Fighting Monsters

Today is the 60th anniversary of the founding of the National Health Service.

There has been a lot of coverage over the last week in every kind of media source to commemorate this.

From finding people born on the same day to relive their lives through access to the health system to much polemic and debate about restructuring and restructuring again.

A look at the past - and a look at the future in the face of the recent reviews that have come out.

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I don’t think I can add anything new to what has already been said - but in some ways, having been born into and grown up with the system as is, I find it hard to imagine things any other way.

I expect to go to the doctor without thinking of cost.

I expect to get a prescription for medication that I need (and still pay my fixed fee for it!).

I expect to be referred to secondary medical services if and when I require.

I am fortunate to be and to have been in good enough health that I can’t  ever remember  having been in a hospital overnight - a few visits to casualty here and for minor stitching ups really is about as far as it goes.

I have family members who have been recipients of a great deal of care of an exceptional quality - and of course, now, I work within (although not for) the health service.

There are likely to be many changes in the future as the health needs of the population change. Introduction of ‘market forces’ has already started. Management layers are added and exist to increase the drive towards efficiency.

Always new restructuring, always new developments.

Expectations of what a health service can and should deliver are changing too - and this monolithic structure - oft-quoted as being the third largest employer in the world - does need to adapt.

But I think she’s not been doing at all badly, when all’s said and done.

And here’s to another 60 years and many many more beyond.

Happy Birthday - and at some point today, I’ll raise a glass to Nye..

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And in other, marginally connected news, The Guardian in its Work and Careers section, spotlights a Social Worker (marginally connected because she is a hospital social worker!).

Earlier in the week,  as a result of the Care Ambassador scheme that I am a party to,  I  had a meeting with a someone from  Skills for Care who is involved in setting up some of the meetings and training sessions with schools.

The Care Ambassador scheme is something I had been involved with for a few years, although somewhere along the line it has changed from the Health and Social Care Ambassador - but the Health part seems to have fallen along the wayside  - my guess would be something to do with the funding being provided now from Skills for Care.. with the changes to the way that its being run it has been relaunched now - hence the meeting.

The idea of the scheme is to promote careers in Social Work and Social Care to younger people who might not have even considered it as a career path.  It is part of a longer term strategy to bolster up an ageing (thanks!) workforce and promote positive images of social care and particularly career opportunities that are available in social care to people who might not  have even considered it as an option.

One of the things we were discussing was things about the career that I found to be positive - and I almost surprised myself by the ease in which I was able to reel off the things I like about my job.

I also had to write a short piece that will potentially distributed to the kids that I work with about myself, my own career path. I was asked where I wanted to be in five years time.

I gulped. I know I was probably expected, in the context of this being about promoting career paths and wanting kids to ‘aim high’  to say that I wanted to be some kind of manager. I really don’t though and couldn’t bring myself, in all honesty to put that down. In the end I said I’d like to see myself doing the same thing that I’m doing now - because its true - possibly in a different setting or a different area - but not fundamentally different. Or some kind of academic work - research or teaching.

I also needed to come up with some ‘interesting’ facts about me that might spark interest.

The woman I was speaking to was giving me examples about all the strange and exciting things other people had written, one, she said, had worked for the Queen at Buckingham Palace. Another had been skydiving.

I tried to wrack my brains for ‘interesting-things-I-have-done’ and offered up a rather pathetic story about an old and rather uninteresting summer job I’d had one summer at school.

And then, as we moved onto other topics, I realised I’d completely forgotten to mention my I’m-quitting-my-job-and-grabbing-a-random-flight-to-the-sun moment a few years  back which resulted in a two year ’sabbatical’.  But that’s a story for another day - sometimes it takes effort to remember I’m perhaps not as dull as I think I am!

It’s an interesting programme and I like the idea of it. As I said to my manager yesterday, I think it’s a good thing for me to do because I have to remind myself frequently about the genuinely positive reasons I do the job and why I chose it. Also, on the basis that I’m going into exclusively inner city schools (we ‘operate’ in the area in which we work)   I think there really are opportunities in the sector that people might not know about.

As I was told, some of these kids (and not just kids!) might have very poor ideas of what social workers are and what they do.. so its a chance to at least change some of those perceptions.

Variety is the spice of life, so to speak and it keeps things interesting for me too, as, I noted in the piece I wrote - one of the things I like about the job is that every day is different..

So, a week from the start of my journey into a Direct Payments referral and I have sent the appropriate forms, documents and paperwork to the appropriate people.  The figures are being checked and the amount that has been requested matched up against  the Fair Access to Care criteria along with a brief (at this stage) breakdown of what each minute paid will be used for.

As is ironic the person to whom I sent them is  on holiday - but this is not ‘urgent’ so it will wait. I doubt that a week or two will make much difference in the long run. So possibly no update next week!

I have asked the daughter to open a separate bank account for her mother - I like to get this done as quickly as possible. We have some pro-forma letters to send to banks to request that the facilitate the opening of a bank account and don’t perhaps, use the usual criteria that used to make opening a bank account quite difficult for some users. The letter is a result of some consultations between the council and the banks.

The Consumerist at Flickr

We also had a very very brief chat about the process of employing a carer.

As for the Carers DP, that has a different path for authorisation. I updated the Carers Care Plan and Assessment sent it to someone else who coordinates carers services to request payments.

Meanwhile, in a somewhat timely manner, The Social Work Blog writes about a GSCC consultation regarding the regulation of personal assistants who are employed by users of Direct Payments.

Up till now, employees of Direct Payments users have not been required to have the Criminal Records Bureau checks required of all over professionals in the social care sector.

This was partly to allow for a more flexible approach to be taken to employments by users and to cut through some of the ‘red tape’ that might prevent users from employing whoever they want.

Personally, I think that’s all very well for some users who are able to  manage and organise the direct payments but for me, it adds another layer to the barrier to being able to wholeheartedly run with direct payments when working with a more vulnerable user group - particularly, I’m thinking of older people.

I have to claim having a slight vested interest in the debate.

My father is uses direct payments and employs carers directly - he has had directly provided services (without too many details, he has been a user of social services care for many years) and he now has, and has had a direct payments care package for a number of years.

He has currently and has been lucky to have almost consistently, a number of exceptional carers - some of whom I’d like to poach for service users that I work with, but I don’t think he’d forgive me!

But I want to know that he has safe carers. That it isn’t a case that anyone can look at an advert in a newsagent and reply and be working in the home of a vulnerable elderly (sorry dad!) person within days.

Sometimes when I’m at work, people might see me as a detached professional without possibly knowing that I have had quite a lot of experience as an indirect recipient the other end.

And that’s what  I mean when I judge the services I provide against ‘Would I want my dad to go here/get this/have this service?’ It isn’t quite as theoretical a question as it might sound..

Both The Times and The Guardian reported that Southern Cross Healthcare Group have been launched into some kind of financial crisis following the failure to repay a loan of some £46 million.

Times are getting harder and a lot of firms are failing - but Southern Cross are the largest provider and operator of Residential and Nursing Care  Homes in the UK.

I actually have to say I have had no dealings at all with Southern Cross in the years I’ve been working. So can say neither good nor bad things about them from personal experience.

But just putting a few pieces of very rudimentary information together

The Guardian quotes the company spokesman as saying that the reasons for their financial difficulties are

.. tighter local authority spending for a period of disappointing occupancy rates. High fixed costs and disappointing occupancy rates meant Active Care in particular was performing “significantly below forecasts”. The company also said occupancy levels had been hit by several unexpected deaths of residents in its homes for the elderly.

I was going to say that I’m no cynic, but that’s probably not true - I was reminded of a story I wrote about at the beginning of May where CSCI (Commission for Social Care Inspection) criticised a Southern Cross Care Home for having poor basic dementia training among other things.

You’d think though, that a large company like this would have contingencies for ’several unexpected deaths of residents’

I know the previous time I wrote about Southern Cross it was in the context of a freeze on placements to a particular home following a poor CSCI report and the death of one of the residents. Disappointing occupancy rates? Quite possibly.

It’s strange that The Financial Times reported back in May that

‘The group has increased the cost of staying in its homes over the past six months, agreeing fee rises of 5 per cent on average with 85 per cent of its local authority customers.’

which is, more or less, in line with inflation and certainly higher than my proposed salary increase this year (!) so, less than six weeks later to blame failings on

‘tighter local authority spending’

seems more than a little churlish.

It seems one of the business practices of Southern Cross was based around building property to lease it back and making its profit partly on property portfolios and management.

The Times quotes the Chief Executive saying

“The care homes sector is cyclical and the cycle has turned down. The margins of two or three years ago will likely be squeezed and fall at least 5 per cent in the next two years.”

I am no accountant but surely cyclical also means, to some extent predicable.. basic kind of saving-for-a-rainy-day type stuff.

Anyway, I am the last person who should really be commenting on Southern Cross’ business model. My idea of wise investment is an instant access savings account.

But I can’t help but wonder what the implications will be for people who are in the residential homes that are failing.

A large proportion of care services,  both residential and domiciliary, has been out-sourced to private companies who have many different interests at heart not least, shareholders.

If they see a death as ‘a disappointing occupancy level’  and lurch towards crisis when there is a cyclical downturn it doesn’t really augur well for planning long term care.

Anyway, at least two of the execs who were in charge of running the company managed to sell their own stock when they were at a high of 550p in December before leaving the company..

The stock fell to 130p yesterday.

And other factors that don’t endear the company, which again, I have had no personal contact include one which was highlighted by Mental Nurse back in April indicating that they were involved in the landmark decision in the High Court which ruled that Care homes can evict residents by being the owners of the Care Home that was trying to do the evicting..

This is also the same Southern Cross that opposed the payment of £7.02 per hour for Senior Care Workers - many of whom were from the Philippines and were refused visas to stay on the basis of the wages that they were receiving - thus being deported.

It doesn’t get much better for Southern Cross (isn’t Google a wonderful thing) as, The Times says again, in another article that

‘In November, The Sunday Times conducted an undercover investigation, with a reporter posing as a carer, and documented a series of alleged abuses and said the home was under-resourced and understaffed.’

At, yes, a Southern Cross Home.

Between deaths, attempted evictions, seemingly poor payment and treatment of staff and undercover reporting that proves, if more evidence were needed, that there is a poor quality delivery of care due to understaffing and under-resourcing.. it is a little clearer why there might have been underoccupancy.

I’m sure in such a large company there are some good quality care homes among there somewhere but reputations do stick when placements are being made - I certainly know there are some companies that I am less likely to make placements with than others, on the basis of how some of the different homes that they own are run - rightly or wrongly you can’t take chances when you are choosing the place that someone is likely to be living for the rest of their life.

But at least some of the executives got out at the top..

I just wonder how this leaves and will leave those who are receiving the services at the moment.

I work in the inner city and have since I did my first practice placement in the first year of my social work course almost 10 years ago now.  For as long as I have been working as a social worker , I have only ever worked in the inner city - different parts of it granted but its what I’m used to and what I know.

While most of the work is in the overcrowded tower blocks that circle the main business districts and higher class shopping areas of the city - neither mental  illness nor old age spare any income bracket or social class.

So yesterday, I found myself in a house that I had to seriously brace myself before entering - and not in the way I’m accustomed to. I am no estate agent, but the size and location would put a fair multi-million estimate on the property.

Inside though, the issues, pain and confusion were the same as those I see in the high rises that are less than a mile away.

Mr A has dementia and goes for his walk in the local area. Mrs A lives with the fear that every time he goes out he won’t be able to find his way home or he gets on buses and ends up the other side of the city.

She surruptiously (as he won’t tolerate identity bracelets or pendants) sticks a label with his name and address on the inside of his jacket when he leaves - just in case. Every day.

They are and have been a very close couple. Now, Mr A won’t see anyone else. I got in because I said I work with the doctor (who had been to assess him previously and asked me to follow up)

Mr A with his confusion is still of an age that equates ‘what the doctor says’ as being irrefutable.

But Mr A won’t let his family visit anymore. He doesn’t like Mrs A going out without him and she doesn’t like leaving him alone.

She told me about the loneliness she felt. Not being able to have her family visit. She told me of a completely different Mr A before the dementia  had taken hold who used to love chatting with his daughters and having the grandchildren and great-grandchildren come to play in the garden.

She wanted him back but over the years had become resigned to the reality of the current situation.

Now, she just wanted to a break.

When I explained to her about the provisions of regular residential respite care she almost snatched my hand off. I ran through a list of the local carers groups and user-led groups that I felt would be helpful. Possibilities of practical things that could be done and help that could be offered.

We ran through the possibilities of domiciliary respite care (where someone comes into the home and provides a sitting service)  and various telecare devices which can provide some reassurance.

This is a situation that is far from uncommon for me and often, when I visit following a medical assessment or diagnosis of dementia, I will be the first ‘face’ of social care than a family have ever been presented with.

And as I was talking, I was aware of my own assumptions - going into a truly palatial home isn’t what I am used to. Perhaps I used to make more assumptions about the way people live and what needs are there.

But really, the work is exactly the same. The needs are still there and the pain and confusion is still there.

I know I wasn’t really expecting it any other way, but sometimes when you walk through those kinds of houses in those kinds of areas and you glance into the windows and wonder what it would be like to live  that way, usually with some wistfulness  - the people inside the houses do live, breathe, worry and feel in the same way - they get old and grow ill in the same ways.

They just probably don’t have to make the judgements about the loaf of bread or the extra winter heating so often…

The new president of the Royal College of Psychiatrists, Professor Dinesh Bhugra, will according to the Guardian use his inaugural speech to lament the problems caused by the shortage of acute psychiatric beds in the system.

This is something we hear a lot about, and indeed, something described on There and Back Again’s blog about waiting for a hospital bed as an inpatient on leave when the ward is running a 150% occupancy rate recently.

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Bhugra suggests that

No ward should ever be more than 80 per cent full if patients are to be safe, properly treated and cared for.

and while the sense of this can be obvious, it is rarely, if ever, the case in practice - or certainly isn’t in my own, admittedly limited, experience.

So something has to be done and Bhugra has a suggestion

‘ (Bhugra)..  is calling on the government to introduce a compulsory kitemark system of accreditation for all acute, inpatient psychiatric wards: ‘Until there is a compulsory kitemarking scheme, my prediction is that, as overcrowding increases, funding becomes more stretched and morale of patients and staff fall, overall conditions are likely to continue to deteriorate.’

Interesting. I know I rant against target-based practice but in can work in some areas. Perhaps if Trusts are told that funding will be cut or increased on the basis of their ability to find these beds - or that the levels of occupancy will be monitored by the Mental Health Act Commission and there will be financial penalties for applying poor standards - there will be more incentives to hospital managers to actually work on a solution - which doesn’t seem to be being done at the moment.

This Kitemark would measure against other standards such as staffing ratios as well and, indeed, in another article in the Guardian which focuses on current inpatient care, a spokesman for MIND says

‘A compulsory kitemark is a fantastic idea; these wards slip under people’s radar and that’s dangerous,’ she added. ‘When patients are sectioned, they literally have no choice at all about where they go. This makes it vitally important for society to be 100 per cent aware if these vulnerable people are ending up in wards where conditions don’t meet the minimum acceptable standards.’

Beds have been reduced as the focus has been on community care but the fact remains that some people need inpatient care and there isn’t always a reasonable substitute.

And with the incoming President of the Royal College of Psychiatrists in stating that

‘Acute psychiatric wards are now so poor, he (Bhugra) has admitted in an exclusive interview on the eve of his appointment, that he would not use them himself - nor allow a member of his family to do so.’

That is, perhaps, the saddest indictment of all.

Its pleasing that at least the situation is getting some more attention and will get even more when Bhugra actually makes his speech on Wednesday but one of the criteria that I have consistently tried to work on when considering placements for residential care is ‘would I be prepared for a close family member of mine to go to that home?’ and if the answer is no, I at least look for alternatives as I won’t use a home that I wouldn’t be prepared for a family member of mine to go to - or at least without offering the families and prospective residents an alternative option (which isn’t always taken or perfect for other reasons, like location but that’s another discussion for another day)

However as far as psychiatric wards go, that’s another matter.

Running acute wards at a 100% + occupancy doesn’t do anyone any favours in the long run and can lead to possibly longer or more frequent inpatient stays.

Where I work, I am fortunate in that I have a lot of faith in the psychiatric wards I normally use when people I work with are admitted.

Certainly on the over 65s wards where I know the staff much better, I can confidently say, I would be happy to spend time on those wards and would, without doubt, be happy for my father (only close family member I have that is over 65!) to go there. Because I know the wards are well-managed by an excellent nursing and medical team.

The other wards in the hospital, that I’ve had a bit less interaction with, have given me at least some faith in my interaction and observations of the interactions between patients and nursing and medical staff. I do know that this hospital is perhaps ‘one of the better’ ones.

Until I was on my placement in a different borough in my ASW course, my current hospital was the only psychiatric hospital I’d been to - I know that people had said it was a pleasant enough hospital but I didn’t know what to compare it to.

On placement I assessed and organised  an admission for a patient to a hospital I had heard about but never been to. We arrived. I was genuinely shocked myself about the look and feel of the ward. She was taken to her room and I honestly didn’t realise that there were wards like that around still. I think and have thought about it a lot. It has to change.

And the more publicity and public attention that is focused on the quality and care that is provided on some (but by no means all) of the psychiatric wards, the more hope that there will be for some change.

As for the running at over-capacity - the only solution in my own, simplistic mind, is more beds which means more money. Not very popular, I fear.

Details regarding the new Equality Bill were announced last Thursday. The Bill seems to be an attempt to consolidate existing legislation related to discrimination - a seemingly uncontentious issue - however combined with this are some new proposals which seem to be garnering attention in different ways.

Community Care unsurprisingly, considering the target audience (social care workers, predominantly) , highlights the inclusion of outlawing age discrimination and the implications that that could have on the provision of social and health care for the elderly population.

EVERYDAYLIFEMODERN @ Flickr

It has long been the case that less money has been assigned to older people’s care services when compared to that of younger adults. The same levels of funding and flexibility are not allowed in the provisions of care for the elderly and it has long been an area that I, personally, have had issue with. Conversely, an equality of service can lead to a massive increase in budgets for the elderly - or a massive drop in budgets for younger adults - which, in my own cynical way, I see as being more likely.

As the article points out

‘While age discrimination is outlawed in employment, it is currently the only equality dimension - the others are belief and religion, disability, gender, race and sexual orientation - where discrimination is legal in the provision of goods and services.

The duty on the public sector will put age on a par with race, disability and gender.’

So this has the potential to be ground-breaking legislation - but I have to retain a healthy dose of scepticism because some of the financial considerations about providing an equality of service could be massive. Still, I shouldn’t be too churlish - this is exactly what I’d been waiting for in the services for many years. Hopefully, it will mean that assessments can be truly needs-based rather than having to be divided and considered on the basis of the age of the person concerned.

Ironically, at the moment, I am working with a woman with early onset dementia (because our team, although basically working with over 65s, does work with people diagnosed with early onset dementia due to the expertise in dementia that is held) - she is in her 50s and because the structure of some of the budgets that are held by the department and the provision of services are geared around over 65s, it seems to be an abnormal challenge to the system to coordinate the funding for her care.

Adult CMHTs push it back to the Older Persons’ CMHT  - who push it back to the younger adults services. And so on (the pushing, by the way, is being done by the financial managers rather than the practitioners!).

The lack of flexibility when it comes to budget-holding is thunderous - to the detriment of the provision of service - well, actually it is to the detriment of the provider of the service as we went ahead and arranged a service for her according to her need - it is just now that the different financial departments are actually refusing to pay the bills that the problem  has arisen. She, herself, is fortunately oblivious to the pushing and shoving behind the scenes.

I read in on the Times website that a letter has been written to the British Journal of Psychiatry,  in which 36 signatories complain that

‘patients with serious problems are often referred to psychologists and social workers rather than clinicians and do not receive the medical therapies they need.’

Now, I don’t have access to the British Journal of Psychiatry so have to rely on the Times reporting.

Apparently, this is a great disservice to the patients who are in need of medical treatment (a position that I can understand as far as it is the case) I’m a little baffled though, as all the referrals we take into our service are referrals to our team which includes a consultant psychiatrist, a  Specialist Registrar (I know, they’ve changed the names - but I can’t remember what grade they equate to now!), a clinical psychologist, some CPNs, Social Workers and an Occupational Therapist. None of us accept direct referrals to individual professionals without the team being involved first.

- and, according to the Times article

The changes came about under a scheme, New Ways of Working, established in 2005. GPs now refer patients with symptoms of mental illness to a team of up to eight people, which will include psychologists, nurses, social workers and a psychiatrist

Now, I reserve the write to be completely wrong here - it wouldn’t be an unusual position for me to take, but my understanding of New Ways of Working initiative is that although a report was published back in 2005, it is still in the consultative phase and was being discussed in 2005 then rather than being ‘established’. Some tentative steps might be being taken in that direction in some trusts but it by no means ‘up and running’

Multi-disciplinary Teams - these ‘teams of up to eight people which  include psychologists, nurses, social workers and a psychiatrist’ have been in play for many years - certainly prior to 2005.

So I’m a little confused by the issues and the facts - although not being able to read the original letter of course, means that I’m relying on the second-hand reporting of the Times.

It seems that the main area of concern is that people with severe and enduring mental illnesses will see one of the team that provides ‘psycho-social’ support rather than ‘medical’ support.

So

‘“If a GP suspected a patient had cancer, he wouldn’t dream of referring him to anybody other than a cancer specialist. A cancer patient might need jollying along, but what he really needs is the correct diagnosis and treatment. That’s what he gets from a specialist. But patients with mental illness are not automatically referred to psychiatrists. If they only see a social worker, there’s every chance that mental illness, or underlying physical illness, will be missed. Patients are getting a bum deal.”

winnie the pooh mbbp at flickr

Of course, I am not a doctor and nor do I want to take the role of a doctor. I don’t want to diagnose or prescribe - but I’d also take issue that people that I work with ‘get a bum deal’ when I am involved in their care - not least because there is not a single person that I see that I don’t discuss in a team setting with our consultant psychiatrist on a regular basis. As I said earlier, all allocations come through a team discussion which includes the presence of doctors initially.

And as I work with someone, when there is any change or concern, he is the first person I would contact to discuss these concerns with.

I can’t say I speak for all multi-disciplinary teams in the country but although I’m not a medic or medically trained, I’d like to think I can recognise areas of concern and bring a psychiatrist in very quickly when required (and sometimes when not required - I tend to play safe) . I don’t need to diagnose in order to recognise.

A part of the multi-disciplinary team structure is to work towards strengths. I would also hope that I provide a little more input than ‘jollying along’ but sometimes you just take what you can get and what you can work with.

The New Ways of Working, is, as far as I understand it, is a way of delivering a wider range of services by a broad group of professionals - but not about training others to do the job of doctors or about deskilling specialists. It is, as far as I could understand, about providing a higher skilled professional with more training , into the picture.

Noone wants to see a poor service being delivered or any kind of practice that would detract from medical treatment being provided when necessary. I would never consider myself a replacement for a medical professional but as a different branch of the same tree - because that’s where my expertise lies. I don’t want to be a ‘poor man’s doctor’. I want to be a social worker and not a doctor and to do the job that I am trained and expected to do and I want to do it well.

If that includes ‘jollying along’ so be it but not at the expense of clinical need. Social circumstances and considerations do have a very important role to play within Mental Health services though and to ignore those needs too can be an issue for concern for the patient.

Direct Payments is the system of, basically, rather than giving a direct service, providing money to the user of the service to ‘buy’ the care that they need directly.

‘Direct Payments were introduced in the UK

- for adults with a disability in 1997

- for older people in 2000

- for carers, parents of disabled children and for 16 and 17 year olds in 2001

Since 2003, councils have been required to make Direct Payments available to those who are able to choose to have them and who wish to have them’

(Source : Direct Payments for people with mental health problems: A guide to action)

I have worked with Direct Payments a few times although it isn’t something that comes up with any great regularity in the field that I am currently working in - mostly because, I imagine, my work is focused on a combination for the two groups of service users who have found the system of direct payments least accessible - older people and people with mental illnesses.

So working in a team for older people with mental health problems seems to be possibly the least likely place for direct payments to be accessed.

I have instigated a few direct payments packages but not a many. One of the things that I have found the most frustrating is the time-lag between going in to someone and identifying a support need - offering and explaining direct payments alongside an explanation of the direct provision of services.

On meeting potential interest, the boxes get ticked but in the meantime the service is needed immediately - it can and  has taken months to get a direct payment service up and running but in the meantime a direct service is needed to meet the need that still exists - sometimes a carer is employed in the meantime with whom the patient gets on very well - seeing no need to change to direct payments after a few months of building up a relationship.

Sometimes the  delay between setting up a ‘new’ system leads to a complacency to fall back to the ‘default’ system.

But sometimes, occasionally, it has followed through.

I have two reasons for bringing this up at the moment

Firstly, I am starting the process of referring someone for direct payments and her daughter for carers direct payments.

I thought it would be a useful illustration of the time it between someone deciding they need a service to its eventual ‘fruition’ if I can follow it here by indicating the different points in the process as they arise.

I hope I will be proved wrong and that we can get things up and running quickly. I really do.

Bit of brief background, service user and potential user of direct payments has an Alzheimer’s type dementia. She has had this diagnosis for a couple of years and can function fairly well. On meeting her, you probably wouldn’t realise she has dementia until you’ve been talking to her for at least about half an hour when some of the conversation begins to repeat itself. She would certainly have the capacity at present to make decisions about her own care and support packages.

She has been receiving a directly provided care package for a while but some of the elements have proved to be less than satisfactory. She doesn’t enjoy the day services on offer and would probably get more from community activities such as tai chi classes at the local leisure centre. One of the ideas of the direct payments is to look at someone to take her to these kinds of activities rather than her going to the local community day centre.

Her daughter is her main carer and lives locally but not walking distance. Her daughter has a young family and provides a substantial amount of emotional support to her mother, visiting most days and taking her mother to stay with her family many weekends.

I’m hoping that Carers Direct Payments will be able to address some of her needs regarding travel costs between the two houses and possibly some of the domestic care.

It’s been a while since I referred a Direct Payment care package so I called the Direct Payment lead (who I get on well with anyway and always find it easy to talk to) to confirm the procedure to refer.

I sent her an initial care schedule with costings and times attached.

Meanwhile, on the ‘Carer’s’ front, I need still (and hope to today) update the most recent Carers Assessment and Carers Care Plan to include the conversation I had with daughter to include Direct Payments for Carers as an outcome.

Anyway, lets see together how long it takes to get these things up and running..

I like talking to people. One of the things I enjoy most in my job and the area that I work in is that I find that the stories people have to tell about their lives fascinating and a part of getting to know someone, their needs, hopes and aspirations is knowing the past histories.

Often when I meet someone for the first time, we tend to go back in time and recall events that were significant and look back on how the past has created the present.

Yesterday, I met a woman and although not for the first time, it was the first time since she had been discharged from hospital. We chatted for a while and spoke about general kinds of things for a while - how things had been since she had come home, the kinds of things she wanted to do in the future, where we could go in the future both metaphorically and physically.

We began to talk about her children (there were photos up around the house and one of the ways I usually initiate conversations is by asking people to talk about some of the photos they have up and around in the house - I find its a good place to start.. ) . We then started to talk about the war (Second World War, that is!) and her experiences during the war - how her husband had been a soldier and she was evacuated out to Worcestershire.

‘Were you evacuated with your children then?’ I asked curiously. My own grandmother had been evacuated with my father who had been a baby and I was taken back to those stories I had grown up with.

She looked at me glacially.

‘I was 13 when the war ended,’ she said ‘I was a bit young for that’.

National Archives via pingnews.com