Fighting Monsters

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I was minding my own business, listening to Moneybox on the Radio at the weekend - when I heard that Benefits Cheques are to be phased out.

The Giro is on its last legs.

I don’t want to be pessimistic at all, in the face of the minister responsible James Plaskitt, being so assured that he would not be completely phasing out the current system until

‘…we are satisfied we have moved everyone onto a system and it is working for them.”

Of course, along with this, he sets a deadline of 2010.

Yes, it’s more expensive to send out cheques and plastic cards and bank accounts are a lot more convenient for, probably, 99% of people.

Yes, Giros have been targeted by fraudsters and they do get ‘lost in the mail’ with alarming frequency (surely, an issue for the Royal Mail - but I won’t get distracted here).

But plastic cards with PIN numbers don’t address a large amount of the people I work directly with who have different carers collecting their money for them - who aren’t allowed to be given PIN numbers due to concerns relating to financial abuses.

They don’t account for people who have grown up an a generation before these systems of cash cards became a widespread convenience.

New pensioners will find these new systems easier and more convenient, but I am more concerned about the older pensioners - 85+ who are not accustomed to remembering or using PINs to access their benefits and pensions - and sometimes not used to or wanting bank accounts at all.

Its all very well the minister saying that these issues will be ’sorted out’ by the time the new systems are in place, but it would have been helpful to know what means are going to be used to combat the concerns and fears before announcing the end of the cheque-based system of payments.

Moving onto the Direct Payment Scheme made the Benefits system easier for a wide-range of people but for some it was made almost inaccessible. It has possibly led to less independence rather than more as people were unable to access their own money through either not remembering PIN numbers or not having any family whom they could give those PIN numbers to, in order to collect the money for them.

The National Pensioners Convention has picked up on these changes

‘Dot Gibson, NPC vice president (who is one of the 400,000 pensioners currently receiving her pension by cheque) said: “For many older people, the cheque payment enables them to easily get a friend or neighbour to collect their pension on their behalf. It’s a flexible approach that helps those who may not always be able to get to the post office in person.”

“Lots of older of older people don’t have, don’t want or cannot open a bank account – but they want to keep using their post office to collect their pension. It’s outrageous that the government is now making it difficult for pensioners to get at their own money. The decision to withdraw the cheque payment is yet another attack on both the pensioner and the post office.” ‘

And they recollect an assurance that James Plaskitt himself gave in 2006

“On 15 February 2006, James Plaskitt MP, Department for Work and Pensions minister told the House of Commons: “It is not the Department’s policy to stop an individual’s pension payments if he or she refuses to receive pension payments by the direct payment method. Customers who do not provide account details are paid by cheque.”

I’m not against change for the sake of it, but I think a lot more explaining needs to be done before we can happily wave goodbye to a system than is a lifeline for a lot of older people - particularly those without friends and family members to support them.

This week is Carers Week. There has been quite widespread coverage in the press - certainly from where I’m sitting anyway. Yesterday the government printed its 10 year Strategy for Carers.

It has been widely reported that the main tenet of the strategy published - as far as I could tell from the reporting of it  as I haven’t actually had time to read it yet, was a Government pledge to increase spending on

Respite care (£150m)

Support for return to work and training and general work/life balancing health checks(£38m)

Training for GPs to raise awareness of Carers’ Health and Input from Voluntary Organisations (£61m)

Focus of young carers (£6m)

Which adds up to the total £255m injection into carers’ services in total.

More money is better than no money. A recent survey, carried out to coincide with Carers’ Week suggests that

‘ a large majority of carers admit to feeling ill, anxious or exhausted, with a staggering 95% of those questioned said they regularly cover up or disguise the fact that their health was suffering in order to continue with their caring responsibilities. Worryingly, one-fifth (19%) of these carers said they ignored feeling ill “all the time”.

Almost 1 in 4 (24%) of carers say they frequently felt unable to cope with their day-to-day duties due to the physical and emotional stresses of their caring role, and a further 64% said they were occasionally unable to cope.’

So pushing finance into a focus on Carers’ own health is a positive step.

Flexible working patterns are, as well, important. I know that some employers are more sympathetic than others to time being taken for caring duties and some kind of statutory guidance that would provide more protection to Carers would be helpful.

Alison Benjamin on The Guardian website sums up some of the responses from the main voluntary organisations which work in the field.

She writes about a scheme of ‘Caring Vouchers’ which has been advocated by leading charities and some larger employers to work in a similar way to childcare vouchers - allowing for services relating to care, podiatry is given as an example, to be purchased with these vouchers.

But these are some of the elements missing from the strategy.

Rethink approaches some of the proposals from a different angle asking

‘What does £15 pounds buy you?’

Noting that dividing the £150m set aside for ‘Respite’ breaks by the amount of carers in the UK doesn’t exactly make for extensive holiday breaks.

But it won’t be £15 each because some people will never claim holidays or respite they are entitled. My difficulty at work has been more trying to desperately convince people to take those breaks that they are entitled to and that they can access money for.

Where I work, there is a fairly substantial pot of money which has been put aside specifically for carers breaks. It is consistently used by the same groups of people which isn’t a problem because there is always some money in the pot as others are so reluctant to consider using it.

Strangely, the existence of money to go away isn’t the issue - it is persuading people to access it.

I work primarily with older people and older carers so I can’t speak more generally, but often, regardless of the amount of stress, time and health concerns, they do not want to leave their partner in a residential home for a week while they go away.

I hope there is more access to creative options for respite such as allowing (paying) for someone to come and allow respite in the home. But the costs of that would, I fear, skyrocket far past £150m.

Bert 2332 @ flickr

The other major criticism of the strategy drawn out by Alison Benjamin is the lack of any revised approach to Carers Allowance.

‘The most glaring omission from the government’s strategy is any proposal to increase the carers’ allowance or provide additional financial assistance to carers who are struggling to make ends meet. Although their role is estimated to save the state £87bn a year, many are living on just over £50 a week, plus other meagre benefits.’

And it is an embarrassing and humiliating attempt at piecing together a so-called ‘benefit’. Perhaps some more money for carers directly, rather than vouchers or health checks or training of GPs would have a more immediate effect quickly.

Of course, throwing money at problems is hardly the most creative approach but the Carers Allowance, is one of the worst examples of a poorly thought out benefits system that is insulting to those who jump through enough hoops to be able to claim it.

My own fear, and granted this is a result of reading the press rather than the actual strategy itself, is that the focus will be on those, again, who can ask for help and who shout for it when necessary. Those who are the ’silent carers’, who need more time, money and outreach may be missed in the floods of additional funding trickling through the system. But I’m hoping to be proved wrong!

How much of social work exists in the Care Management model? It’s a question I’ve been toying with for a fair amount of time - especially as most of my work, post-qualification anyway, has been situated very much within the care management model. Although now, I have a slightly different role within Mental Health services, the domain of care management even within a multi-disciplinary team is seen very much as that of the social worker and the place of both is something I have been considering over the past few weeks.

One of the CPNs in the team I work in (bless her) constantly talks about ‘doing social worker’s jobs for them’ or ‘using social work’ language. She’s a great nurse with very high standards and we get on well, but she doesn’t think much of ’social work’ in general (individuals notwithstanding!) and certainly not when she feels she is being asked to do this at the expense of therapeutic or clinical work.

My current role does give me more therapeutic leeway, although I am very much a product of the ‘care management system of social work’ as I trained when the NHS and Community Care Act (1990) was already very much entrenched in the systems. People spoke fondly and wistfully of ‘old style social work’ but beyond vague helping notions, it wasn’t something I could necessarily link immediately with the work I was being asked to do. After all, the idea of the new legislation was to be a provider and buyer of services that would give the end user a better quality and variety of care and would allow the care manager to manage on a strength-based model - that’s how it was sold to us when we were studying anyway…

When I was operating in an environment where I was primarily a care manager above and beyond all else, thought I felt that any individuality and professional competencies that I had worked to achieve were being sucked out of me almost before I’d started to work. All ideas of ‘buying services’ was throttled out of my by service level agreements and commissioners dictating which providers could meet the needs of the local authority in terms of pricing.

I was going into people’s houses, judging their needs against dry ‘Fair Access to Care‘ Standards - which were very tightly controlled by commissioning bodies.

stephmcg @ flickr

I was then matching those needs against a local authority list of times (I did actually have a physical list) - so 30 mins was allowed for a shower in the morning, 45 mins if breakfast was to be prepared as well - all mechanical, all prescribed. Anything above and beyond that time allowance would have to be justified in triplicate.

Paperwork completed, a few phone calls made and the package was in place.

No real need for any professional competence derived from graduate level study. Not really. Of course, the profession likes to make you think there is, the academics like to make you think there is. But I am confident that any non-qualified community care assistant could do an equal job , if not better job - especially after a few years. When the need for critical appraisal and considerate reflection is lost on a day to day level, the elements that identify the profession seem to fade.

Supervision was a list of what you had done that week/fortnight/month in terms of targets - and what you still had to achieve.

Of course, communication is necessary. You have to talk to people to make them feel better - to help garner information successfully but it’s hardly something that demands a rigorous academic approach and discipline.

This frustrated and continues to frustrate me.

Of course there is more complicated work coming in and there would be some marginal therapeutic work around, in some situations - but it is almost the mechanism that frustrates than the work. The de-skilling seemed to be more or less complete.

It felt like I was bestowing the beneficence of local government funding and for all the academic discussion of strengths-building and relationship-building - you’d likely only see someone a couple of times - to assess and then to review unless there were particular difficulties.

I remember once trying to explain to a woman that I visited why I couldn’t explain what Pension Credits she might be entitled to (I can just about manage Attendance Allowance or Disability Living Allowance - any other benefits remain a blur in my mind) and then, why I didn’t have access to any cash to give her (the social worker who had helped her when she was a foster parent had given her money directly so what kind of a social worker was I if I couldn’t provide cash?).

There was a hope that Direct Payments would go some way to solving this - but direct payments, while extremely liberating for some younger disabled adults, have proved harder to ’sell’ to older people and those in mental health services.

Namely, they are easier to sell to those who want to be sold to. When there is someone who needs more support in order to start having direct payments - the care manager isn’t, in my experience, given much leeway to have the time to explain, assist and support - well, certainly not in older person’s services where timescales are tight because of targets and turnaround is expected and pressured.

I can proudly say I was relatively successful in pushing direct payments out to older adults - more possibly than most in the team I worked in - because it was something I felt quite passionately about at the time. But even for me, operating in a target-driven system, it took time that I sometimes wasn’t allowed. All very well if the service-user is able to advocate for him or her self, contact the right people to assist with payroll and recruitment or has family around to help, but if they don’t - it’s a time issue for the care manager who is being pushed to targets, targets, targets.

Peter Beresford, writing in the Guardian, reviews a new book called The McDonalidization of Social Work by Donna Dustin. She writes (apparently because I haven’t read the book) of some of the effects of the care management that resulted from the 1990 NHS and Community Care Act.

The era of Personalisation is upon us which is apparently being welcomed as a move away from ‘care management’ and towards ‘individualised personal budgets’. The Care Manager is dead (so to speak) and long live the ‘traditional’ social worker. But I wonder how this accounts for social workers already burnt into the Care Management system who are too young to remember the glorious ‘old style social work’ era. What tools do they have to equip themselves with, years out of college but nested firmly in the bosom of the NHS and Community Care Act.

Social Work needs to reclaim some of the ground for itself in a target-orientated environment. If not, practitioners will become mechanic and complacent. Time needs to be given to workers to actively engage - but I can’t see the time ever being there as long as local authorities have tick-lists of ‘targets’ that need to be followed.

In my previous job we had a target to meet about adult protection investigations. If not enough people needed protection within a quarter, that was another target failed! There is nothing needs-led in the system of targets. It is completely service-led.

And I can’t be convinced by personalisation until I have seen concrete proof of its benefit to older people who are not able to speak or shout loudly about their needs. Within the pilot studies, I’d like to know how people with dementia are going to have their needs met or if personalisation is again, like direct payments, going to be a buzz word about individuals and choice - depending very much on who the individuals are and how much choice they are able to make without professional support.

I first saw on the news over the weekend about the report produced by the Institute for Public Policy Research related to  Personalised Budgets for Carers and it baffled me a little bit.

Don’t get me wrong, I completely think that carers need, deserve and are entitled to a lot more support than is available presently.

The Carers Allowance is, quite frankly, an insult to those who put in so many hours and whose lives are changed by the amount of care that is put in (as well as, on a less emotive level, the amount of money that is saved by both the NHS and Social Services). Also (for what its worth) it’s linked to Disability Living Allowance/Attendance Allowance and is means-tested. All of which contribute to its inefficiency.

But the call for personalised budgets seems to be, as far as I can garner, more or less the same as Direct Payments for Carers - which is explained much better on the Worcestershire County Council site (thank you, Worcestershire - and no, I don’t work there - actually, I don’t think I’ve ever been there!) as follows

‘Support for Carers

A Direct Payment can be provided to enable family and informal carers to purchase the services they are assessed as needing as carers to support them and to maintain their own health and well-being.

A Carers Assessment and Support Plan should be completed to identify the impact of caring on the person’s life along with the support they require to continue caring or to take a break from their caring role.

Carers are able to use Direct Payments to purchase support in any variety of ways including:

• Short breaks for themselves and/or the people they care for;
• Personal assistance within the home;
• Sitting services;
• Social, education and leisure activities;
• Transport costs;
• Equipment
• Relaxation, stress management and holistic therapies.

Some of the intended outcomes of using Direct Payments for carers are:

• Promoting social inclusion through greater opportunities for carers to actively participate in family and community life;
• Greater opportunities for the personal development of carers;
• Promotion of the carer’s health, well-being and coping skills;
• More responsive, timely and consistent methods of providing support, with greater opportunities for creativity;
• Values the essential contribution carers make to family life and the wider community.

Under the service, young people, aged 16-to17-years, are also eligible to receive Direct Payments to support them in their role as young carers and to minimise any difficulties or isolation they may experience in undertaking their caring responsibilities’.

psd @ flickr

I have to say I like the direct payment scheme as it works for carers because it is incredibly flexible. Indeed, I’d say it is the easiest way to provide direct support to carers and in the most visible way - so I’ve got a fair amount of experience using it.

In a lot of ways, it is a lot more flexible than the direct payments provided for service users because it can be used for ‘anything that would support the carer’ - so gym membership, travel costs, parking costs, washing machines - there is the ability to be much more creative. ‘

And it exists now - today and has been used with frequency.

So that’s why I didn’t really understand the call by the IPPR for personalised budgets with no comment about what is actually happening in social services departments to support carers today. Maybe they are calling for more money to be a part of the personalised budgets (a good thing) or more control (although the control can be basically in the hands of the carer themselves), more exposure to issues that matter to carers or less scrutiny from local authorities who provide the funding.

I suppose I’ll have to actually read the whole report rather than just the reporting of it!

I noticed that Sophie Moullin from the IPPR wrote about this in the Guardian and from what she says, I can’t see any difference in the new system she proposes to what is actually, legislatively in place at the moment.

I am absolutely in favour of anything that will help though and if the proposed system will ringfence more money or provide more exposure or utilisation of services then I’m the first person to applaud it.

But to promote the new system which has a lot of links with Carers’ Direct Payments without discussing the failings of that particular system and to look at the issue as if this system didn’t exist, seems not to be giving a true picture of the situation as it is today. Perhaps more needs to actually be done to increase awareness of the system as it exists today and promote use and access to it.

The Independent writes about the link between bipolar disorder and overspending. It doesn’t really come as any surprise and seems logical that a link would be made.

I remember a conversation I had with a patient who spoke in terms of genuine regret that her care coordinator at the time had completely bypassed any financial issues as he had not felt that they were the priority when she was so unwell - but as a result of her illness, her house had been repossessed.

We concentrate a lot (naturally) on social factors around illness and social models of mental disorder in the work we do. Ignoring financial matters can have massive future implications.

So it was timely that I found the Mental Health and Debt site which seems to be aimed at Mental Health professionals and provides practical ideas and ways that debt management and budget management in general can be approached. I personally, have found it very interesting and potentially (because I didn’t know of it’s existence until the weekend) incredibly useful.

If we work towards recovery - assisting with management of finances when someone is unwell forms, in my opinion, part of that responsibility.

The Guardian published an article this week about the germination of a New Deal for Carers and the results of the consultations that they ran over a period of a couple of months.

I hadn’t known this had been going on so thought I’d look at some of the interim findings regarding the challenges faced by carers.

1. Poor Information. There seemed to be a kind of dichotomy between people being bombarded with not-necessarily-relevant information (I presume, bundles of pre-printed leaflets and telephone numbers) and not being given enough or feeling that they had to ask specific questions in order to get the ‘results’.
2. Postcode Lottery - Without centrally provided or determined resources (and even with - to a certain extent) services will always have a different kind of provision in different areas. I’ve also found it can change very much from worker to worker - not necessarily the actual provision but the quality of service definitely. I know some people are more forthright in offering Carers Assessments than others (who might carry out their statutory duties by offering them but sometimes without explanations of their benefits).
3. Inconsistencies of Care. I think this is an issue across the board and not restricted to carers solely. The report offers the existence of a body similar to CSCI to monitor care workers but as most agencies are inspected by them anyway, I’m not sure that would make a difference.
4. Cohesion between services. Carers have a perception that ’services are centred around the needs of professionals’. Services are not necessarily well-coordinated. I wonder who the professionals are that are creating this perception of inflexibility and inertia. I think carers services (particularly with carers direct payments) have a lot of scope to be extremely creative but it takes time - like everything. Services really do need to set priorities.
5. Delay in the provision of services. This, I’ve seen, and been a part of many times. Sometimes the wheels can and should move into place earlier. Everytime something is attempted that is a bit ‘different’ or more personalised, it seems to take longer to set up or to get approval for. There is no logical reason that this should happen.
6. Bureaucracy. It’s everywhere and is inescapable. Forms and pieces of paper flow like a stream from every source. I think, in a way, targets are not as helpful as management imagine them to be.
7. Recognition of carer status. I think clearly this is something that potentially can change immediately and should be happening for the most part, in that carers’ are the experts on care for the cared for person and should be approached as such by professionals. It doesn’t always happen but it is something that can definitely be provided more concretely.
8. Attitudes of others. This is linked, I think, to the recognition of status. Sometimes it is ignorance that makes people dismissive of carers or just the knowledge that the familial ties make it more awkward to ask directly for help.
9. Lack of opportunities. An understanding employer can make a big difference but only to a point. I think there needs to be more motivation - forcible if necessary, which will point people in the ‘right’ direction.
10. Financial impact. Carers Allowance is laughable and an embarrassment to the government in my opinion. I am almost ashamed to mention it except that I believe it is an absolute entitlement. There are so many completely illogical aspects of the benefit system that seem to work against some sections of people but the treatment of carers is one of the most glaring omissions.

So out of these, some things that I think can change immediately

• - Professional attitudes to carers as experts

• - Information being personalised rather than just pushing leaflets and telephone numbers to people

• - Promoting more flexible means of providing support (Carer’s Direct Payments, Holiday Funds).

• - Building work with carers into the ‘targets’. Currently, where I work any time spent on carer support isn’t ‘logged’ as work completed. It sounds idiotic but each ‘piece of work’ is monitored so if carer support work isn’t monitored, it is definitely not prioritised.

Future possibilities:

• - Benefit reform - it has to come. It is a pathetic excuse for a benefit that benefits very few and many many more should be entitled to more money.

• - Carer Key Worker - not necessarily the same worker who is allocated to the person being cared for. Sometimes needs can overlap when they need to be separated.

• - One point of contact - for professionals as well as carers! Sometimes it can be incredibly difficult to set up what should be a basic service because of additional hoops to jump through.

• - Acknowledgement, support and assistance for carers who might be marginalised by mainstream support services. Support must be provided on an outreach basis as I know many carers who are more or less restricted to their own home. Sometimes some of the ethos of assertive outreach can be applied to carers who might be ashamed or embarrassed to ask for help.

• - Clearer expectations on a national level. There will always be some differences in provision between local authorities but there must be a minimum standard expected.

Well, 11 years actually since the Labour Party swept into power.

I’m not surprised by the poor performance of the government in the local elections this year. People tend to get tried of the same faces but there were some very obvious pointers too.

The abolition of the 10% tax band was very poorly judged. It’s one of the few issues that I was motivated to write to my MP about.

There are mutterings of climb downs by the government but any kind of reimbursements through the benefits system seem to be more than a little cynical.

Claiming back is always tougher than not taking in the first place and although I can understand the reluctance for blanket benefits and blanket taxation - I have seen many people hesitant, either for a matter of pride and perception or just the thought of endless forms asking no end of questions - to make claims that they are entitled to. I’d pretty much wager that there is more money that is not claimed by those who are entitled to it, than misclaimed by people trying to con the system.