Fast tracking Mental Health Social Work

First they came for the children and families social workers..

Last year, the government announced the shiny ‘Frontline’ scheme which was designed to fast-track ‘elite’ graduates into child protection jobs in ‘tough’ areas and push these sparkly bright graduates into ‘leadership’ roles. At the time, I moved this blog out of retirement specifically to challenge the processes, thinking and mostly the lack of consultation and involvement of children and families social workers – or indeed any social workers – when this scheme was developed. I’ve written about it here.

I spoke out and spoke up as best I could because I think these ‘fast track’ schemes are a folly and are attempts at solving the wrong problems. I lost that battle because it was the government doing what the government wanted to do. Yes, those in favour say, this is just about another route in to social work – perhaps I’m simple-minded, not being an Oxbridge graduate and all, but I thought we already  had the post-graduate route in to social work training (Masters qualification route). We even had a specialist child-focused route in to social work (Step Up to Social Work – which I’m also not a massive fan of, incidentally) but no, this would be different because this would fast-track even more and focus even more. So it would take all the worst parts and combine them.

This morning, the Independent reports that the IPPR (the same think tank of policy bods who haven’t got a clue about what social work actually looks like) are presenting a lovely report to Norman Lamb about encouraging graduates to move into mental health social work and this week ‘Think Ahead’ will be launched. Actually just typing that causes a deep nausea in my stomach and makes me shake with rage. ‘Think Ahead’ – that’s nice.

This is what the Independent says

Just 10 Oxbridge graduates studied for a social work master’s degree in 2011-12, compared with 10 per cent of the entire cohort applying for Teach First, the successful graduate teacher training programme. Despite the high skills required and difficulty of adult social work, very few top-flight students regard it as a prestigious job, the IPPR report says.

So that’s it, guys. Quality is judged by whether you are an Oxbridge graduate or not. Apart from the nausea, I have to say the tears are coming now. There are fantastic mental health social workers out there. There are fantastic mental health social workers coming through. This is a kick in the teeth of the highest degree. If we didn’t go to Oxbridge, clearly we aren’t good enough. Is there so little understanding that the issue is not about new entrants into mental health social work but the pulling apart of mental health social work so that there aren’t any jobs anymore. Surely we should be focussing on THAT. There is no shortage of newly qualified social workers who are very skilled who want to work in mental health. Maybe pushing some of the money and support into building strong post qualification frameworks to support them might be a better idea than pulling in people who don’t really have a clue what social work actually is.

 

Government endorsed ageism

I worked in an older adults mental health team. It is vital that I had a good understanding of adult social work as well as mental health social work. Lamb’s comment sticks in my stomach.

Mr Lamb said last night he was “very enthusiastic” about Think Ahead. “We are looking for people who can commit to do something to make a difference to young people with mental health problems, particularly people in their late teens and early twenties,” he said.

See, as far as Lamb is concerned, his focus is on making a different to YOUNG PEOPLE. Does he even know what mental health social work is or is he trying to develop a programme which is a mix between Frontline and Think First because, you know, Frontline blatantly isn’t focusing on anything other than child protection social work. This is evidence of the clear folly of building social work into specialist silos. This pot is where Mental Health goes. This pot is where Child Protection goes. We’ll train you as a ‘specialist’ social worker – whoops, what do we do if a child has mental health needs? Heaven forbid someone has dementia and that needs specialist social work input. Has there been ANY thought about it because it doesn’t look like it. I’d like to know from Lamb how many practising social workers they spoke to and where those people work – as well as their names – as they clearly don’t have a clue what happens in mental health social work nor what is happening now as local authorities pull their social workers out of mental health trusts. And that is happening all over the country.

What is social work?

According to the Independent article

The IPPR research shows that nearly 50 per cent of local authorities have problems recruiting high-quality adult social workers.

Well, I, for one, can’t wait to see the figures behind that research and there seems to be some confusion between adult social work and mental health social work which are not actually the same thing but I doubt the IPPR Oxbridge PPE graduates realise that. We are increasingly seeing a fragmentation of social work into discrete areas – you are a child protection social work or a mental health social worker etc. This is not helpful as the thing that makes the profession cohesive is our broad generic base. If we look at what social work is, it’s about a value base, an emphasis on reflection and social justice, a key understanding of how pieces fit together which are beyond labelling definitions and a focus on strengths-based models of working with people using specific approaches. This is beyond child protection processes or care management processes and it is what makes the profession one. I was disappointed to see one of the Chief Social Workers (for children and families) ask why genericism was important on twitter this morning when nurses had specialist training. What an utter heart-sink moment that was. If we have to explain why genericism is important to the fundamental definitions of social work to someone who defines themselves as a government appointment social work ‘leader’, I’m afraid we, as social workers are losing the battle. It is important that as social workers – social work practitioners, students, academics and social workers internationally, pull these definitions back from our government which is trying to define us by the processes that they ask us to do. We are far, far more than our tasks and that is why generic qualification is necessary and important. We need the space to understand beyond our specialisms and to grow and explore our values – because it is social work values that make social workers, not knowledge of specific child protection processes.

 

Choosing your team

Then the Independent goes on to say

The Think Ahead scheme will run as a social enterprise and operate rigorous two-year courses, starting in September 2015, for the “best and brightest” who could bring leadership to the profession. The board of the social enterprise will include Paul Farmer, the chief executive of Mind, and Dame Carol Black, the chairman of the Nuffield Trust and an adviser to the Government on health and social work. Mr Lamb also consulted Alastair Campbell, who has written extensively about his personal struggle with depression, on creating the programme.

And we get to the point. These are going to be the leaders and not the practitioners. They are not remotely interested in promoting good practice in mental health social work but producing a fast track leadership programme for privileged people who wouldn’t want to dirty their hands with actual social work. None of those people mentioned, the so-called ‘great and the good’ who are going to be on the board of this social enterprise are social workers. NONE OF THEM. Can we stop and think about that. Can we think about another profession that the government would treat with so little respect? We saw Ed Balls consult an agony aunt from the Sun to decide where social work should go after Peter Connolly’s tragic death. Now Lamb is no better in asking Campbell. This is a mess and it’s a government promoted mess. But he doesn’t need to bring social workers along with him because he is going to grow his own social work leaders who look like him, went to Oxbridge and don’t need to have any understanding of mental health social work. It makes me sick to my stomach and it’s difficult for me to even read but I’ll go on.

 

Kicking the profession while you’re at it

Now this bit made me laugh.

The new IPPR report says that “more than 90 per cent of directors of adult social services believe more needs to be done to attract the highest possible quality candidates into the social work profession”. Directors believe many job applicants lack analytical ability and intellectual capacity, awareness of evidence, practical experience of social work, and leadership skills.

The Director of Adult Services in the local authority I worked in didn’t actually realise that we, the mental health social workers which he had seconded into our mental health trust, were employed by him. He certainly wouldn’t have a clue what we did on a day to day basis or how skilled we were. And if he had said we lacked analytical ability and intellectual capacity, well, I’d have asked him (but he wasn’t remotely interested in what we did) to come out on a Mental Health Act Assessment with me. Does the government realise how insulting all this is? I think it does. They want to divide and rule and tell us how rubbish we are so we need to fling some Oxbridge graduates into the mix. Does Lamb or the IPPR even KNOW the difference between adult social work and mental health social work? Do they know that most Directors of Adult Social Services don’t know who their mental health social workers are because they are mostly seconded out? It sounds like pure ignorance of the sector to me. It seems like the government have built a solution without actually knowing or analysing the problem and certainly without an understanding of mental health social work.

And then the article says

Demand for adult social workers is high: a third of all families includes someone who is mentally ill, while one in four people will experience a mental health problem during their lifetime. In 2010, more than 1.25 million people used specialist NHS mental health services.

Ha ha. Ha ha. Seriously. Does the writer of this article actually know that these services have been slashed to pieces. Yes, more people need mental health social work  but there is less money and far, far fewer social workers delivering social work in Mental Health Trusts than there was in 2010. This makes a mockery of those of us who know how hard the cuts have hit.

 

Then we have the final kick in the teeth

Jonathan Clifton, senior research fellow at IPPR, said: “As the number of people diagnosed with mental ill-health increases, there is a moral imperative to develop effective services that can support each of them.

“Too many people can be let down when things go wrong, causing distress and putting vulnerable people at risk. A fast-track programme like Think Ahead could be one step on the journey towards changing this.”

Oh, dear, Jonathan Clifton, you really are a bit thick and haven’t done your research very well if you are the best they can do with a ‘senior research fellow’. The issue isn’t the quality of support and the fast track programmes. The issue is mental health services have been utterly decimated by this government and there isn’t money left to pay those who did the job well. I know because I left when we went through cuts which actively harmed people who used the service. Yes, vulnerable people are at risk but they are at risk because of people like Lamb cutting mental health services and support  – not because there aren’t people coming into the profession.

 

Rage, rage against the dying of the light

This scheme is ill-thought out, ignorant and insulting. It shows no understanding or insight into mental health services or social work services. The quotations are muddled, the thinking is illogical. As social workers who are committed to driving the profession and most importantly supporting and advocating for people who use social work services, we need to shout out and long about these destructive programmes and the lack of input that social workers have had into them.

If we want to look at what will ‘save’ mental health social work – I’ll  happily tell Lamb but then, as a social worker, I’m not the kind of person he’d want to consult with – especially as I guess he’d say I lack intellectual and critical rigour and analysis (although I’d like to see him say that to my face). You see, Lamb needs cleverer people than social workers to decide where social work needs to go – clearly. We are too thick and too many of us are plebs for us to be properly informed and consulted. No, it needs a think tank and other professionals to tell us. But if he were to ask me, this is what I’d tell him.

1. Fast track isn’t the answer. Longer, slower track is.

Keep the generic qualifying routes we have. We have postgraduate qualifying routes. What’s wrong with them? THEN, then, we have a robust, compulsory one year additional course supported by employers to get the specialist skills embedded but where this ‘let’s focus on young people’ thing comes from I don’t know. If we are going to build specialisms, please lets have an older adults one too which combines specialist mental health (particularly around dementia and late onset functional mental health needs) and physical disability which often affects older people.

We need more time not less time.

 

2. Consult social workers who are actually doing social work

I know, this is blue sky thinking. Who would think they could change the profession and actually ask the professionals working in the field. What would we know? But it would be nice, wouldn’t it.

3. Listen to people who rely on social work services.

Quick, let’s find ‘one of us’ who has had a mental health difficulty and shove them in the consultation. Ergo Alistair Campbell. No, Mr Lamb. Find someone who is currently using a mental health social workers’ services. Someone who has been detained by one of us. Find someone who is living in poverty and is being supported by a social worker because they don’t have any other support. Of course, have Mr Campbell as well but he may not be representative of all people who use social work services. Show a bit of respect to those who are reliant on these social workers coming through.

4. Drop the leadership strand.

You can’t train new graduates to be leaders without actually doing the job. We would be creating the wrong leaders. Look what the NHS graduate leadership programme does when leaders grow who haven’t had any clinical experience. The focus is on providing good quality social workers so why push them into leadership roles immediately. Leadership has to be earnt.

5. Genericism is important.

I won’t repeat myself but it is what makes social work, social work. We can’t allow others to define it for us. Let’s focus on post qualification training and make that more robust. Let’s push the focus into retaining and supporting good social workers. Let’s emphasis time to reflect and grow rather than jump on fast track scheme. That will improve mental health social work.

Bedlam – Do we need stories to understand?

I watched Bedlam, a documentary based on the work done in the South London and Maudsley (SLaM) NHS Foundation Trust last week and this week. I was reassured by last weeks’ episode, titled “Anxiety” which followed some people who had obsessive compulsive disorder so I was looking forward to the episode broadcast last night titled “Crisis” which was based in an assessment ward (which they called a Triage ward) where, the programme makers told us, decisions were made about whether to admit over longer periods or discharged home.

The “story” aspect of the programme focussed particularly on four people – two men and two women who had found themselves in situations which had necessitated (or where they had chosen – in the case of informal patients) to be admitted to psychiatric inpatient wards.  Fashionable documentary style is very much in the ‘story-telling’ vein. We like stories. We like stories with ‘happy’ endings and as the programme finished, they made sure we had the resolution we required but I was left uncomfortable by a number of aspects and details in the programme. Maybe I was more critical this week because it was an area I had more experience of but I didn’t walk away from the programme thinking it had necessarily reduced stigma and instilled a greater understanding of the mental health system as it is. Of course, that’s not the purpose of TV programmes at 9pm. The purpose was entertainment and perhaps that’s where some of my discomfort lies.

I saw a lot of the positive waves of support for the programme, helpfully tweeted out by NHS Maudsley through the programme. Interesting (but of course, unsurprising) that they didn’t deal with some of the criticisms. I know the issue of capacity to consent to filming has been raised and the programme makers have addressed it.

The producers state

One of the complex questions for filming on the ward was that of patients’ capacity to consent. We’d agreed a rigorous consent protocol with the Trust which included getting an initial steer from a lead consultant in charge of the patients’ care before even approaching an individual. At times we just got a patients’ consent to film them, we had to return to them at a later date to get consent to broadcast the material. We filmed with one lady, M, for a number of days while she was on the ward and then when she was discharged home we met her for lunch and she decided not to be involved further. Central to the filming was a respect for people’s right to privacy and we respected M’s decision.

Clearly they have covered themselves legally but some of the situations presented made me wonder how much thought had been given to the future impact of the broadcast on recovery in the long term and a full understanding of the implications of being filmed at your most unwell “in the public domain” for perpetuity – and the effect on yourself and your family of this. Of course, I’m sure these issues were covered but I was uncomfortable in the same way that I was with the ‘much lauded’ Protecting Our Children series. I’m not sure that seeing people at their most unwell or disturbed is ‘entertainment’ and now ‘educational’ it is. Do we need to ‘see’ crisis? Do we need to see a psychiatrist telling a patient he is going to use section 5 (2) of the Mental Health Act to demand that he remains on the ward when he has asked to leave? Are some things necessary to film and show on the television with real people to understand?

Perhaps I’m too sensitive because I’m thinking that for me, the thought of being filmed if I were to be restrained and forceably medicated by a team of staff is abhorrent personally. And thinking about the shots of someone being ‘persuaded’ to take their medication and forceably injected, I wonder how much it was necessary to see it. It reminded me of Panorama where the abuse at Winterbourne View was shown – not because there was abuse, clearly, but because I wondered at that point too, how much needed to do shown on camera and whether we were indulging voyeurism too much. Of course, legally, the Trust and TV production company had consent tied up but I can’t say it didn’t leave me with unease at the way we view entertainment and couch it in ‘education’ and ‘attention raising’ to make us feel better.

My other discomfort, and I’ve been criticised for raising this, was some of the racial undertones and stereotypes that I felt were perpetuated by the ‘storytelling’. Dominic, the white middle class man who would be someone who could be ‘identified with’ by many at home, was a ‘danger to himself’. Rupert, a black man, was presented as having been a ‘danger to others’. I felt distinctly uncomfortable not with the people telling their own stories in the context of the programme but with the narrative of the documentary makers that ran over it. The sequence with Dominic and Rupert singing together, seemed particularly focused on the viewer ‘empathising’ with Dominic – possibly at Rupert’s expense. Dominic was someone who was ‘like us’ – at least, until he got his ‘new’ diagnosis of having a personality disorder which immediately ‘othered’ him. Rupert was presented differently. Perhaps I am too sensitive to these things but having worked in mental health services in central London, it’s hard not to attune to race as an issue – particularly when we look at compulsory admissions.

Lots happens on admissions ward but in terms of staff, we only saw doctors and nurses. It’s a shame that there was a missed opportunity to see some of the multi-disciplinary work that happens on inpatient wards constantly especially as people move towards discharge but perhaps that’s an unfair criticism, after all, it isn’t an ‘entertaining’ as seeing people in distress. The ‘follow ups’ we got intimated that hospital admissions were successful. If that’s the case (and it isn’t always although obviously, we hope it is), I’d have liked to have seen some of the ‘why’ that we saw last week. Apart from seeing someone medicated, what other ‘tools’ are used to help prepare someone to move out of crisis. In my view, that’s an opportunity that was missed.

Early in the programme, I heard the documentary makers mention that patients who were ‘informal’ needed to see the doctor before they could leave the ward. This, I have to admit made me bristle. I hope it was a misunderstanding on the part of the documentary makers as it is veering dangerously close to ‘de facto detention’ on the part of the Trust. Someone asked me, during the programme to explain this better so I’ll give it a go. An ‘informal’ patient is a patient who chooses, willingly and with capacity understanding the implications of their actions, to admit themselves to a psychiatric ward. They are free to leave whenever they like. They are not under any compulsion to stay. If staff feel they are making a clinical decision that there is a need for someone to  remain on the ward, or ‘see a doctor before they leave’ they have to ensure they have the legal authority to do so so as not to breach article 5 of the Human Rights Act – either by a detention under the Mental Health Act (known as ‘sectioning’) or by using immediate short term holding powers under section 5 of the Mental Health Act (5(2) is where a doctor can compel someone to stay on the ward until an assessment is carried out and 5(4) is where a nurse can do so for a much shorter period). Leave cannot by restricted for an informal patient. If they need to stay, or if their leave needs to be restricted there are legal processes which need to kick into place. Detaining someone is a massive infringement of human rights and needs to be considered carefully. It cannot be a flippant comment by a member of staff on a ward about ‘staying to see the doctor’.

So Bedlam this week, definitely not leaving me feeling that it was waving the flag for stigma busting. It’s a shame as the opportunity was there but the need for stories and entertainment were paramount. Personally, it compounded my view that fly-on-the-wall wouldn’t be my personal format of preference for gaining insights into worlds that might not be apparent to others. I am of the view, and I am aware I’m probably in a minority on this, who thinks that created drama without ‘real’ people on camera – at least during their moments of crisis – would be a better way to achieve this. Drama created by people who have understanding and experience, absolutely,  but I’m not sure how much seeing the ‘real time’ distress and illness is a help to those who are experiencing it. Is that my inherent paternalist nature creeping out? Perhaps it is. Perhaps I overthink things and should let people get on with it but frankly, after last week, I was disappointed with last nights’ episode – as a rather sad epilogue, I am also thinking, thank goodness the Trust I worked in didn’t agree to TV cameras. Stories are good. Stories are necessary. But do we need every part of a story to understand? Do we need to see the needle being injected, the distress and confusion, do we need to see all that in ‘real time’ to understand? Maybe we do now. I accept I probably don’t  hold the majority view on this, judging by the waves of praise for the Trust and the TV production company  but it doesn’t shake off my general unease.

RIP NHS?

Andrew Lansley, British politician and Shadow ...

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A truly national health service as conceived in the post-war years has been tottering on the brink for a number of years.  As the previous Labour government sowed, so the Liberal Democrats and the Conservatives will reap today as the NHS and Social Care Bill reaches its last stages in the House of Commons  and the Conservative Party  institute their idealised version on a market-led health service which will deliver profits into the hands of investment companies and will place efficiency above effectiveness in treatment delivery methods.

Yes, I feel bitter, very bitter. I don’t see the Labour Party hauling us out of the mess that the both the Liberal Democrats and the Conservative Parties have conspired to leave us with because the Labour Party in their previous guise very much laid the groundwork for this to be done.

I find it hard to believe the audacity and the incompetence of our political elite as they push through a hugely unpopular bill tonight but then, as I pause, I wonder if it is truly incompetence as they are ‘getting away with it’.

We have been confused by details and have been tricked into believing a ‘consultation’ process has taken place. It has taken place very much on the government’s own terms and the listening that has been done has been very selective.

I try not to have a blanket opposition to the ‘private sector’ and ‘profit-making’ in the health and social care sectors but I’ve been burnt by experience. There are some companies that may well be able to improve some aspects of service delivery and I completely accept we all need to move away from the blind public/private being good/bad depending on where you stand on the political spectrum. That’s quite hard for me to ‘get my head around’ as I feel instinctively that profit should not be made from ill-health but equally the government’s obsession with public being bad is equally short-sighted and damaging.

What really sticks is the way that Cameron has blatantly misled the country in the quest for votes. ‘No top down reorganisation of the NHS’ he said, lying openly to the nation and yet we have to accept the mishmash garbage that he is now leading through Parliament as the Health and Social Care Bill and it moves towards it’s Third Reading in the House of Commons today.

I feel angry at the way that language has been turned and stolen from us.

‘Choice’  has become a catch-word but as I have discovered through the ill-spirited and contemptuous way that ‘individual budgets’ have been delivered in social care – choice mostly a luxury of the ‘worried well’ or the more affluent middle classes – in whose ranks sit all those MPs who vote on these changes today.

Choice means very little if you are not in a group that can cost a company money rather than increase their profits.

We have been hoodwinked into believing that ‘choice’ will genuinely exist when these private companies rip up our public services to deliver profit to their shareholders? I think we should ask whose ‘choices’ is it that the government and the health companies that support then, they will be?

Let me turn to the social care sector again because that’s an area I am familiar with. I am very familiar in the ways that privatisation has worked or rather, not worked and the way that ‘choice’ has been promoted – falsely – as the achievable outcome for all end users.

The pushing of the public sector from social care delivery has decreased ‘choice’ in many instances. In the areas I’m familiar with, local authorities have been pushed out as providers of residential and home care services to be replaced by companies such as Southern Cross (RIP), Bupa, Care UK (always worth repeating that they donated to fund Andrew Lansley’s private office)  and homes have closed, block contracts have been signed to provide care at the cheapest costs which increases profits for the private companies of course and limits choice for individuals who need these services.

Anyone who claims that the roll out of personal budgets has or will change this and has increased ‘choice’ I will point to those who have capacity issues – those without family or friends to support them – those who are more marginalised have far fewer choice than the ‘mainstream’ who are able to engage in the process and that suits the government and the propaganda machine just fine.

That is what I fear for with the Health Bill (I am not sure why it’s even called the Health and Social Care Bill as Social Care is so obviously a troublesome ‘aside’ for the government).

Choice may well be nice for making decisions about which hospital is most convenient for a scan but what is being done to assist, support and advocate for those who are not able to make choices?

We are all in this together? Really? I doubt it.

As for me, I’m off to the vigil outside the Houses of Parliament tonight with my local Unison branch.

The TUC have also organised an ‘online vigil’ to oppose the passage of this Act.

And then.. to the Lords. But I will take careful note of the voting as it happens tonight. And I won’t forget.

Sadness, Sympathy and Self

Sometimes, some days feel filled with sadness. I had one of those days this week. I don’t like to use the word ‘hardened’ but to put it this way, in over 10 years of frontline social work practice in some of the most deprived areas of the country and in the inner city, I’ve seen a fair bit of what society has to throw in terms of crumbs to those who are some of the most vulnerable members of it.

I look at the high rises that skirt around the cities and I see hundreds of lives being lived, families existing and stories being told. Some with hope and pride. Some with desperation and despair. All different, all a part of this community and society we live in. Poverty is real. Despair is real. The two don’t have to go hand in hand though.

I have a strong stomach and don’t bat an eyelid at all sorts of things when I walk into a house. I’ve probably seen worse.

In some ways, human misery is a part of my trade. Not always, of course, because there are the wonderfully reassuring smatterings of hope but difficult social circumstances and social deprivation run a theme through my career.

Although I often emphasis that mental ill-health is certainly no respecter of social class or financial assets, it is sometimes the level of deprivation and the difficulty and shame of poverty that I see that reminds me of the way that this political class intentionally ignores and isolates some members of the community.

Perhaps the most difficult part of  my job is wrapped up in the AMHP (Approved Mental Health Practitioner) role. It is a mirror into my ethical compass and while I enjoy the aspects that were involved in training and the support and development and even community feeling I have with other AMHPs, the process of making a decision about someone’s forced detention in hospital or a forced medication regime is never one that can be taken lightly and I don’t think it is one that should ever be ‘enjoyed’.  It is power, writ large. It is control.

Sometimes people thank you retrospectively for ‘making the right decision for me at the time’ but more likely that isn’t going to happen.

This week, I carried out a Mental Health Act Assessment in a hospital. That is very far from unusual. When I read the background and the circumstances, when I conducted the assessment and made the application for detention, which I did, I was overcome with a feeling of sadness for the action that I had taken and for the life that it predominantly affected.

For obvious reasons  I won’t go into details – anyway, even if I did they would possibly sound fanciful and unrealistic. To people who think that I have a ‘difficult’ job, I would say I  have had a walk-on part among some fine and very strong people who have had to contend with sickness, pain and family circumstances that have rolled all the dice against them in the lottery of life.

And when I sign the papers and write up the report, I don’t forget. I think, I reflect and I try to learn. What could we have done to prevent this situation from having occurred? Sometimes the answer is nothing but sometimes there might have been a different path, a different action or different guidance that might have led to a different outcome.

Sometimes, some days, I just feel overcome with sadness. Sadness at the injustices that are meted out by life, fate and circumstance. Sadness at the way that this society perpetuates and builds on those injustices of circumstance. Sadness at my role my own complacency in accepting that we have created such an unequal and unfair society.

In a community where people who live on state benefits are treated with an intention to humiliate and scorn and where the government not only condones and supports this, it tries to create further barriers between the ‘haves’ (with ‘have’ meaning working tax-payer) and the ‘have-nots’ (meaning those who depend on the state for income) it sickens me as I know that the rhetoric of ‘choice’ and  ‘community capacity building’  are empty words which mean nothing without the world of privilege. By privilege I don’t mean money, necessarily, but include the privilege of having family or friends around, the privilege of being well enough to build up networks of support, the privilege of being a part of a community. There is so much more to privilege that cash assets or income.

Sometimes I want to shout against the system that I am a part of. The social care system in this country is not ‘fair’ – it reeks desperately of unfairness and the pushing of ‘choice’ in very narrow terms onto a wide range of people who in reality have no choice whatsoever further marginalises and discriminates against poverty, incapacity and isolation.

But I continue in my job. I go into work and ‘buy into’ the system. In my own defence, I fight as hard as I can from the inside and I don’t forget the names, the faces and the stories of those whose lives touch mine.

I remember, I note and I learn and sometimes, that just fills me with sadness – but when I stop feeling that sadness, I stop learning, growing and trying to create a better world. One person at a time. In spite of the system I work in and with rather than because of it.

Selling the NHS – The Beginning

The National Health Service Norfolk and Norwic...

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Yesterday, while most of the media, fixated self-referentially on the Murdoch hearings and Cameron was flying back into the country,  Lansley began to dismantle the National Health Service.

As The Guardian reports

In the first wave, beginning in April, eight NHS areas – including musculoskeletal services for back pain, adult hearing services in the community, wheelchair services for children, and primary care psychological therapies for adults – will be open for “competition on quality not price”. If successful, the “any qualified provider” policy would from 2013 see non-NHS bodies allowed to deliver more complicated clinical services in maternity and “home chemotherapy”.

So we are led to believe that being open for ‘competition on quality not price’ will act to pat us on the head, reassure us, and direct us back to the ‘big media story’.

It worries me and it worries me for a number of reasons. Lansley’s words are couched in the words of ‘choice’ but I wonder exactly whose ‘choice’ it will be to make these commissioning decisions for which, no doubt, large amounts of money will change hands and profit-making publicly listed and private companies will be able to partake.

I admit to a bias having been exposed and having experience in the adult care sector which was subject to a similar rollout of competition which was supposed to increase choice and quality.

I’ve written many times about the end result and how it is one that has inherently favoured larger providers and companies that have been able to deliver on economies of scale rather than the poetic vision of small scale providers delivering local services. Those small scale providers were quickly priced out of the market and I fear this will happen again.

But wait, I hear, ‘quality not price’ Lansley says.. to which I reply, ‘nonsense’.

Why? Because there will probably be minimum standards of ‘quality’ that a service has to reach and beyond those, it will be a price competition. That’s what is supposed to happen in care – but who checks the standards? who will check the standards? How can we have confidence in a well-resourced and well-delivered service when regulators are so weak.

I do not want any private company to make a profit on my potential need for services for my back pain, my hearing or a child’s wheelchair.

Of course, making the publicly delivered service is clearly both too expensive and veering against the government doctrine of handing the healthcare to private companies.

I am sure the first few providers will intersperse local voluntary organisations with large multinational corporations in their delivery methods. Again, I point to the adult social care sector. We started along the path with the NHS and Community Care Act (1990) having a lot of local providers together with a few Southern Crosses and Care UKs. The local providers were eventually priced out.

Of course in the case of podiatry and hearing services as well as primary care psychological therapies, we can see these as almost discreet services. The ones that will potentially be easy to deliver and it will always be possible to find wonderfully successful outcomes for people choosing Boots rather than the local NHS for their podiatry appointments because it is more convenient. And I’m sure it seems to pave the way for Individual Health Budgets where people  are given the money to ‘spend’ on the services that they need. Choice you see. Choice is what it’s all about.

I turn back and look at what has happened in social care. Choice has been extended in wonderful ways to those with the loudest voices but in some ways those with the highest needs have been left behind. That is my main concern about the introduction of private into public.

For some people, the people in the comfortable middle classes of Chipping Norton, this is fantastic news – they can access their IAPT (or equivalent) by a local provider when they are feeling a bit down. They can have their feet checked in a local branch of Boots instead of having to travel into Oxford. All’s well.

Those will be the areas where both competition and choice are the highest.

My concern is that people who experience the degradation of poverty will have quieter voices and less choice because there may be higher multiples of health difficulties and choice is determined through power. I can’t help but think of people who are restricted in their choice by issues of capacity. Will they be given advocates to assist with the process or will they just be ignored? Will the choice by made by GPs who are courted by these private companies, just as they are currently courted by drugs companies?

How equitable will the ‘new’ system be?

If we are extending choice, we have to extend safeguards and checks.

If we are extending choice, we have to extend quality.

It hasn’t happened in social care – there is no reason to believe or trust that it will happen in healthcare.

It does make me wonder – Are we all in this together? Really? With the impact analysis projects that are carried out to ensure equality, I know there are provisions to look at ability and disability, gender etc but are social class and income level also considered?

And think – Lansley considers putting ‘quality’ in as a concession – he was happy to go ahead with the Bill and with a pure ‘cost’ factor. This is his so-called concession but it is no concession at all if we don’t have a definition of what ‘quality’ is. After all, the CQC – too look at the Health Care regulator – defines ‘quality’ on the basis of paper documents and paper inspections given to them by provider services.

If that doesn’t wave any red flags, I don’t know what will.

This is a government of interests rather than representatives. The shame is that the last government was too and likely all the future ones will be as long as we allow our heads to be turned more quickly by celebrity gossip than the tragedies unfolding in our adult care services.

Initial thoughts on the Dilnot Report on Funding of Care and Support

Scheduling and exhaustion meant I didn’t have time to look at the Dilnot proposals in detail yesterday so this morning I have fired up my browser and am going to make a few initial comments on the baseline main recommendations and hopefully over the next few days can look at some of the details.

The Dilnot Report on Funding of Care and Support runs at 82 pages.  It attempts to forge a solution for the currently antiquated and inequitable system of care funding that is currently in place. Much talk has been made of the current threshold of £23,250 of assets, at which people currently become responsible for paying for their own care services but little made of the current discounting of homes in certain circumstances and the ability to raise a charge on a property to postpone payment of costs for care services. Nevertheless, this threshold was deemed as being too low. People who own houses like to keep houses for children. People don’t like those who ‘haven’t worked as hard’ or ‘saved as much’ getting something for free.

The system is broken though, don’t get me wrong, I just think the focus of the discussion has been too much around middle class fears of actually paying for something they believe should be free. Now, I’ve got that off my chest, back to the report.

The main recommendations are

- to cap lifetime costs of care between £25,000 and £100,000 – with a suggested threshold (which is used throughout the report for ease) of £35,000

- means-tested assistance will be extended to those who have between £23,250 and £100,000 of assets.

- Those who ‘enter adulthood’ with support needs will not be means-tested and care will be provided free.

-Universal disability benefits will continue but may be some differences in names regarding Attendance Allowance. (erm.. DLA?).

- There will be a cap on so-called ‘hotel costs’ in residential care between £7,000-£10,000

-There should be a national, portable eligibility framework which is more transparent.

- A government awareness campaign about planning ahead and preparing for potential age-related disabilities. And their costs.

- There should be a new information and advice strategy to help people through the confusing forest of knowledge.

- Better carers support and information.

- More health and social care integration

Of course, these recommendation run alongside the Law Commission’s report for changes in adult social care law. Together they could create a much better and clearer system than we currently have.

The ‘lifetime cap’ allows for insurance policies to be generated and probably very profitable ones too for the insurance companies. Most people do not need high level social care provision but the fear generated by the media is enough to drive right minded people into the arms (those who can afford it and who have substantial assets) into the arms of the insurance companies. I’m not sure how comfortable I am with the lifetime cap on care costs. It means the more wealth someone has, the more they are protected. I understand the logic behind it in that noone chooses ill-health and disability but the more than government spends on those who do have substantial assets, the less there is for those who cannot afford it and the higher the criteria to access support rises.

I just have a few queries which may be answered in the details. If Mrs Smith has a house worth £300,000 and she lives alone with no other substantial assets – say, for example, she has savings of £10,000 – is her house sold to release the asset worth up to the cap of £35,000 – assuming she doesn’t have an insurance policy? If she chooses to live in a care home which is private, but then the money runs out, will the local authority still move her? Will she ‘top up’ the local authority fees, paying above the ‘cap’ to do so? What is she lacks capacity and has no family?  I suspect all these answers are in the report but they will be questions I will be looking for.  The system of deferred payment is mentioned and I’ll hunt around for clarification.

The cap though, seems to be there to protect middle class votes.

I do, however wholly support the increase in the level of means-testing. I think it is entirely right to continue to means test up to £100,000 and I’d even go further than that. I don’t have a problem with mixed funding, I am just not entirely comfortable with the capping.

Again, the clarity of the coverage of those who ‘enter adulthood’ with care needs is entirely right. There is a necessary distinction between working age adults with care needs and older adults with care needs but quite rightly it is wrong to have a distinction fixed at a specific age. Indeed, Dilnot proposes that those who develop long term care needs before the age of 40 should continue to have a zero cap and costs should be met fully by the state. Above the age of 40 there will be some kind of tapering of the cap up to retirement age where the full proposed £35,000 cap would be reached.

Regarding the accessibility of universal disability benefits, Dilnot clarifies that he does not propose any reform that would lead to anyone losing their disability benefits and that attendance allowance will continue. I do wonder though how this ties in with the government plans to remove 20% of DLA claimants.

There are some recommendations though to change Attendance Allowance (AA). Firstly to change the name to something more understandable and an appreciation that many who are eligible for it do not claim it. That absolutely reflects my experience.  People who reach the cap when the government takes over payment will not continue to receive Attendance Allowance (or whatever it will be called) because the government is fully paying for their care needs – which makes sense to me.  The Personal Expenses Allowance (PEA) is proposed to continue – this is the payment that is made to people whose costs are met by the government in residential care and is currently about £23 pw – there is a suggestion that it should increase but not a recommendation.

The cap on hotel costs is excellent news in my view because I saw this as a potential ‘get out’ clause for residential homes. I do want to know how some of the private homes will adapt to these new systems though and what the cap will mean for overall quality of care provision.

The idea of clearer, portable assessments is a good one and long overdue. Eligibility criteria interpretation can differ wildly and there needs to be more transparency.   The minimum threshold would be applied at the ‘substantial’ level of care so I wonder how this portability will work for those who live in areas that meet lower levels at present.  It seems that there is some kind of recommendation to do away with FACS over the longer term.

Can’t be soon enough – a new assessment framework will be developed ‘with experts’. Please please please can front-line practitioners be involved in these developments – not just people who professionally develop policies and have never needed to use assessments in their lives. This is why we end up with unusable systems. There is also a way of building self-assessments into these new models. That’s the idea anyway.

The last recommendations about building awareness and improving quality of information seem to be sound all round. Nothing to argue about there.

I am interested in the recommendations as they relate to carers. As far as I am concerned, I want more than just an assessment for carers, I want the provision of more services. Supporting carers very well both financially and with practical and flexible support is probably the one aspect which can potentially save the government more money in the longer term than anything else – but more than that, it is an issue of ethics and morality. I know that doesn’t often come into government services but it’s something I feel very strongly about.

There is more commentary about the details of Dilnot in Community Care, the Guardian has extensive coverage (including an article I wrote before the details were known).

I also recommend Arbitrary Constant for links and discussion about Dilnot.

Weekly Social Work Links 22

A quicker than usual version for this week as I’m a bit pushed for time this morning so apologies in advance for any omissions but as always, if you see something I’ve missed, please feel free to use the comment section.

A post from The Masked AMHP is always a treat – this week he turns his attention to a question I sometimes ask myself – Why be an AMHP?

And a new and interesting looking blog about a soon-to-be social work student ‘From Media to Social Work’ about a career changer (yes, I know it’s obvious from the title!) finding difficulty securing voluntary work.

Congratulations are due to S.Wangene at A Social Worker’s View who reaches her first year anniversary of her blog from Kenya.

And to Fareez at ‘Do No Harm’ from Singapore who celebrates five years of being a social worker! He shares some things that have kept him going in the job for five years (and it isn’t just chocolate.. ).

SocialJerk shares some of the ‘joys’ of working with schools.

And How not to do Social Work shares some of the frustrations of social work and the systems that grow around it.

Nectarine at Going Mental shares a link to a campaign to change the FBI’s definition of ‘rape’.

The Nudge Patrol discusses the importance of professionals taking therapy. Interesting – I’d venture a guess that approaches to this might be culturally different in the UK.

Mike Langlois shares some thoughts about ‘safe places’ which we might be kidding ourselves about to the detriment of those we work with and for.

Malcolm Payne asks if all practice in a religious social work agency has to reflect that religion. Great piece.

Meanwhile Dorlee continues with her job search and shares 20 questions every interviewee should know the answers to. Best of luck to her.

One of the reasons for the rapid round up is that I wrote this weeks ‘This Week In Mentalists’ while will be available at some point here. (it hasn’t published yet at the time of writing but it’s a great site so explore all content there in the meantime!)

Two round-up posts before 9am on a Saturday. Phew. I’m off to enjoy my weekend and wait for the so-called heat wave!

Have a good weekend all Smile