Fighting Monsters

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

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

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

The Consumerist at Flickr

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But just putting a few pieces of very rudimentary information together

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

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

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

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

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

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

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

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

‘tighter local authority spending’

seems more than a little churlish.

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

The Times quotes the Chief Executive saying

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

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

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

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

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

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

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

The stock fell to 130p yesterday.

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

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

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

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

At, yes, a Southern Cross Home.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now, she just wanted to a break.

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

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

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

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

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

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

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

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

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

EVERYDAYLIFEMODERN @ Flickr

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

As the article points out

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

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

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

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

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

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

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

‘Direct Payments were introduced in the UK

- for adults with a disability in 1997

- for older people in 2000

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

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

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

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

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

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

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

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

But sometimes, occasionally, it has followed through.

I have two reasons for bringing this up at the moment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

She looked at me glacially.

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

National Archives via pingnews.com

Image via Wikipedia

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

The Giro is on its last legs.

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

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

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

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

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

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

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

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

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

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

The National Pensioners Convention has picked up on these changes

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

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

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

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

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

There is an interesting article published by Geriatrics entitled Does Alzheimer’s really exist?. It consists of an interview with two authors of a book called The Myth of Alzheimer’s.

I thought it raised some crucial points. Of course, biologically, Alzheimer’s exists and that isn’t the issue that is being made, but the book seems to try to approach the onset and development of Alzheimer’s from a different angle.

Rather than focusing on the scientific search for a cure, they emphasis the need to look at ways in which the development of Alzheimer’s can be managed within a sociological, cultural and community framework.

One of the authors,  Dr Whitehouse, states

‘Instead of asking ourselves, “What drug should I prescribe”? we should be asking, “How can I help my patient stay alive, enjoy a good quality of life and remain engaged in society”? We have medicalized aging to an extreme degree.’

Image via Wikipedia (donezipil)

It seems like they are carrying out a lot of studies related to how older people with Alzheimer’s interact and what kind of interactions benefit them and in what ways.

I have to say, it was a heartening and inspiring interview and I thought it was a key approach to take as often we work, within our service, in a psycho-social model but sometimes it feels that we are battling against a tide of medication (which, don’t get me wrong, has its place but not by any means exclusively).

I sometimes feel frustrated that age has so many negative connotations in our society. It is not seen necessarily as a part of the life as a whole or the aged, confused individual as a part of who they were, are and will be.

Daniel George, the other author, writes

‘We are all going to grow older. We are all going to die. That may sound somewhat negative, but it is reality, and it carries a message of hope. No matter what we do, we can’t fix all the problems of aging. But we can foster a sense of solidarity. We are all in this boat together. And we can’t throw anyone overboard just because they’re unfortunate enough to be labeled with a mental illness such as AD.’

In a society that sometimes seems to eager to throw those that don’t fit the ‘model’, overboard, it is good to see the work being done.

Dr Whitehouse and Mr George continue to update their blog in relation to their research and ongoing methods. I’ve found it useful to keep track of.

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

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

Respite care (£150m)

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

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

Focus of young carers (£6m)

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

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

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

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

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

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

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

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

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

Rethink approaches some of the proposals from a different angle asking

‘What does £15 pounds buy you?’

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

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

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

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

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

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

Bert 2332 @ flickr

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

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

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

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

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

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

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

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

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

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

stephmcg @ flickr

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

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

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

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

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

This frustrated and continues to frustrate me.

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

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

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

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

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

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

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

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

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

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

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