timeframe
  • when this is not possible there will be two other outcomes:
      • you will not receive any advance notification and will have to wait on the paper certificate which will still be in an expedited timeframe
      • you will receive a notification advising that we are unable to prioritise your application at this time and will be unable to give a timescale for completion

If we do not send you a disclosure, either by email or certificate, please do not assume this is because we are late or have made a mistake. A small number of applications need us to be fully operational to process and that is impossible at this time. At this critical time, we are providing a safeguarding service to ensure the vast majority of applicants can get cleared to help with coronavirus.

If you are submitting urgent applications related to coronavirus in the following weeks please contact our dedicated helpline on 0141 302 8511. We will want to plan with you how we go about doing this most efficiently.

As it stands the list of prioritised roles remains:

  • Healthcare
  • Pharmaceutical
  • Childcare
  • Social work
  • Social care
  • Prisons and justice

As the situation develops and evolves, the list of prioritised sectors may change as Disclosure Scotland identifies other sectors with roles critical to supporting the Scottish Government during this crisis.

Thank you for your patience during this critical time,

 

Gerard Hart

Chief Executive

Disclosure Scotland – Further guidance during Covid-19 on PVG applications

Please see below for latest guidance from Disclosure Scotland on PVG applications during Covid-19


In relation to identity for PVG’s I have included the details provided in the DS Code of Practice below regarding identity. The guidance states that originals seen are better but ultimately it is for the organisation to determine the process they use and naturally given the current situation to physically see a person’s ID would be against the greater good of the current crisis and against government guidance so the proposal to scan seems very sensible.

Employers must satisfy themselves of the identity of those applying for positions or those already employed who are, for example, joining the PVG Scheme for the first time. Although Disclosure Scotland will conduct its own identity checks, these should be supplemented by the checks undertaken by organisations and employers. Whilst Disclosure Scotland may have a record of the types of documents which were viewed for identification purposes, it is recommended that employers retain details of identity checks undertaken in case of further enquiry by Disclosure Scotland.

Those countersigning or making a declaration on disclosure applications or requests should encourage those involved in the recruitment process to ask for documentary evidence of identity from individuals. It is required that three pieces of information are requested to support identification. Where possible one of these should be photographic (for example, a current passport, new style UK driving licence, a Young Scot card or a National Entitlement Card, etc.). One item of address related evidence containing the name and address of the individual and one item confirming the date of birth of the individual should also be sought. In the absence of photographic evidence, a full birth certificate with a date of birth confirmed will carry more weight than a copy issued more recently. Consistency between the supporting information and the information provided by the individual in his or her application or request tends to lead to a greater level of confidence in their identity.

Where an individual claims to have changed his or her name by marriage, common law relationships or any other mechanism, the employer should seek evidence of such a change.

A disclosure certificate or record issued by Disclosure Scotland must not be taken as evidence of identity.

Individuals who were born outwith the UK or who have lived outwith the UK

There are two issues to be considered regarding the appointment of individuals who were born or who have lived outwith the UK: the first relates to the identity of the individual and the second relates to checking his or her criminal record.

With regard to the identity of the individual, employers should take particular care during the recruitment process, ensuring they follow up references and undertake other relevant checks before making an appointment. Consideration should still be given to the information described above, albeit this will relate to foreign documents.

Registered persons should still request a criminal record check for an individual with no, or very little, address history in the UK. While it may seem to be of limited value to obtain a disclosure for such an individual, under the 2007 Act the individual will become a scheme member and subject to continuous updating which will provide reassurance that the individual is not barred from regulated work and ensure that a registered person will be notified if the barred status changes.

Employers can ask prospective employees and existing members of staff to provide a criminal record certificate, where available, from their government or an appropriate government/police agency in the country where they were born and or resided.

It is suggested that the onus is put onto the individual to provide details of their criminal conviction history from their home country or countries of previous residence. It should be remembered, however, that these may require to be translated from the relevant language into English and they may contain details of offences which may not have a direct equivalent or similar offence in Scots law. Disclosure Scotland has no role in this process and the individual or the employer has to meet any additional cost.

 

 

Disclosure Scotland update on PVG’s

Please see below for update from Disclosure Scotland regarding PVG’s during the Covid-19 pandemic. 


Disclosure Scotland is working closely with the Scottish Government and key stakeholders on our response to the COVID-19 pandemic. We have invoked our Business Continuity plans to prevent any disruption to our safeguarding services at this time of crisis.

We will prioritise checks for those who have the most sensitive roles in supporting this crisis. The criteria for prioritisation is based upon the role, namely:

  • Healthcare
  • Pharmaceutical
  • Childcare
  • Social work
  • Social care
  • Prisons and justice

Disclosure Scotland recognises the urgency in the current situation. If you have urgent applications that need to be prioritised because of COVID-19 please contact us on [email protected] with the application barcode and ‘position applied for’ – please ensure that you only use this email for critical applications, submit other applications in the normal way. When sending an urgent application through the post, please ensure the envelope is marked ‘urgent’.

If you are submitting urgent applications related to COVID-19 in the following weeks please contact our dedicated helpline on 0141 302 8511. We will want to plan with you how we go about doing this most efficiently. We are actively planning ways to be even more responsive to this crisis and we will keep our customers informed about any changes we are making to the PVG process.

To ensure Disclosure Scotland can rapidly react to the changing environment, the UK Coronavirus Bill introduced into the UK Parliament yesterday contains two provisions about the PVG Scheme.  The first provision means organisations recruiting staff ahead of a PVG check can do so without the risk of committing an offence. Barred individuals who seek to exploit this will be reported to Police Scotland. The second change will allow Disclosure Scotland to process all PVG disclosures as if a check of the UK barred lists had been requested. Once these changes have been brought into effect, Disclosure Scotland will engage with stakeholders, setting out what they will mean in practice. 

As the situation develops and evolves, the list of prioritised sectors may changes as Disclosure Scotland identifies other sectors with roles critical to supporting the Scottish Government during this crisis.

Thank you for your patience during this critical time

‘Directed by North Merchiston’ – five extraordinary films with care home residents

Scottish Care is privileged to have been involved in this innovative project with Luminate and film maker Duncan Cowles

‘Directed by North Merchiston’ is a series of short films by Duncan Cowles in conjunction with residents of Four Seasons’ North Merchiston care home in Edinburgh.

The project was the brainchild of Duncan Cowles, a BAFTA Scotland Award winning documentary filmmaker.  He said:

“One of the biggest issues for older generations today is loneliness. I wanted to give the residents of North Merchiston Care Home a voice. So, instead of me coming in with my camera and making films about the people living there, I wanted the residents to think of themselves as the filmmakers and develop the stories they’d personally like to tell.”

The project was commissioned by Luminate, Scotland’s creative ageing festival, and was supported by Scottish Care.  The films had their first screening in front of North Merchiston residents, families, staff and project partners as part of the Luminate festival in October.  Some of the films were also shown at Scottish Care’s annual Care Home Conference in November 2016.

**Please note, one of the films (Keep Your Eyes Open and Your Mouth Shut) can only be viewed by entering a password on the Vimeo site. To be sent the password, please contact [email protected] **

 

Take part in Arts in Care – Luminate’s creative project for care homes

Background

Arts in Care is an ambitious new project developed by Luminate in collaboration with the Care Inspectorate, Creative Scotland and the Baring Foundation. The aim of Arts in Care is to embed high quality arts in care activity across Scotland, with a long-term aim to build the skills, capacity and strength of both the arts and care sectors. Artist training and professional development will run alongside a creative programme for residents and staff in 30 care homes across Scotland.

Opportunity for Care Homes

Luminate are now inviting care homes for older people to apply to take part in this project.

Each selected care home will host an artist to deliver 5 half-day creative sessions with residents and staff at no financial cost to the home. This activity will take place between February and May 2020, with dates and times to be agreed between participating artists and care homes.

30 care homes for older people from across Scotland will be selected, they are looking for a group of homes with a range of different attributes - urban and rural, mainland and islands, homes of different sizes and with different governance structures (local authority, private, voluntary/not for profit organisations); as well as a diversity of experience delivering creative activities.

Embedding creativity in care settings has been shown to be hugely beneficial to residents and staff, improving wellbeing, providing opportunities to socialise and to learn skills, as well as helping people living with dementia. There are already many examples of fantastic creativity happening across the sector, however we acknowledge that there can be barriers to facilitating such activities, whether that is due to limited resources and training, or the challenges of meeting the specific needs of individuals amongst a large group.

This project aims to build capacity, skills and confidence of the care sector through learning opportunities and knowledge exchange between artists and care staff.

Each selected care home will receive:
• 5 x 1/2 days of high quality creative activity delivered by skilled artists, at no cost to the home.
• Opportunities for residents, staff and managers to engage in activities to develop skills, confidence and creativity.
• Participation in a Scotland-wide project with ambitions for long-term impact on the sector.

Each participating care home will commit to the following:
• Care home manager and other staff will meet with the artist in advance, to help him/her plan the project. Activity coordinators are also welcome if there is one.
• Care home staff will support residents’ engagement with the creative activity during each visit.
• Supporting staff and managers to participate in sessions to enhance their own learning and development
• Care home manager and other relevant staff will contribute to the evaluation of the project (an independent evaluation body is to be appointed, and will produce an evaluation report which will be published at the end of the project).
• Please note that you must seek permission from residents/family members before consenting to take part in this project as photographs, filming and other collection of data may take place.

Selection criteria

Please note that this opportunity is open to care homes who achieved grade 3 or above for all five key questions at their last inspection. If not all key questions were inspected against please use the grade from a previous inspection.

• How well do we support people’s wellbeing?
• How good is our leadership?
• How good is our staff team?
• How good is our setting?
• How well is our care planned?

Successful care homes will be able to demonstrate:
• How you will maximize the potential impact of the creative project in your care home.
• How you will support the artist and participating residents throughout the project.
• How you will support staff to participate meaningfully in the project and any activity.

Please note that the final selection will take into account the need for a geographical spread and mix of urban and rural locations, as well as a diversity of scale and governance and experience of supporting creative activity. The Arts in Care project will be supported by an Improvement Adviser from the Care Inspectorate.

How to apply

Interested care homes should:
• Apply in their own words as to why the feel their care home is suitable for this project, with particular emphasis on why they feel the arts are important to their residents and to overall wellbeing outcomes.
• Please include general (not confidential) details of any particular health needs of your residents that may need to be taken into account.
• Please include details of the expected number of residents taking part and any issues around space or facilitation.
• Include all this information in either one Word document or a PDF.

Please email your application to Lisa Maynard, Improvement Adviser, Care Inspectorate at [email protected] with ‘Arts in Care: Care Homes Opportunity’ in the subject line

All applications must be received by 23rd October at midday.

Applications will be reviewed by a panel comprising representatives from Luminate, Creative Scotland and the Care Inspectorate.

If you have any enquiries about this opportunity, please contact Lisa Maynard, Improvement Adviser, Care Inspectorate, ahead of the deadline: [email protected] / 01382 207393 / 07970405050.

Update Piece on Arts in Care (002)

 

‘Always caring, always nursing’ celebration

This year marks 100 years since the establishment of the Nurses Registration Act 1919. This act brought together nurses under one profession in the pursuit of ever-improving care and greater trust from the public. The Nursing and Midwifery Council (NMC) is honouring this historic occasion through the 'Always caring, always nursing' celebration, which celebrates the expertise, experience and knowledge that nurses have which makes them the most trusted profession in the UK.

The celebration started on the Saturday 14 September 2019 and will last 100 days, with a range of different activities and events planned overthe Autumn months.

Throughout the 100 days, nurses are encouraged to share any interesting or inspiring stories that NMC could use on their website, blogs, social media, videos and news articles.

Do you know anyone with an interesting story? It could be about their professional journey, or something outside of work that brings to life what nursing means. Do you know someone who has come from a long line of nurses? Or maybe you know an inspirational nurse who has gone above and beyond to deliver exceptional care?

If you know anyone who you think embodies what being a nurse is all about, you can either get in touch by emailing [email protected] or by visiting NMC'S website website and submitting their story online here:  https://www.nmc.org.uk/nursing-stories.

Nursing has always been vital for the care home sector, with over 5,000 nurses employed by Scottish Care member organisations across Scotland. These individuals are key contributors in the delivery of quality, person-centred care and support to some of our most vulnerable citizens. Therefore, Scottish Care strongly encourages you to take part of this 100 day celebration, and help raise awareness and recognise the professional pride and important role nurses play in our society.

For more information please see: https://www.nmc.org.uk/always-caring-always-nursing/