Category Archives: direct payments

Care plans – Now and Future Me.

This morning I read a post by Mark Neary (whose blog I highly recommend) which highlights the hypocrisy and inaccessibility of the language of social care. I am used to jargon. I have been working in health and social care since 1993 so a lot of the language comes easy to me and I can almost forget what is jargon and what is usable by ‘normal’ people. It is posts like Marks that remind me of where our sector has lost its humanity. When we talk about ‘accessing the community’ rather than being a part of it as a part of a personal budget, we seem to have lost the idea of what community actually is.

 

Mark’s post got me thinking about how my life would be in the care and support plans I used to write so I’m going to imagine and put myself in that situation and see what my care plan would say. It’s not quite going to be ‘me me’. It’s going to be the me who, in 30/40 years time is living with a dementia which has affected my cognition. I’m in my 80s. I’m living alone and have no children. I’m a bit of a loner because I always have been and don’t have many friends living nearby.

Because someone in an office decides I may not be able to make decisions about what care I need, those decisions are made for me. I have a personal budget, of course, because everyone does. It isn’t a snazzy flexible one because I get confused by money and finances and am not sure I’d be able to make decisions about money management. I get my £5 and my £50 mixed up and that’s got me into all sorts of trouble at the local supermarkets. Sometimes some of the local lads offer to clear my garden. I give them £100 for an hour’s work because it seems fair to me and they are such nice lads. They always smile and they come every week. So my ‘personal budget’ is managed by the local authority.

 

Between 7.30am – 8am I have a carer to come and give me a shower or strip wash. The carer often doesn’t turn up until past 8.30am. I’ve always been an early riser so sometimes I try and get up and dressed within her help. I don’t like waiting till 8.30am when I’ve been up since 5am. I can’t manage the shower though and she thinks it’s a shame to change me after I’m already dressed.  “Carer to help with shower or strip wash”. Sometimes I’d like a bath. There isn’t enough money for that. That’s a shame. I last had a bath four years ago. I remember it sometimes.

 

I sit in the lounge. The carer sometimes puts the television on before she leaves. I don’t pay much attention to it. Because I’m over 65 now, I don’t get any ‘day opportunities’. The day centres have closed and I don’t have any family to visit. I sit and watch TV. It’s ok. I don’t want enforced company so I’m not so lonely. I miss going out to the shops though. Accessing the community? That would take too long and cost too much so I just have a carer come once every fortnight to do my shopping. I write out my shopping list in advance. Mostly it’s the same from week to week. I don’t do spontaneity anymore.

The carer comes at 12pm to make my lunch. Lunch is a tuna sandwich. Lunch is always a sandwich because there isn’t time to cook. It’s always tuna because I once mentioned I liked tuna 2 years ago. Now I have tuna sandwiches every day.

“carer to prepare light lunch and cup of tea. Clean up afterwards”. Sometimes I miss coffee.

 

It’s Thursday which is shopping day. Shopping day is only once a fortnight. So shopping is lots of instant meals which don’t need to be prepared. I wish I could go out sometimes and potter around in the supermarket. But that would take too long. You see, my allocated hour wouldn’t be enough because I’m a bit slower on my feet. It’s tins of spaghetti hoops. Bread for the freezer. Milk for the freezer. Chocolate hobnobs. Some cheese. Lots of tuna. I like all these things but sometimes I miss sushi.  “fortnightly local shop. Collect list. Leave change”.

 

It’s nice when it’s shopping day because it means something different happens. Mostly I just sit and watch TV. That’s my meaningful activity.  I have a personal budget. Look how well self-directed support works for people like me. What do you mean it’s no different? This is innovation. I know how much my care package costs now. That’s changed my world.

 

I can’t wait until dinner. At 5.30pm my carer comes and makes me something ‘light’. But this time it’s a hot meal. Spaghetti hoops on toast. I like that. Sometimes I put some cheese on the top but have to be careful with the toaster. I can’t manage it on my own. At least I get another cup of tea and help to the toilet. Sometimes I miss coffee.

“5.30pm – 6.15pm Prepare dinner – leave with cup of tea. Help to toilet if necessary”.

After dinner I watch TV for a while. Usually I fall asleep.

The carer wakes me up when she comes at 9pm to assist me to bed.

 

So that’s what the day looks like. I get up later at the weekend. That’s nice. But I like getting up early.

 

Now coming back to my present self, I wonder how my own care plan would look in the language of, as Mark calls it, ‘Carespeak’.

So snapping out of reality, this is my current ‘care plan’. I wake at about 5.30am and interact constructively with other household members, which is problematic to those who don’t want to be awake at 5.30am. This is evidence of my self-centred nature and need to mind my anti-social behaviours around waking early. Sometimes I don’t have breakfast. This presents a risk to my nutrition and hydration. Occasionally I might eat an unhealthy breakfast, like a croissant. This is high in fat and could lead to unhealthy habits and putting on weight which could affect my health.

I have a shower and this means that my needs related to hygiene are met. I ensure that I wear clean clothes which are appropriate to the season. Although sometimes I judge poorly before leaving the house and this means that I may not be protected from the risk of inclement weather. I don’t own an umbrella. This is a risk as it often rains in London. I am able to meet my personal care needs.

I go to work. Now, I’m accessing the community and engaging in a meaningful activity because I have economic worth. Although sometimes it isn’t meaningful. Sometimes it’s sitting in front of a screen staring at spreadsheets. It has economic value and therefore it is meaningful. Daytime activities, I have them, you see. All is good.

I might go out after work. This means I am socially active. I am engaging with my informal support network i.e people who are not paid to be with me. I can tick off my ‘social network’ tab on my care plan. I have friends.

When I get home, I should really clean the house a bit. But I sit on the sofa and fall asleep in front of the TV. This is a risk. This means that I have not been able to meet my domestic care needs. The washing up is in the sink. I am, therefore, in a house, where there is a concern that I am not managing domestic care sufficiently. This worries those people who write care plans. All is not well.

I go to bed at a reasonable time. I don’t have any problems with sleeping and am not worried or concerned by my lack of sleep. All is well.

 

So why is it worth considering? These two care plans say different things but in the same way. We can look at aspirational documentation and what we should strive for. I always want to strive for better. But those who are striving, don’t forget the people like me or the future me. Don’t get carried away with the language that can actually mean less than it should. A personal budget does not mean choice. Choice does not mean choice as often as not. If we want to solve problems, we have to know the problems and how they would affect us.

 

It’s worth considering how are lives are and how they would be in the context of ‘care planning’. Would we plan care for others, the way we would want it planned ourselves? And if not, why not?  Food for thought.

Personalisation in Practice

(Note – I wrote this for something else where it was not used but thought, I’ve put the work in and might as well see if anyone else finds it useful/interesting! That’s why it’s a slightly different style from my usual rants and definitely drier#.. and why there’s a bibliography!)

Personalisation policy and the principles of developing person-centred care have promised a great deal in terms of increased choice and control for service users, and a change in focus towards greater user participation in services. While putting people at the heart of services is fundamental to a progressive and ethical social care culture, the gap between practice and policy in relation to the personalisation agenda can look like an insurmountable chasm to the practitioner. This is an area where promises have bounded ahead of practice experience.

What is personalisation?

Personalisation is a process which puts people who use services at the heart of decision-making about what is right for them and how their care and support needs will be met. The opaque jargon of social care can be a barrier to communicating key concepts, and defining ‘personalisation’ is crucial as the term is used in different ways and attracts meanings which can depend on the agenda of the speaker. Sometimes personalisation can be used as a synonym for person-centred practice and support. Gardner (2011) explains that ‘personalisation’ incorporates “different strands of ideology, theory, policy and practice”(p2). Not all definitions are inclusive of the groups of people who may lack capacity to make decisions for themselves about their care needs so it is easy to see how the rhetoric can overtake the reality.

The ‘personalisation’ agenda as it has been known is more than moving people to ‘personal budgets’ and the roll out of direct payments as a default mechanism for delivering social care. It is about moving the paradigm of ‘power’ away from the centre and towards the individual. The development of this personalisation agenda took place in the context of a great deal of excitement and promise. In the early stages where the Independent Living Fund (ILF) was created in 1988, allowing for the first time people who used services to directly commission and purchase their own services. This continued through the various configurations of direct payments (initially introduced through the Community Care (Direct Payments) 1996 Act) as they made their way through different user groups and the scope extended, leading to Putting People First (2007) which pushed through the ‘transformation agenda’ in adult social care to move towards personalisation for all.

It is important that we don’t confuse ‘personalisation’ with ‘direct payments’ nor ‘personal budgets’. Different models of providing people with more choice and autonomy over decisions which are made regarding their care can be done in many different ways and in some ways, the handing out of money and telling people to get on with it – with or without the requisite support – is a very narrow attitude to take in terms of allowing choice. Choice has to include a choice in the way that we can choose about what we receive, but there has been a political emphasis on direct payments as the gold standard of choice and that leaves some at a much greater disadvantage than others in terms of having control over their own support packages. The jargon and language attached to the change in adult social care creates a layer of professional knowledge so that in itself, it removes elements of knowledge and control from people who use services.

Gardner (2011) states that “Personalisation reinforces the idea that the individual is best placed to know what they need and how these needs can be best met. It assumes that people can be responsible and make their own decisions but people need information and support to do so” (p34).

Personalisation is about far more than ‘cash in pocket’. The system embraces models for establishing different routes to choose but in practice some of these are scarcely developed. For example, using individual service funds to buy support for older adults and people with mental health needs. This focus on the individual being at the heart of the process of choosing and having more control over the care that they are provided with and establishing a framework for person-centred practice lies at the heart of the ‘personalisation’ agenda. However, the path towards a goal that it is impossible not to support wholeheartedly has become muddied with the realities of spending cuts, local authority processes and challenges which have been continually ignored rather than addressed.

The policy has been driven by the wish to overpromise in terms of extending personal budgets (and hence the ‘personalisation’ agenda) to all within specific time frames where the reality has not been able to keep up. So we have seen the reinterpretation of ‘personalisation’ to represent care and support packages that in reality look no different at all to those which were delivered 5 or 10 years ago but with a different layer of language and bureaucracy layered on top of them. This creates further disillusion within the profession, especially as the social work profession is committed to increasing person-centred practice and empowerment of individuals in the face of the ‘system’ which can sometimes be oppressive and dictatorial.

The implementation challenges for the personalisation agenda have been extensive. While this is to be expected in any process involving widespread changes behind both the philosophy of a system and the systems themselves, the agenda of promoting user involvement, choice and co-production has moved at different rates for different user groups. For example, while the roots of the personalisation agenda lie in the Independent Living Fund and the processes built on driving forward choice and control for adults with physical disabilities and learning disabilities, SCIE report 40 (Newbronner et al , 2011) explains that “There is a risk that people in later life are being squeezed into a ‘one size fits all’ model of personalisation designed with and for younger people with physical and/or learning disabilities”.

Practitioners on the ground who are often the key to success of failure of these policies in practice perceive that there is little interest in addressing their experiences or hearing their feedback.

Why personalisation?

Personalisation is an important policy aim and it is important that it works. The idea of self-directed support (or personalisation) has been a process and direction through which policy has been travelling for decades. It touches on the fundamental aims of what social work is about and how it is used in practice. There have been many changes in the way adult social work has operated since the NHS and Community Care Act (1990) was rolled out and particularly as ‘social work’ developed into ‘care management’ through this period. So why was ‘personalisation’ needed? As local authorities disavowed themselves of delivering services directly, the logical step, as purchasers of services would be to ask people who used those services to have a greater input and role in making decisions about which services were commissioned. That, at the heart of it, is personalisation. One of the main criticisms within the care management model of services and care plans being written by social workers with services being defined by block contracts was that there was that this was very much a ‘one size fits all’ attitude which left people with little choice apart from accepting or declining the services which were on offer (Maclean, 2011).

The policy move to change this and to shift the ‘power’ from the provider to the user has been wholly positive. There is no professional expertise in deciding what meets the needs of individuals that cannot be trumped by the individual deciding for themselves. For this policy to move into practice, there have been accompanying bureaucratic and process-driven changes, such as the introduction of self-assessment processes and attempts at rationalising resources with some transparency (with mixed effects) around the amounts of money spent on care so that people can make their decisions about the services which best suit them. While the direct payment model is the most touted, there are also routes through local authority managed budgets and individual service funds (ISFs) where budgets are shifted to service providers to deliver as required by the service users.

How is personalisation?

The barriers to extending personalisation have been addressed in numerous research literature. There is much evidence which seems to repeat the same conclusions that the progress of different models of delivering care, because ‘personalisation’ is about more than direct payments. This leads to frustration among practitioners that the current barriers are exactly the same barriers which were identified to the same groups of people as those to direct payments five years ago with little progress in some areas.

SCIE carried out research (Newbronner et al , 2011) focusing on people with mental health needs and older people which were the groups of people where the take up of personal budgets has been slower to gain traction. They looked at the different ways that personal budgets were offered: namely those which were directly commissioned and managed by the local authority, third party managed accounts, direct payments or a mixture of these things. They found that there was a risk that inherent processes to assess and allocate resources such as the RAS (resource allocation system) and the assessment process which may be initially a self-assessment or a facilitated process of assessment depending on the local authority and the individuals’ needs, needed to be tailored more finely towards the relevant user group.

“Where a generic system [for RAS] was used it highlighted inequalities for resource allocation between client groups. Older people, especially those with high care needs, appeared to be the most disadvantaged.” (Newbronner et al , 2011) p9

This lack of equitable access through the ‘front-door’ leads to increased disillusionment with a process which is supposedly designed to be enabling and supportive.

Another barrier is that of attitude of social worker and organisation, which is mentioned in an Age UK report “Personalisation in practice” written in 2011.

“There was a concern among support providers and some LA/Trust staff that many PB (personal budget) holders, especially older ones, were being steered away from direct payments and towards managed accounts or services by the LA (local authority” p9.

This indicates that some of the ‘blockage’ on progress and implementation is within the systems which are meant to promote it.

The intransigence of social workers and the lack of desire to embrace new models of service provision which move the locus of ‘control’ away from the professional and towards the person who uses the service has often been argued as a reason for the poor take up of direct payments first ( (Littlechild, 2002) where they say, in relation to direct payments, the forebear of the current personal budgets “it is not disabled people making informed decisions to reject the idea of a direct payments package, but their social workers effectively depriving them of access to direct payments by failing to provide information and support” (p138). This is a harsh judgement to put at the feet of practitioners but it is one that is popular among policy drivers as it is easier to blame the attitudes of practitioners than to evolve methods to promote and simplify the methods of delivery of the personalisation agenda.

Unfortunately the ‘blame’ agenda took hold early in the development of policy making and has led to greater alienation of practitioners who do want to try and make things work. There is a sense of being blamed for not embracing personalisation when the system is flawed, not because they are negative but because the processes are inexorable and have been built to reflect the needs of particular service user groups whose needs, priorities, and abilities are not universal. Effectively, policies are designed to fit some service user groups at the expense of others. Glasby (2012) states “one danger [of the roll out of personalisation] may be that current policy rhetoric is so strong that it is difficult for people with legitimate concerns and questions to raise these in an open and safe environment. Speaking to front line practitioners, some feel as if expressing doubts can be seen as ‘heresy’ and they are reluctant to say what they are thinking. While this may not have been the intention of policy makers, it could be a significant barrier in change if people feel concerned about a policy but don’t feel comfortable exploring this further, and simply disagree in silence.” (p8)

In some of the legitimate concerns, (Newbronner et al , 2011) explains that there is an inherent biases present. Referring to resource allocation schemes (RAS) the study found that “Where a generic system was used it highlighted inequalities in resource allocation between client groups. Older people, especially those with high care needs, appeared to be the most disadvantaged.” (p6)

There are therefore, many legitimate concerns which have been evidenced through research into ways that personal budgets have been used with different user groups has shown. It is vital that the cautions voiced by less enthusiastic practitioners and service users are embraced by those who are guiding policy, rather than being written off as being ‘negative’ without having the chance for their voices to be heard and for lessons to be learnt as a result.

Another challenge that is faced in practice is one of time. Quality support planning needs the investment of time. In the ideal world, presented by those who ‘run with’ the agenda, everyone is able to take an active part in making decisions for themselves and choosing their own care to meet their needs, as defined by themselves. The reality is that some groups have not been able to engage in the process of taking an active role in their own support planning; they are effectively excluded. This may be because they lack the capacity to manage a direct payment or organise a personal budget themselves, or because they lack support systems around them, such as family to help them do this.

SCIE report 40 (Newbronner et al , 2011) emphasises the fact that older people are more likely to need care during a crisis. People undergoing a crisis are likely to be less able, at least initially, to engage in the process of planning and organising their own care. Intermediate care teams typically assess and set up a temporary interim care plan and budget. Support planning then takes place a second time once the person is in a more stable situation and able to take stock. The time taken to set up a more personalised care plan in terms of the administration hoops to jump through are a significant barrier to some people and some ways of providing support.

Where does Personalisation go?

The ideology behind personalisation is sound and needs to be embraced wholeheartedly.

As practitioners we want work to support, involve and include people who use our services. The future must involve a stronger focus on services and delivery of services in conjunction with people who use them, but in order to get there, we need there to be a realistic, no-blame space for discussion between those who make policy and those who implement policy, as well as those who use services who lie at the centre of the social care system. There is still a disparity in terms of those who are best served by current practice. People who have benefited most from personalisation are those with the best advocacy and loudest voices. For the policy to embed itself in practice, it needs to offer the same quality and opportunity for flexibility to all user groups including those who are not able to raise their voices and who don’t have family advocates to speak for them. That’s where the role of the social worker has scope to be established to a much greater extent. As practitioners on the ground they have some of the most acute understanding of the challenges faced by people they work with, particularly people who are not able to best articulate their own concerns. If personalisation is going to work for everyone, we need to hear the voices from practice.

 

Biblography

Age UK. (2011). Personalisation in practice : lessons from experience. London: Age UK.

Netten et al (2012). Personalisation through Individual Budgets : Does it work and for Whom? . British Journal of Social Work , 1556-1573.

Gardner, A. (2011). Personalisation in Social Work . London : Sage.

Glasby, J. (2012). The controversies of choice and control – why some people might be hostile to English Social Care Reforms . British Journal of Social Work 1-15

Littlechild, J. G. (2002). Social Work and Direct Payments. Bristol : Policy Press.

Maclean, S. (2011). Personalisation and Person-Centred Care. London : City and Guilds.

Newbronner et al . (2011). SCIE report 40 : Keeping Personal Budgets personal : learning from the experiences of older people, people with mental health problems and their carers. London: SCIE .

Technology, Social Media and Social Services – Finding new ways to ‘help’

iPad con dock y teclado inalámbrico

Image via Wikipedia

I have some across lots of discussions and debates about ways of using social media and new technologies and interactions to ‘help’ social services become more effective. Most of it seems to revolve around building online directories and databases of micro providers and services that are available which build on so-called community capacity to improve the way that personal budgets can or might work.

At the risk of sounding overly cynical there is nothing ‘innovative’ in my mind about building a directory of services.  To me, this is not a particularly innovative way to use ‘technology’ in social services.  It taking a very obvious and well-trodden route to using new technologies. Providing directories while being useful to a certain group of people again exacerbates the isolation of those who are not party to or able to use them.  Being innovative isn’t always necessary to be helpful but it is very important that new ideas are focussed so we don’t just end up with increasingly specialised, localised directories that might have more ‘interactive’ features and feedback, look more ‘user led’ and compatible with the buzz words of social media but in the end they are brushing the surface of possibilities.

It feels more and more as if that there is a growing division between the ‘haves’ and ‘have nots’ as far as personal budgets have been extended and does absolutely nothing to address or use technologies to address those who reside continually in the ‘have not’ section.

While at work, we labour with database systems that have clearly been developed through conversations between commissioners and software companies without any recourse to frontline practitioners, nice new provider directories are being tinkered around with while the fundamental foundations of the systems we work with remain resolutely inaccessible.

I’ve had a few ideas myself and whilst I lack the technological expertise to see any of these ideas to fruition, this is a kind of ‘wish list’ of the sorts of things I’d like to see.  I’m under no illusion that these are ‘new’ ideas. I am sure similar things already exist in some form but they are things I’d like to see pan out in the longer run. Things I’d like to use at work.

I’d like to see more creativity in the use of technologies to assist with decision making for adults who have some kind of cognitive deficit. I’m a great fan of the ‘tablet’ and ‘touch screen’ model as I think it is intuitively an easier interface to understand.  When I see people instinctively reach out to touch the screen of my Kindle (which isn’t touchscreen!) I realise that we are becoming conditioned to seek the easiest input methods which are about touching a screen and speaking into a microphone and perhaps writing on a tablet. Now, voice recognition has improved, I’m yet to come across very successful handwriting recognition (possibly because I have scrawly almost illegible handwriting) but there is potential there. In the meantime, pictures and touchscreens seem like a good way to go.

Using pictures/sounds/music it can draw on multi-media ‘shows’ and explanations of different options – moving beyond the ‘written word’. Providing documentation in aural form or in pictorial/moving form rather than reams of leaflets. Having recordings of familiar voices or pictures of familiar faces might help to reassure. I’m a great fan of telecare in general with the proviso of always being mindful that the human contact is not replaced but in days where human contact is sparsely provisioned anyway, it may be something that can be experimented with.

Why not a YouTube type video to explain how services can be chosen instead of reams of ‘easy read’ leaflets which really aren’t remotely ‘easy read’. Instead of flooding people with lists of providers (which, while good for some ignores those who are restricted in terms of capacity and carers to choose ‘freely’ the types of services they garner) why not explain and expound in different ways the ways that services can work?

Why not explain providers in terms of what they can actually provide and what purpose they serve rather than creating directories that are meant for people with a good understanding of what they want and need?

I was in a day centre last week and there was a seemingly unused Wii. I wonder if he Kinect might be a better project to develop some type of interactive play, exercise and work as it doesn’t need a controller at all and uses the more innovative way of body movement.  Using participatory games with larger screens in company can provide different stimuli. I know why games developers  haven’t tackled directly the ‘older’ market with games that might otherwise reside in memories but why not repackage old school yard games and board games with Kinects and iPads? It may be a good way to introduce the use of these new technologies in a ‘friendly’ manner which may then see them used in other wider ways – such as directories or personalised information sources. Using YouTube video channels for personally designed ‘reminiscence’ therapies could personalise the delivery of memories and digitise memory boxes where items are not there to build up the frames of someone’s life and people aren’t there to fill in the gaps.

There are many ‘dating site’ type services that match people and organisations. Volunteers to voluntary groups etc. How about a type of match between schools and residential homes? I know it’s something that’s sometimes done locally where I work and having spoken to both providers and some of the kids who go in, they seem to enjoy it and it can change and break expectations – each of the other.  I

We talk of social media a lot and often it is used to provide ‘recommendations’ to particular services through these databases. Perhaps more user and carer led general recommendations can be collated. Crowd source an ‘introduction’ to social services provisions by those currently using the service.

Ask ‘what do you wish you’d known?’ ‘what do you wish someone had told you?’ and while taking out all the obviously libellous stuff, a local authority must be brave enough to leave in the criticisms. We learn through complains and criticisms and it can take a lot of guts (or anger) to make a complaint or to criticism and that MUST be respected by the service and the individuals at fault and used as a means of improvement.

I don’t want to see local authorities ‘whitewash’ problems in order to gain sparkling OFSTED or CQC inspections. It sullies the whole process and makes the inspections worthless. Regulation should be less authoritarian and more about actually making improvements and making things better for the end user – not about allowing local authorities to produce the ‘right’ results while poor practice is brushed away from the sight of the inspectors.

But back to my point about using social media to crowdsource – it is important that social media ALONE is not used as an ‘answer’. Crowd sourcing must be honest but it must also be broader than putting out an ‘internet consultation’ and having a Twitter account or blog. There must be pounding of the streets too to engage those who are not able to use digital means to put their points across. There should be knocking at doors and face to face discussions – not leaflets, not inaccessible (for some) groups.

Talking about crowdsourcing though, there’s a much better and perhaps more obvious way it can be used and certainly isn’t being used at the moment and that’s to engage other social workers and professionals into putting together more information and useful methods of practice for ourselves. Sure, it needs time but we remain reliant on organisations to provide ‘guidance’ such as SCIE (who do provide fantastic resources) and BASW and the College of Social Work but why none of these organisations who purport to exist to help social work and social care practice actually engage more directly and use social media and open access blogs/discussion groups/forums/micro blogging etc to engage with currently practicing social workers is completely beyond me.

I’ve become very interested in open access education and resources and feel there is great scope for professional engagement and information to build its own resources and information together with users and carers, together with other professionals but there has to be a push for social workers to see the benefit of sharing and finding appropriate ways to share the information that we learn every day.

I have other ideas which will come in different posts  but I’d be interested in hearing other peoples’ ideas for uses of ‘technology’ in the very broadest sense and how they can develop to help the broadest range of people we see in social services – particularly those who are less able to look information up in various fancy online directories.

Human Rights, Home Care, Personal Budgets and Cost Saving

I read on the BBC website among others that there is a report suggesting that care provided in the home by local authorities to older adults may be overlooking human rights issues.

Old man exmouth market

Daniel2005@flickr

An inquiry into this  was initiated by the Equality and Human Rights Commission in November 2010 and will report in December 2011 but some interim findings have already been published.

I think the context in which the inquiry is taking place is crucial in times that Cameron trying to pretend that he invented the personalisation agenda and rebrand it as a version of ‘Big Society’.

The scope then of the Inquiry as to determine where the responsibility of the ‘public authority’ under the Human Rights Act actually lies and I’m going to quote directly from the EHRC (Equality and Human Rights Commission) as I think this is a crucially important point in the progress of personal budgets and home care provision (n.b. the underlining is my own).

The nature of social care is changing rapidly with a greater emphasis on personalised services and choice.  The majority of social care services are already delivered by private sector agencies, either via contract with local authorities or directly with individuals through a mix of public and private funding.

This complex web of transactions is combined with a narrow judicial interpretation of the meaning of ‘public authority’ under the Human Rights Act. This combination has created a confused picture concerning the duties and obligations of the various groups involved in respecting, protecting and promoting human rights.

Further, an increasing number of care transactions are likely to take place at the margins of, or even outside of, regulated care. There is the possibility that these transactions are beyond the present human rights obligations of the State.

We are also seeing the emergence of new on-line care marketing and brokerage services aimed at people purchasing social care with either ‘individual budgets’ or private funds. These marketing and brokering services are currently completely outside of the regulatory system with no means of monitoring the quality of the advice and services they offer. The Government wants to accelerate the pace of reform even further. While personalised care and support has many potential benefits, this is uncharted territory. There are concerns that human rights protection (and other issues) could fall between the gaps.

I’m going to come back, I’m afraid, to my perennial bugbear of people who lack capacity to make choices regarding care provisions and care delivery and wonder again how this group of people without family members, friends or advocates will be able to secure their own well-being in a world where responsibility of the state and the public authority is being discharged to private individuals. Will it become the responsibility of an advocacy service to determine that the support package and the provider of the support package are of a good quality? Or the carer/family member? Hardly the same as a protection under the Human Rights Act.

Food for thought and while I am extremely happy with the forward march of personal budgets and direct payments to those who are able and happy to manage their own budgets, the way that local authority managed budgets provide ‘more of the same’ regarding cheaply bought, block contracted social care remains floating fairly close to the edge regarding what is acceptable and what isn’t.

My fear is that the roll-out of personal budgets has not led to choice for all. It is a false choice and a false impression of the so-called ‘success’ of the roll-out. It has led to great benefits and more choice for some, yes, but I worry that this is actually at the expense of those without the louder voices to shout who have, again, been pushed to the bottom of the pile when quality services are being distributed.

So back to the reports findings so far.

Back to the BBC report

The Commission describes cases of people being left in bed for 17 hours, or more, between care visits and a failure to wash people regularly.

It received reports of people being left in filthy nightwear and bedding after a homecare visit, or without a wash or hair wash for several weeks.

Visits are sometimes so brief, the report says, that people have to choose between having a cooked meal or a wash.

The short visits also mean that staff have to rush tasks like washing and dressing, which frustrates elderly people and care staff

That doesn’t even bat an eyelid with me. This is what I have dealt with for the years I have been working in adult social care. Complaints and apologies about the time we can allocate for specific tasks due to budgets. Apologies on behalf of private agencies who have block contracts that cannot assure any kind of continuity of care.  That’s not even mentioning the  missed visits, the non-payment to staff of travel costs so they are cutting short visits in order to make it to the next ones. This is the reality of social care for older adults in the UK. Not the ‘season tickets to football matches’, not the ‘let me choose nice Mrs Walters’ daughter who I know from church to be my home carer’ kind of idyll that we are presented in the personalisation literature.

The reality for the people I work with and for is increasingly rushed visits and yes, choosing between a cooked meal (but only if it is a microwave meal because there is never ever time to cook a meal more complicated than tinned soup or beans on toast from ‘scratch’) and a shower.

The way to solve this problem and promote dignity is to increase and not reduce budgets for social care in the home. But budgets are being cut and cut hard.

Local authorities use block contacts with private care agencies to save money. The private care agencies generally pay staff at minimum wage. There are some fantastic carers and some fantastic agencies but they are penalised if they don’t offer their services at the very very lowest cost.

As for personal budgets? It is a wonderful reality for some but for most of the people I work with and for, it is a pipe-dream for people with a different kind of disability and with different kinds of support needs from the ones which are mostly promoted in our training programmes and in our policy documents.

If the government truly and genuinely means what it says about increasing and drawing out the personalisation agenda and increasing personal budgets delivered by direct payments there have to be ways clear and research undertaken to help us to create protective and interactive systems for people who are not at the forefront of the march because they don’t realise how much they are being penalised for not having a family member who is able to help with choosing and designing a care package and because they are not able to do this for themselves.

There has to be money spent on developing ways to allow those who at the moment are most at risk of vulnerability to be protected and cared for.

There are so many problems with a society that treats older adults or, in fact, anyone in the way that older people who are in need of care are treated currently. No-one wants to address it because no-one wants to pay. And it will cost.

No-one wants to lose their homes. No-one wants to lose their savings. No-one wants to pay higher taxes. No-one wants to lose weekly bin collections. No-one wants to pay insurance premiums.

The people who hold the reins of power will never be subjected to the humiliations which become a part of daily life for older adults who have need of support that is provided because they’ll be able to buy in their own ‘help’ privately.

Older people in need of assistance are less noisy than younger adults and less emotive than children in poverty and need. Ultimately we shouldn’t ration compassion and there’s no need for a choice to need to be made between one group or another

In the roll out of direct payments and then personalisation and personal budgets, it is the more able younger adults who have led the march and those who have been setting the policy and agenda seem to have completely forgotten the group of older people who don’t have involved family members and who  might not have the capacity to take decisions about care needs for themselves in the rush towards pushing the responsibility for support planning and choice of care routines. They  have forgotten amid the wonderful stories of attending football matches instead of day centres that some peoples’ reality is more about choosing a microwave meal or a shower.

Until those issues are addressed and the protection of the most potentially vulnerable groups of people is managed, the new system will not be equitable and it will not be fair. But perhaps that suits this government that wants shift responsibility from the state to the individual – which is fine to an extent but there are some people who really need that protection.

I look forward to the final report of the EHRC in December.

Personalisation and Professional Disillusionment

Yesterday, Community Care published the result of a survey they had undertaken about ‘personalisation’ among social care professionals.

The headline figures while wholly unsurprising, make for interesting reading where only 41% of respondents felt that service users would benefit from the implementation of personal budgets and 83% felt that cuts would impede the progress of the personalisation agenda.

To which my first thought was ‘only 83%’?

Anyone who has read some of my previous writing/ranting about personalisation will be pretty clear where I stand.

While the idea and the concept of introducing more person-centred support planning and opening up direct payments to a wider range of people is absolutely fantastic as a concept, the implementation has been dire.

There has been a complete side-lining of service user groups that don’t fit into the ‘easy’ mode – namely those with mental health problems, older adults and those who might not have capacity to involve themselves fully in the support planning process, the same figures and quotes that the government and her agencies roll out again and again about the man who pays for a PA to go with him to a football match instead of a day centre are so completely off the radar when the smaller pool of money available for care services exist that they are almost insulting to those for whom a) the thought of having enough money allocated to pay for two tickets to a football match would equal 7 showers a week – so it’s football or cleanliness and b) that group of people (because, yes, much as the government don’t want to accept it, they do exist) that actually WANT to go to day centres.

And so we plough on.

But even though I have had many criticisms of the way that personalisation and particularly personal budgets either managed centrally by the local authority (where the end effect is exactly the same for the service users in most situations) or delivered by direct payments (where someone has to have capacity and desire to take on the direct payment and employ assistants or have someone who is willing and able to do that for them) – there is more to the personalisation agenda and process which is in danger of being lost in the process.

Personalisation as a value base and an approach to work and social work in particular with people who need or who are eligible to receive services for care ties in perfectly with aims of re-addressing the power differential between provider and ‘receiver’ and the imbedded dichotomy between ‘giver’ and ‘taker’ in society.

That model of giver/taker which is bound within the welfare state system can create an imbalance and the potential to give back some of the ‘control’ and some of the decisions to the person who receives services may, in some way, redress elements of this balance. There is no way that my training and experience has taught me better than anyone else, what YOU as a recipient need. Yes, I learnt my theories and my models and understand that building social networks is important but if you prefer to do that at a coffee morning at the local museum instead of at a day centre that’s perfect. If you want your neighbour’s granddaughter to help with your personal care rather than an anonymous and frequently changing ‘carer’ from a local agency who is paid at mimimum wage and has a day full of appointments and who isn’t paid for travel time by her agency so she needs to cut short on some of the time – perfect.

But we already had that system with Direct Payments. Where is the difference?

Ideologically, the difference was that everyone would know how much money they were ‘getting’ – whether directly or managed and they would be able to be consumers. Our society tells us that money is power. Money creates consumers and the market will right itself.

Even, theoretically, when a personal budget is managed by a third party (and I include the local authority as a potential ‘manager’) you will know how much is ‘allocated’ to you so that you can ‘spend’ it in the way you want.

This doesn’t happen in practice though because local authorities need to save money and are still tied up into procurement contracts that make agencies unequal when ‘bidding’ for the funds that have been allotted via personal budgets.

I know this is getting a bit technical and complicated but it’s important to understand. I don’t think anyone can oppose ‘personalisation’ as an approach regarding empowerment and ideology.

The implementation, however, reeks of money-saving and penny pinching. It also has pushed the responsibility for services away from the local authorities and onto individuals and their carers.

You have £100 per week, find the care yourself – then we (the LA) aren’t responsible anymore.

I’m wholly in favour of contracting out assistance and advice on self-assessments and support planning to local voluntary sector organisations. My own LA tried that. We referred lots of people to them.  They withdrew because we were referring too  many people to them and the local organisations didn’t have the resources (or the contract) to undertake as many support plans as were being referred – but the idea is not one I have any problem with and in fact, I rather like it.

But this wasn’t offered to people who do not have the capacity to lead in their own self-assessment and support planning. The organisations couldn’t do that because they were not experienced in non-directed advocacy work – it takes longer.

It is hard to see through the budget cuts as well towards a future where, as Burstow as said he wants direct payments to be the ‘preferred method’ of delivery of personal budgets.  I don’t want to detract from the fact that this is and will be fantastic for some, perhaps most people, we move to a model where there is – again – a ‘one size fits all’ approach.

The true tragedy of the personalisation agenda is that is has and is coming to fruition during a period of cuts – the government (and the previous Labour government too) want to pull back the responsibilities of local authorities and with the criteria for accessing any support is rising rapidly it may well be that more and more personal budgets are delivered directly from peoples’ own savings or disability benefits (while they still exist).

I am fearful of the future for adult social care but I’m not necessarily unhopeful.

I think there is potential for change and development but unfortunately the ways I see of improving systems come at higher cost.  There has to be some major research and debate about the delivery of personal budgets and the way that personalisation encompasses people who lack capacity and lack advocates (family and friends) and how they can best benefit from this process – perhaps access to additional funds to pay for the trust fund type system of management we were assured would happen but in practice is not feasible for a relatively small sum of money as it costs more than it might deliver.

We need to see more about how support planning can work in the voluntary sector as, speaking personally, I genuinely don’t have time to do the process of support planning any justice as a part of my day to day job. It ends up being rushed because I can’t devote a couple of visits of a couple of hours to talk through and develop a truly person centred support plan.

The process of self-assessment needs to be reconsidered because while the idea is fantastic for some people – our self-assessment forms are biased towards physical disabilities and look scarily similar to a DLA form where people are asked to explain how they are on ‘their worst day’. That doesn’t really help with confident-building when you are working with someone who has very low self-esteem and depression/anxiety. The process of self-assessment in itself can and has been traumatic – let alone the person who is not able to engage with the assessment process due to a lack of mental capacity where questions about ‘dreams, hopes and wishes for the future’ while well-intentioned, can be hurtful and hard for families to listen to when they are asked to their parent who has advanced dementia.

I fear we have allowed a great conceit to be steamrollered into simply another ‘one size fits all’ approach to developing social care. It doesn’t have to be like this but that seems to be the government perception about what ‘personalisation and personal budgets’ are.

Choice is fantastic of course, but sometimes people want quality as well. It shouldn’t ever need to be an either/or. It does feel like it at the moment with the promotion of choice above all things.

So where are we going? Personalisation isn’t going away and nor should it. Personal budgets aren’t going away and nor should they.  Local authorities, however, might be going away – further and further away from social care and the responsibilities that they hold towards it.

We keep up with the advocacy and with the systems that are failing because we owe it to those who are reliant on these systems to make them work as best they can but we keep trying to pinpoint and pin down the flaws in the implementation with the hope that sometime, some day, someone will listen.

As professionals we don’t oppose personalisation. We have always been trying to use person-centred approaches. We just dislike injustice and inequity and that seems to be painted all over the current implementation and the frustration is that so few people (if any) in government seem to be aware.  Am I disillusioned? Yes, definitely. We were promised new ways of working in a more person centred way.

Desperate, no, not yet though as long as there’s some fight left in the belly to keep banging on and on and on about what personalisation SHOULD be and why it isn’t working yet. Not for everyone.

Are Beans more valuable than People? – Or A Day at Community Care Live 2011

Yesterday I went to the C0mmunity Care Live conference. It is an annual event put on by Community Care Magazine and runs across two days. Being one of the very few free events (and excellent – free isnt the ONLY reason I go but it does help!),  I’ve always made an effort to attend on one or other of the days and try and catch up on the workshop and debate programme that is put together about a very wide range of subjects relating to social care in the UK.

I went to a few workshops and my attempts at ‘live tweeting’ were scuppered initially when a colleague from work came to sit next to me in the first session.

It was a packed session run by the Mental Health Foundation about their Dementia Choices project and the title of the session was ‘Can personalisation and direct payment support work for people with dementia?’. There was an initial presentation about the research evidence and the project that the Mental Health Foundation had put together to pilot direct payments among adults with dementia  and then there was a talk from the daughter of a service user whose direct payments had changed her life.

I was a bit disappointed though. Not with the presentation and talks – they were very good and it was obviously something that was very deeply felt by those who have direct payments working for them but, in a sense, I felt that the speaker who first received direct payments for her mother in 2003 (I think – that’s from memory but it was a good few years ago) could have made the same speech about their use about 2 or 3 years ago before the move of the more widespread personalisation agenda. Her mother had been receiving direct payments for 8 years. What was ‘different’ then with this new push towards everyone receiving a direct payment?  I refer to my previous points about us knowing that direct payments can work incredibly well if there is an involved family to provide support for the person who may lack capacity but for the isolated older person who lacks capacity there is no ‘magic wand’ to make the systems that are over-complicated seem suddenly more empowering if there is no-one to take on the support planning role.

I’ve said this before and will again that I feel currently there is a two-tier service that we are providing where those with involved families and carers may receive the more individualised support plans simply because the additional time burdens of arranging support is placed on informal carers whereas those who do not have those networks receive exactly the same services as they always do – we just call it ‘managed personal budgets’.

The workshop instilled in me a kind of despair that this group of people that I work with a lot has again been sidelined in favour of the ‘easier’ groups. Where is the research with people who have greater cognitive impairments and who don’t have family members or carers who can or who are able to manage their support plans for them? Ah, a role for the voluntary sector perhaps? The problem is that the voluntary sector is also shrinking and someone needs to pay them so that a role for ‘support planning’ is likely to mean a lower personal budget.

Still, I know I should try and be more cheerful about it. It just seems that so much of the research time spent about personal budgets has been telling us things that we already knew about research that had taken place around marginalised groups regarding direct payments.

The second session I went to was about the need for media and social workers to work more closely together. Social Workers should not be afraid of the media and the media (and by that, the panel were referring particularly to main stream media – because that’s where the battles are to be won!) – should have a chance to engage more with social workers. The usual subjects of local authorities barring their employees from speaking to the press came up and hopefully the College of Social Work will be addressing this on a broader scale.

There are a lot of inaccuracies reported and it would be good to see more social workers able to contribute to debates about the work which we do to quell some of the misunderstandings.

I then went to session on Making Personalisation Work in an era of cuts. I almost didn’t go because I thought (wrongly, as it happened) that it would irritate me and that it would be people lecturing to us again how it is the intransigence of social workers which is holding up the forward march of social care.

It wasn’t that at all and for once, it really did sound like people were actually listening to what I wanted to say about the personalisation agenda and my fears for it. There is nothing at all I would like to do more than work in a person centred way regarding care and support planning. This is something I hope that I have always been doing since I qualified though. If it can be improved, it must be and I am more than willing to change every way I have of working in order to improve it but, and this was noted by the speakers, Peter Beresford and Miranda Wixon (of Think Local Act Personal) in some ways the government’s agenda of cuts has overtaken the meaning behind the ‘personalisation’ agenda.

Unfortunately, there has been a drive to try and deliver more for less and it is not only unrealistic, it can involve pushing people into making choices that they don’t necessarily want.

Beresford made the point that the government agenda is about pushing everyone onto direct payments as the ‘preferred method’ of delivering personal budgets but, he said, crucially – ‘preferred by whom’. Well, that would be the government.

There are more ways of delivering person centred planning and person centred support than providing the cash for someone to buy their own services and while it can work incredibly well for some people, there is the very real and often ignored or side-lined issue that it is not everyone’s choice to have that choice.

The excellent concept of personalisation and putting the primary role of designing support into the hands of the user of that support and the services is being lost to the marketisation agenda.

There was a speaker on the floor, in the question time who explained that the rate of pay for carers was lower than the rate of pay for employees in Tescos – asking, ‘Do we really value cans of beans over human life?’. It makes you ponder for a while – but there are vast issues about the undervaluing of care and support staff in our culture – not just through poor pay but through poor status. Surely the ‘heroes’ of our society should be the home carers and the support workers as much if not more than the professionals whom we traditionally hold in high esteem such as doctors – who, while performing fundamental roles are at least well-compensated for it.

Another speaker spoke about an issue that I am all too aware of where choice is actually reduced for service users as in-house local authority provided services are frozen out of the provider choice that has been given to users.

Can personalisation work then, in an era of cuts? We don’t have any choice. It will because the concept is a good one although the danger is that it has been completed hijacked by a government’s cost-cutting enterprise which will end up making social care delivery so restricted that it will barely exist in all but the most extreme situations.

It is not possible to detach ‘personalisation’ from ‘the era of cuts’ as local authorities have to divest themselves of many of their functions. I see a lot of third sector organisations and possibly private sector organisations moving into the support planning and assessment verifying and supporting roles. The money (when it comes) may come from the local authorities but they will not necessarily be involved in many of the intermediate processes. It may well be that some aspects of the work are far better done in other sectors. It will become far more usual for people to pay for their own care as the eligibility criteria rise – those who can afford it anyway – those who can’t afford it may well be waiting until they meet the critical bands of need before they receive support.

There will be a two-tier system of social care support. Those who can afford to meet their own ‘moderate/substantial’ care needs according to the Fair Access to Care Services and then shift to maybe receive some support from the local authorities as their needs increase – and those who can’t afford to meet their own moderate and/or substantial needs who will deteriorate more quickly and reach the ‘critical’ band which will qualify them for support quicker at the cost of their health and independence.

I am trying to think of a positive to end on. It was good to hear some of the concerns about the pushing out of the personalisation agenda are being heard. It was good to see groups of social workers who want to be engaged in the process of change.  I got a good supply of pens and although I wasn’t able to nab a mug, I did get a frisbee!

I almost forgot too, that the announcement of the memorandum of understanding between BASW and the College of Social Work – great news. Long overdue in my view!

Personally, I enjoyed being able to catch up with some people I’ve known a long time, others I’ve come across before and some I’d only ever met in a ‘virtual’ capacity – thanks to Shirley Ayres, the team at RiPfA and of course, the Community Care team as well as others who will remain nameless!

Law Commission Report on Adult Social Care – some thoughts

I’ve not had much time to look through the Law Commission Report into the proposed changed in Adult Social Care Law but to say it’s been long needed is an understatement. Adult Social Care Law is a hotch-potch and a mess. A couple of weeks ago, I was talking to a student who asked for some help with her law revision and she put it very succintly to me when she said it was much harder to understand community care legislation because it was ‘all over the place’ as compared to legislation related to work with children or in the mental health fields.

Hopefully, there is an upcoming reassessment and improvement in the way that community care legislation and legal duties are delivered through a single Act. That was the purpose of the Law Commission Report.

There are 12 parts to the report and I’ll briefly look at each section and make no apology for summarising the bits that I, personally, will find useful and interesting. The report in full and in summary can be found here. Among all the links, there is also an audio version available.

Part 1 – Introduction

Unsurprisingly, this explains the background to the report namely that adult social care legislation is currently spread across disparate Acts of Parliament and there are some pieces of legislation that remain ‘on the statute book’ but are not currently in use/useable (s47 of the National Assistance Act!)

Usefully, this section does introduce an initial brief definition of ‘Adult Social Care’ as being

the care and support provided by local social services
authorities pursuant to their responsibilities towards adults who need extra support. This includes older people, people with learning disabilities, physically disabled people, people with mental health problems, drug and alcohol misusers and carers.

The introduction continues to explain the timetable for the change process and some of the policy developments (most notably ‘personalisation’ and the move towards personal budgets in social care) that are taking place in the context of this review.

Part 2 – Defining Adult Social Care

While a brief definition was given in the introduction, this second section explains the need for a more robust definition of what or rather, who, comes into the definition of ‘adult social care’ in legislation.  This ‘definition’ will go beyond who receives services from social services departments and will include those who are not eligible for services so as well as duties regarding assessment and provision of services, there is likely to be a duty around providing more general information and advice.  This comes from splitting into two the principles of provision of social care – the universal (where the advice, information and support would come in) and needs identified following an assessment.

Part 3 – Structure of the Reform

This talks about the need for a consolidation of social care legislation. Currently, the suggestion is that there will be one single ‘Adult Social Care’ Bill which will cover both England and Wales (although this depends on how far Wales may diverge post-election).

As for the details of legislative powers and guidance, there are going to be three ‘levels’

- Primary Legislation

- Statutory Instruments

- Statutory Guidance

This seems to make sense and is particularly uncontroversial but I was particularly pleased that there will be a Code of Practice introduced (the Statutory Guidance). Those of us use to working with the Mental Health Act and the Mental Capacity Act will have a good understanding of how Codes of Practice link to primary legislation and I think they have been enormously helpful in explaining the legal issues to laypeople and practitioners.  It is actually specifically mentioned that the role of this Code of Practice will be similar to that in the MHA and MCA.

Part 4 – Statutory Principles

These ‘principles’ are familiar to those of us who work with Mental Health (and Children’s) legislation whereby there will be some underlying guiding principles and ideas to pull through the whole legislative framework.

There is an interesting discussion in this section about the way that the content of these principles had been considered when open to consultation. One of the principles (and the ‘main’ one) will be about a general aim to promote and contribute ‘to the well-being of the individual’ but the Act will also encompass some of the ways that this can be done by ensuring the individual in question is included in the process.

There is also a principle (unsurprisingly) about safeguarding adults from abuse and neglect and using a ‘least restrictive’ principle which will be familiar from the Mental Capacity Act. I am interested in how a ‘least restrictive’ principle will work in the context of people who do not lack capacity but I expect the issues will become clearer in the passage of time.

Part 5 – Assessments

Ah, the Assessment – that ‘core legal right’ at the heart of the Act and what will be the ‘gateway’ to services however they are delivered. Firstly the term ‘community care assessment’ was criticised as being old-fashioned. To be honest, we don’t use the term in any context except a legal one anymore anyway.

It is agreed that the threshold for accessing an assessment should be low and and that the assessment itself could be seen as a ‘service’ in its own right – the comparison is made with having a GP check up.

The local authority would be able to flag up voluntary sector services for people who did not meet the eligibility criteria and would be a source for advice and information as well as services.  The paper also talks about clarifying the position of people who refuse assessments so they might be able to access information and advice without having to have an ‘assessment’ of any kind.

The threshold for a fuller assessment will be met when a person may have needs that could be met by service provision so there will be a change of language in the law however there is a (quite right) determination that the threshold will remain low – because you might not know  if the need could be met until you have assessed!

There are a number of more specific guidelines mentioned about the way assessments should be conducted and who might conduct the assessments and how they would be undertaken. Generally, there are likely to be statutory instruments covering some of these issues and the details will follow, no doubt. There will be some scope for specialist assessments to be requested in certain circumstances where the user might have specific needs.

There was some mention of this being a reserved task for social workers but that was dismissed quite summarily (because there wouldn’t be enough social workers, I presume) and will be a matter for the statutory instruments!

There will also be further specific guidance about the scope and place for self-assessments in the process.

Part 6 – Eligibility

This is quite a complex one but basically, the recommendations include codifying what is, in effect, current practice – namely that the social care needs identified through an assessment are measured against eligibility criteria and if the individual meets those criteria as determined, the local authority arranges or provides services to meet those needs.

There would be in indication in the Code of Practice regarding the levels of eligible need and how the councils would interpret them.

The law is not going to specify where the line should be drawn by the local authorities regarding setting the ‘thresholds’.

Interesting discussion in the document about duties under s21 of the National Assistance Act. I won’t go into details because I don’t have time but it looks like the duties will be recommended to be retained.

Part 7 – Carers Assessments and Eligibility

Unsurprisingly, there will be a consolidation of duties under various carers’ legislation to provide a carers’ assessment. I’m shocked when I hear of the number of people who are not being offered carers’ assessments when they should always be as a matter of course. Hopefully, this will be an imagining of a long distant past.

The ‘cared-for’ person needs to have at least some social care needs for the carers assessment to be ‘triggered’ and not only ‘medical’ needs. This is a bit of a blind spot in my view but the document recognises this and feels that any changes made in regard to this have to be done as a matter of policy by the government.

The requirement to provide a carers assessment will though apply to any care provided and not be limited to those providing ‘substantial’ care as it is as at the moment.

It is proposed that rather than the carer needing to request an assessment, the local authority will have a duty to provide which is far better as I see it.

Part 8 Provision of Services

There is an discussion in this section about whether or not to define what ‘services’ actually are in the context of that which can be provided. It was felt by the commission that there should be some kind of list involved and that there was also a need to specify preferred outcomes of the provision of services. The list will take the form of categories of support in the context of those which will provide the desired outcomes.

The recommendation which explains it far better than I can annotate, explains

Community care services (however named) should be
defined in the statute as any of the following provided in accordance with the
well-being principle:
(1)  residential accommodation;
(2)  community and home-based services;
(3)  advice, social work, counselling and advocacy services; or
(4)  financial or any other assistance.

The statute should set out the following list of outcomes to which the wellbeing principle must be directed:

(1)  health and emotional well-being;
(2)  protection from harm;
(3)  education, training and recreation;
(4)  the contribution made to society; and
(5)  securing rights and entitlements

I actually really like the idea of including the outcomes. I think it adds significant clarity to the position and scope of provision of services overall.

It’s also interesting that social work services are seen as a discreet ‘service’ as opposed to advice, counselling and advocacy. I wonder if that is a shoe-in for a different type of social work with adults in the future. We can but hope.

Carers’ services will follow similar guidance as above.

A care/support plan must also be provided in written form for the user and carer (if necessary) that should include assessed needs, eligible needs and desired outcomes. I see in my future more paperwork but actually, if it is going to be an improvement, I’ll welcome it with open arms!

Direct payments will be retained in their current form and interestingly there is a proposal to introduce them to allow for payment for residential services.  I am not necessarily opposed to this however I do think there are some practical issues that are a concern. I’ll have to come back to this though in a post of its own!

None of the existing provisions for services that are being provided free of charge (for example those subject to s117 aftercare) will be affected by this and they will continue to operate in the current form.

Part 9 Adult Protection

There will be a specific role for the local authority to lead on safeguarding processes regarding adults at risk of being abused. In fact, the term ‘vulnerable adult’ will be replaced by the term ‘adult at risk’.  The document states:-

We, therefore, proposed that an adult at risk should be defined as a person aged 18 or over and who:
(1) is eligible for or receives any adult social care service (including carers’
services) provided or arranged by a local authority; or

(2) receives direct payments in lieu of adult social care services; or

(3) funds their own care and has social care needs; or

(4) otherwise has social care needs that are low, moderate, substantial or
critical; or

(5) falls within any other categories prescribed by the Secretary of State or
Welsh Ministers; and

(6) is at risk of significant harm, where harm is defined as ill treatment or the
impairment of health or development or unlawful conduct which
appropriates or adversely affects property, rights or interests (for
example theft and fraud).

Quite a broad definition but contrary to be beliefs of some, does not include everyone over 65!

Harm will be defined as

(1)  ill treatment (including sexual abuse, exploitation and forms of ill
treatment which are not physical);

(2)  the impairment of health (physical or mental) or development (physical,
intellectual, emotional, social or behavioural);

(3)  self-harm and neglect; or

(4)  unlawful conduct which adversely affects property, rights or interests
(for example, financial abuse).

but significant harm will be a judgement process.

Section 47 of the National Assistance Act will be repealed which is unsurprisingly and there will be another commission to look specifically at what it should be replaced by. This is, perhaps, where compulsory powers of entry will come in.

Adult Safeguarding Boards will be put on a statutory footing and there is some additional guidance on how they will operate.

The qualification that Guardianship can only be used for people with learning disabilities when there is abnormally aggressive or seriously irresponsible conduct’ will be removed which I think will allow for better protection for people with learning disabilities in the longer run.

The other sections of the report, I’ll cover very briefly

Part 10 Ordinary Residence and Portability

There is some clarification on the rules about residency in a particular authority and the principle of being able to take the assessment between different local authorities is, quite rightly, introduced.

Part 11 Overlap Issues

This part clarifies some of the areas where there are different pieces of legislation and particularly where there would be a crossover between health and social care issues but also with housing issues, forensic services and with childrens’ services.  There is some guidance about clarity regarding continuing care guidelines and how direct payments might work if they are extended into healthcare (which is likely).

It also recommends that adult social care teams can assess 16 and 17 year olds .

Part 12 Other issues

This includes a look at the right to advocacy which the report says should be retained as far as it already exists but not extended.

The local authorities will retain their registers of people who are blind and partially sighted and have discretionary powers to maintain other ‘registers’.

There will be a continued review about a proposed definition of ‘a disabled person’.

So that’s all! Well, it’s been interesting to read through. Generally it seems like a substantially positive review and I think it will improve the way that services are delivered and at least make it clearer. There are parts of the review I’d like to explore in more detail – particularly the safeguarding arrangements and some of the items in the overlap issues like continuing care but I’ll have to come back to them.

I’d be interested to hear other thoughts about the process!

Personalisation in Mental Health and Older Adult Services

Personalisation is a very broad brush term to describe the so-called ‘transformation’ agenda in adult social care. In very general terms it refers to the process of moving from resource-led to needs-led systems of service provision (just as the NHS and Community Care Act 1990 was supposed to do) but this time… with individual budgets.

The idea is one is it difficult to find fault with. Users and carers would have more control in choosing the type of care which was provided through having ‘pots of money’ either virtual or actual payments  and deciding how best they could be used.

The change was led, ironically, by the soon to be extinct ILF (Independent Living Fund) which was the forerunner of the Direct Payment system whereby money was put directly into the hands of service users to choose and buy their own support and hire their own carers (with substantial support regarding admin and regulation if necessary). It was a new way of doing things and it generally worked very well.

Then with the ‘Putting People First’ white paper, the idea was to be rolled out to everyone receiving a package of care from the local authority. Wonderful. We would be living in a world where patronising social workers wouldn’t be dictating that ‘they knew best’ and imposing care packages based on large scale contracts negotiated down to reduce the costs and people would be able to choose the services they wanted and the carers they needed and liked. It would all end happily ever after.

I was a great campaigner for direct payments. I saw a lot of people do extremely well from them. I also think a lot more needed to be done though in increasing the take up and levelling the parity of service provision.

It appeared to me that those best able to advocate for themselves or who had active and involved families got the lions’ share of the services and were able to cherry pick whereas those who weren’t able to access the best systems either though lacking mental capacity, through lacking the desire or just being so knocked out by disability/age or lack of family got the scraps left behind by the system. The contracts that had been negotiated by commissioners who never themselves would actually use the services of minimum wage carers who were overworked by the care agencies determined to slash costs in order to win these prized contracts.

Soon though, the announcement came that everyone would get ‘personal budgets’ for social care. Wonderful. That would level the playing field, surely.

It was quite exciting. For a time. Until we realised that the people the local authority were ‘piloting’ the system with where exactly the people that they knew the system would work with – namely those who had successful direct payments packages.

Now, in my time, and the only time I’ve done properly authorised and supervised research as a practitioner, so happened to be related to direct payments. I spent a few months researching the lack of take up of direct payments by older adults and adults with mental health needs.

Now, my research was primarily literature-based. I did no direct interviews (ethics committees take time!). There was substantial sources of literature available, even at that point.

So what was learnt from the research that had taken place at that time and how was this used to improve the service provision when personal budgets were rolled out?

It wasn’t. So we find ourselves in the same place years later.

That’s a very long background to my point this morning but I think it’s important to emphasise the context through which I read the SCIE report ‘Keeping Personal Budgets Personal : Learning from the experiences of older people, people with mental health problems and their carers’.

I read this report last week and as is the case in all the best research, it backed up, with evidence my own feelings and ‘hunches’. I like research that does that.

The main learning from the report is that the key to the implementation of a successful personal budget is both information and involvement of a professional. People wanted support with completing self-assessment questionnaires in general so while our local authority employers promised us (don’t worry, we never believed them for a second) that time saved in leaving people to complete their own self-assessment questionnaires is time we could use in ‘creative support planning’ actually, the SAQ can be a daunting document.

In my experience, it is extremely poorly drafted (possibly because the focus groups were very narrow) and I am almost embarrassed to give it out. It focussed heavily on physical care needs and asked particularly strangely worded questions about capacity which shows the author of the forms have no understanding of the Mental Capacity Act and the idea of ‘decision-specific capacity’. It reminds me (and service users I’ve taken it to) of a DLA form. Jumping through hoops and ticking boxes to get money is not dignified.

The SCIE research also emphasises the importance of having a consistent person available to take a user through the process. Again, less necessary when there is a someone who is high functioning or who has highly involvement family/carers but the resource distribution of support doesn’t create an equity for those who need more. Professional time is increasingly stretched and the time spent rushing through a SAQ and package of support is not respecting the principle of self-directed support. As professionals with heavy caseloads though and targets which are tracked and time-limited, it is hard to balance this ethically.

Moving onto the Resource Allocation Systems (RAS) which is the way that the self-assessment ‘turns into’ a sum of money – either real or virtual for the user to ‘spend onservices’. I can’t express my anger about the RAS system strongly enough. It is heavily biased against older adults. It is even more heavily biased against people who have carer support.  I don;t know how widely this information is known  but if you have a family member providing support, you suffer massively when the finances are pumped out of the ‘RAS system’. The more help the family member provides, the less money comes out. I feel this is immoral and short-sighted. It places additional stress on unpaid carers and pays no heed to preventative care.    Yes, individual cases can be argued but that takes more time and effort.

The we move to the support planning stage. You have the ‘virtual budget’ in  hand so what amazingly creative package of care can you create. Again, the evidence in the report shows that it is often information that is shared by the professional in the first place that leads to the quality of support planning.  Users wanted continuity of staff throughout the whole process of assessing and support planning so our local authorities great idea of commissioning organisations to help might miss this point – although that idea and those commissions fell through when the organisations they had commissioned were so overwhelmed with referrals they were unable to take on any more users. Oh, and the user groups that were commissioned? Physical and learning disabilities charities. Nothing for mental health or older adults. Surprise. Even though those were the groups least likely to get the support and planning needed.

There is so much in this report and it is worth reading if you are involved in any way in implementing personalisation in adult social care in the UK.

The sadly predictable thing is that I could have told the councils these messages 5 years ago but noone would have listened – come to think of it, I DID tell the implementation team 5 years ago and many times in between. They are so vested in this new system of delivery of services being ‘better’ that they are blinded to the vast swathes of people who are again increasingly sidelined and excluded from the positive thrust of the personalisation agenda.

Sadly, it feels like the lessons will never be learnt because the wrong people are being asked. No-one wants or is able to invest real money in providing better services and more flexible and easier ways of managing the service provision in the less engaging client groups.

It’s unfortunate that the agenda has sprung into life at a time when cuts are at the front of our communal minds. It has become too easy to see personal budgets and cuts in the same sentence when they were never meant to be.

The truth is that the whole system is failing those who need the support, advocacy and choice the most. You know, those elderly people with dementia who have care staff on minimum wage coming for 30 mins in the morning to give them a shower. There are lots and lots of them around.

I want to ask how is the personalisation agenda helping THEM? How is it helping us to help them? We are closing day centres because people can ‘group together and commission day services jointly’  but sometimes the purpose of a day centre is the company that you surround yourself with, the support of peers and not about completing a specific task or learning a specific skill.

More able, more active older adults may well use their ‘day services’ budget to go to the local bridge club or swimming pool – but how about those with advancing dementia whose carers need the respite that day services bring as much as the company and hot meal are welcomed by users. Are the local swimming pools and adult education colleges going to be suitable for all?

The idea of personalisation was the it would be something that would be actively chosen and engaged with and there is no doubt, it works very well for those who are actively interested and engage with their care services.

My concern is that the process has, again, run away with itself and left behind, far behind, those who cannot make decisions for themselves about their own needs and who don’t have family to advocate for them. They are left with the same ‘old style’ service delivery model of the cheapest agencies providing poor quality care by rushed carers on minimum wage. The difference is now the day centres are closing and the government are telling us this system works better.

The sad thing is, if they had read and understood the research that was available at the time regarding the take up of direct payments by adults with mental health problems and older adults, they would have learnt all these lessons and maybe put better systems in place. The cynic in me says they only wanted to see success and the same groups of service users suffer yet again.

One of the things that saddens me the most on a personal level, is that I was always a great advocate of the direct payment system. I plugged away with it and got some incredible results with specific service users.  I was the little pet of the direct payments team, explaining again and again to my colleagues who wonderful it was to be able to reliquish control and allow and promote user choice.

I wanted and was sure the system of personal budgets would be even better. It would be more inclusive. It would fix the faults of the direct payments system because, look, we had research to back up why it  hadn’t worked so well with these particular service groups (older adults and people with mental health problems).

All the research was ignored. Mistakes were replicated and exacerbated. If anything it is even more exclusive and inequitable than the previous system and no-one seems interested in listening to any of the real concerns and criticisms.

A great opportunity has been missed. Hopefully someone somewhere will actually read the SCIE research paper and think about making real changes in the systems of delivery and implementation. It could all have been done in advance though and that’s the true tragedy of the personalisation agenda.

Cuts – a personal tale

A couple of weeks ago, I had one of those deeply depressing moments that will generally punctuate a career in social care.

I had to go and tell a woman, who cares for her mother with enormous patience and dignity, that we could not increase their personal budget although her mother’s care needs had grown.

I suppose I went to my manager in a relaxed almost casual way and explained how the needs of the older woman had changed and to ensure her well-being, she needed additional time.

I was told, with a degree of equal sadness and regret that there would be no increase. If we were to provide what I felt was a necessary increase in care, the time had to be taken from the the hours already allocated.

She did, to her credit, try to have a discussion about this with her own manager but there was no budging on budgets. Despite the change in various situations, there would be no extra money. In fact, she added, the plan really needed to be cut.

It had been my first personal budget implemented. The council, in an attempt to encourage and prod us to implement these personal budgets had promised us and by extension, the service users and carers we work with, that no-one would be disadvantaged by moving to a personal budget so even if the RAS (resource allocation system – the way that figures are attached to needs through the personal budgets  system) did not ‘deliver’ enough money to provide an equivalent package of care that had been delivered under the ‘old’ system – it would not be reduced (and here’s the key) at least, not initially.

Now this particular service user and her daughter had what was a high package of care. It had costed much  more than the ‘RAS’ had spat out.

After making the promises, after the move to personal budgets is no longer an optional roll out of volunteers – the cuts are coming.  There is no longer the carrot to offer of ‘equivalent packages of care’ because we now offer everyone as a matter of course a personal budget and those who were not receiving them are being transferred over to the new system regardless – they don’t have to be self-managed, of course, but they have to exist.

So I visited the family and we looked at ways of shifting around hours.

The hours that were cut were the respite hours.

I suppose it was inevitable.

Family carers are invisible. The work they do is not costed. Of course the daughter was sacrificing her own needs for a few hours respite to her mother’s needs for additional personal care.

This is what the cuts mean to one family.

I had to tell them and negotiate with them about what to cut from their own package of care.

Not the Prime Minister. Not the Millionaires in the cabinet. Not any elected politician or Council Chief Executive. No councillor had to sit in that room with me and look the service user and carer in the face and ask them what they would prefer to give up from their package of care.

I’ve known this family for many years. I have a good understanding what is at stake for them and how much these cuts are hurting. I also know they won’t complain or grumble or shout from the rooftops.

They are not going to be going on any rallies or demonstrations against the cuts – not least because the respite hours have been cut.

We who can, have to demonstrate and shout and scream on their behalf.

And you know, as I know and I say this with a heavy heart – they’ll be much more of this to come.

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