Overview of selected research: Background

'Modernising social services' (DH, 1998) set the tone for the future by acknowledging the importance of dignity for all people using services. The NHS Plan followed in 2000 by including a chapter on 'Dignity, security and independence in old age', and many subsequent documents developed the theme. The National Service Framework (NSF) for Older People (DH, 2001), for example, which established a ten-year service development programme, 'was triggered by concerns about widespread infringement of dignity and unfair discrimination in older people's access to care'. Opportunity Age (DWP, 2005), the strategy for improving services for older and more vulnerable citizens, also highlighted the need to continue the fight against ageism and age discrimination, and defined one of the principles of service provision in terms of older people's entitlement to dignity, respect, freedom from abuse and good-quality care.

Health services, in partnership with social services and other agencies, will need to recognise the specific needs of older people in caring for them:

  • demonstrating proper respect for the autonomy, dignity and privacy of older people
  • treating the person, not just the most acute symptoms, by taking account of the full needs of older people, including the importance of good nutrition. and enabling the older person to remain as active as possible while in hospital
  • making high-quality palliative and supportive care available to those older people who need it
  • ensuring good clinical practice which recognises the complexities of caring for older people.

NHS Plan, Ch.15

Following an extensive review of the implementation of the older people's NSF in 2006, the next stage was deined in terms of three campaigns: dignity in care, joined-up care and healthy ageing (Philp, 2006). Ten programmes of work were launched within this framework, including a Dignity Programme focusing on nutrition and the physical environment, the workforce, inspection, dignity and mental health, dignity at the end of life, equalities and human rights, and raising awareness and championing change. In addition, a second programme of activities focused specifically on Dignity and the End of Life.

For the NHS, the Healthcare Commission 'decided to focus on 'dignity' as a key theme in the annual health check for 2006/2007'. The report, based on targeted inspections of acute trusts found encouraging evidence of increased awareness among managers and practitioners, but plenty of room for improvement (Healthcare Commission, 2007). From 2007, dignity has featured in the performance management of local services. The five-year strategy for improving health services, NHS 2010-2015: From Good to Great (PDF file), included a statement of patients' rights contained in the NHS Constitution, and number 11 in the list reads: 'You have the right to be treated with dignity and respect, in accordance with your human rights'. In the same month (December 2009) the NHS Operating Framework for 2010/11 (PDF file) was published . This set priorities and performance indicators for the NHS, and a 'patient and user reported measure of respect and dignity in their treatment' is among the 'vital signs' listed for local action.

Towards the end of 2006, DH launched the Dignity in Care Campaign designed to stimulate discussion and awareness of the need for dignity in health and social care across the country. By 2010, a network of more than 12,000 local Dignity Champions had been established. A review of the Campaign in 2009 found that the campaign had indeed had an impact on the ground, increasing the priority given to dignity issues, stimulating useful local activities and promoting a common understanding of what dignity means in the context of care (DH/Opinion Leader 2009) . At the same time, all available sources of dignity-related data for health and social care services were brought together in a report on systems of measurement ('metrics'). This was able to draw some positive conclusions but recommended that it should be used primarily as a benchmark for future studies (NHS Information Centre, 2009).

Similar themes have appeared in documents by a range of agencies. They deal with all services for older people (Audit Commission, 2004) housing and housing-related support (Housing Learning and Improvement Network, 2006) mental health services (Care Services Improvement Partnership, 2005), consent to treatment: standards in care homes (DH, 2004a), social exclusion (SEU/Office of the Deputy Prime Minister, 2006) and so on.

Towards the end of 2006, DH launched the Dignity in Care Campaign designed to stimulate discussion and awareness of the need for dignity in health and social care across the country. By 2010, a network of more than 12,000 local Dignity Champions had been established. A review of the Campaign in 2009 found that the campaign had indeed had an impact on the ground, increasing the priority given to dignity issues, stimulating useful local activities and promoting a common understanding of what dignity means in the context of care (DH/Opinion Leader 2009). At the same time, all available sources of dignity-related data for health and social care services were brought together in a report on systems of measurement ('metrics'). This was able to draw some positive conclusions but recommended that it should be used primarily as a benchmark for future studies (Analysis of dignity metrics (PDF file), NHS Information Centre, 2009).

Similar themes have appeared in documents by a range of agencies. They deal with all services for older people (Audit Commission, 2004) housing and housing-related support (Housing Learning and Improvement Network, 2006) mental health services (Care Services Improvement Partnership, 2005), consent to treatment: standards in care homes' (DH, 2004a), social exclusion (SEU/Office of the Deputy Prime Minister, 2006) and so on.

In March 2006, Sir Derek Wanless completed his Social Care Review (Wanless, 2006) for The King's Fund. This used the idea of dignity in care as one criterion against which the relative fairness and value of different funding systems for future social care for older people should be judged.

The Royal Colleges have collaborated in producing practice guides on a range of dignity-related topics. The Nursing and Midwifery Council UK code of practice begins: 'To justify that trust, you must make the care of people your first concern, treating them as individuals and respecting their dignity; while the International Council of Nurses Code of Ethics 2006 declares that, 'respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect,' is fundamental to nursing.

Voluntary organisations have based campaigns around the idea of dignity in care: for example, Age Concern and Help the Aged (now joined forces as 'Age UK') have both pursued campaigns throughout the decade, and Help the Aged has recently supported detailed work on identifying indicators for measuring dignity (Magee et al., 2008; Picker 2008).

In the international field, both the World Health Organization and the Organisation for Economic Co-operation and Development have called for healthcare systems that promote the dignity of older people, while the same principles are upheld in the work of the EU's European Social Network. AGE - the European Older People's Platform - is developing a Charter of Rights for older people who need long-term care as part of the EU Daphne Programme. Article 1 of the 2008 draft covers the 'right to dignity, physical and mental integrity, freedom and security'.

International awareness of and interest in the theme is also demonstrated by the research literature which will be considered next. Research has analysed dignity in care - the term itself, what it means to older people and their carers, and the care professions working with them, and what the implications are for care of all kinds.