Category Archives: older people

On Capacity and Deprivation of Liberty

Having been a Best Interests Assessor since the position came into being, I have a particular interest in how the deprivation of liberty safeguards (DoLS) work (or don’t) in practice. I am a fan of the Mental Capacity Act (2005) to the point of becoming quite defensive in the face of opposition to it. This is because having worked in older adults services (and more specifically in dementia services) since before the Act came into force, I’ve seen the big changes that it has made in codifying and protecting the rights of people who may lack capacity to make specific decisions at certain times in their lives.

What was a previous reliance on ‘common law’ principles of professionals/family members making decisions which were more often than not ‘in people’s best interests’ changed to become codified and provide protections to people who are in these situation where no specific legal reference existed before. While the ‘Daily Mail’ crowd grumble about decisions being made by ‘shady secret courts’ or even shadier ‘professionals’, the reality is that for decisions to be made on behalf of people, all those involved including family members and professionals where necessary, should decide together what is in someone’s best interest on the basis of previous wishes where they are not able to explain. The legislation and code of practice sets out, what was lacking before, in terms of expectations (nay, demands) of involvement and the responsibilities for decisions about capacity to be made by the most ‘appropriate person’.

Criticisms come, of the Mental Capacity Act (2005) through the Deprivation of Liberty Safeguards. I have written before about them here as I’ve been involved in making decisions and carrying out assessments. There is no doubt that the system in place is flawed. We identified some of the flaws when we did the training before the provisions came into force. Subsequent case law has not always been helpful. In the light of the CQC report published this week about the use of Deprivation of Liberty Safeguards, I thought it would be useful to reflect on some of my personal experiences of using them and observing others using (or not using them) rather than look through the report which others do far better than I would be able to.

The Deprivation of Liberty Safeguards (DoLS) were intended to provide a level of protection to people who lacked capacity to make decision about care and treatment either in hospitals or care homes, regarding situations when they were being deprived of their liberty and therefore had no recourse to any appeal process – unlike, for example, people who are detained under the Mental Health Act (1983) who have access to a tribunal system. Deprivation of Liberty Safeguards have their own Code of Practice (which is useful but got out of date rapidly in the face of changing case law). There are particular processes required for an authorisation to be made (by the supervisory body – which is the local authority) and it is based on assessments made by two people. One is a Best Interests Assessor (which was the role I took) and the other is the Mental Health Assessor (who  is a doctor with special training although I wouldn’t lay too much confidence in the ‘special training’ as I’ve known it to be as little as a day). Having attended some joint training with Mental Health Assessors, I have to say, I wasn’t inspired with a great deal of confidence about some of the understanding of the processes but perhaps that’s changed in the year since I’ve practiced.

Problems with DoLS

One of the main problems I see with DoLS is that people are told ‘They are complicated’ and that seems to act as a disincentive for managing authorities (the care homes or the hospitals who may be depriving people of their liberty) to actually think about them too much.  Or staff who work in these areas think they are ‘someone elses’ business. I’ve come across that before – hospitals who have one DoLS/MCA lead who is seen as the only person who needs to know about them. I would say that’s possibly not the most helpful way to think about it. As long as people think they are complicated, they will ignore them in the face of busy work environments.

I try to tell people, when and if they are interested, that everyone doesn’t need to know the intricacies of whether a particular practice is a deprivation or a restriction before making a referral – it is the job of the Best Interests Assessor to make that call as a part of the Best Interests Assessment and it is something that will depend, very much, on the individual circumstances of an individual person. What is important though, is that staff can identify some key issues that may come up that could trigger a referral at the very least. If staff are to be provided with such a list by their employers (which I’ve seen) then at least those employers should ensure that they update this checklist frequently in line with case law and they emphasise that it is not exhaustive. As frontline practitioners, we talk about hating check box lists. This is exactly an area where a check box list is supremely unhelpful unless it is changed frequently and concerns strong provisos – allowing some professional judgement.

The name is a bar too, of course. Deprivation of Liberty Safeguards – people seem to concentrate on the deprivation part and ignore the safeguards bit so they are seen negatively. Actually, it’s a way of protecting the person whose liberty is being deprived and without the safeguards they would not have the same level of protection. When I see the Mail/Express headlines like this we can see the danger of misinterpretation of the language. I don’t believe for a  moment we have ‘more people subject to chemical cosh’ or ‘older people being tied up’ or ‘people denied from seeing their relatives’ than we did 10/20 years ago. We just have more understanding of when it’s happening and some of those people have had specific assessments to determine whether it’s in their best interests – where before it would just be a decision made without those safeguards.  The language is troubling to tabloid news journalists who don’t look beyond the ‘deprivation’ word. Mind, it’s not just tabloid journalists – it’s care home managers who see it as a ‘bad thing’ if they make an application. Personally, I’d be delighted to see more referrals drip through as it means that there’s a possibility that some people will have access to the protections.

Some people want a list of things that are a ‘deprivation’ and what isn’t. The lack of such a list leads to an ‘it’s complicated’ charge. The reason there isn’t a list is what may be a deprivation of liberty to me, might not be to you. I’m generally quite a solitary person and am quite happy spending a day pottering around at home, doing not very much. My partner needs to go to the supermarket every day to get fresh fruit and vegetables. He will not buy fruit or veg a day in advance and doesn’t believe in weekly shopping (this is sometimes an issue between us!). Not allowing him out of the home (if we both lived in a care home) would have a far greater impact on his liberty than it would on mine because of our usual habitual behaviours. Whereas keeping me away from a television for more than a day would have a big impact on me but wouldn’t bother him in the slightest. Silly examples but it’s the reason we can’t make blanket decisions or say ‘locked doors = DoLS application”.

The interface between DoLS and the Mental Health Act (1983) is a particular bone of contention – in my experience. Having worked in older adults’ mental health services, I saw many situations on older adults inpatient wards where, if someone wasn’t battering down the door and actively attempting to leave at any opportunity, they were deemed to ‘comply’ with the detention without the need of any of those awkward legal-type powers. Unfortunately I haven’t seen a great deal of progress in this and some psychiatrists seem to dislike using the Mental Health Act (1983) to detain people who lack the capacity to consent to treatment/admission. DoLS does allow, potentially, another avenue although case law has been quite fluid in terms of where we stand. What I’ve seen FAR more of is a lack of use of either Mental Health Act or the Mental Capacity Act and somehow thinking that ‘informal admission’ is the ‘right’ answer if someone isn’t battering the door. Sometimes opposition to a detention can take other forms – increased levels of distress, lack of engagement with staff/family but I fear there is little flexibility in interpreting the ‘objecting’ patient when people are not actively saying ‘I want to go home’ every second – and even sometimes when they are ‘Oh, they are just like that’ or ‘that’s the dementia talking’.  The thing is, this needs to be challenged and sometimes hierarchies within hospital systems don’t allow it. This is why I think the BIA role is crucial and that hospitals, in particular, should engage with genuine understanding of DoLS and what their actual purpose is rather than assuming they know.

I have a slight problem with the assumption that the Mental Capacity Act is ‘less restrictive’ than the Mental Health Act. To the person who lacks capacity to consent to treatment or a hospital admission – they are being kept in a place they don’t want to be and treated against their will regardless what legal framework (or none) they are subject to. The Mental Health Act offers more and better appeals processes (and more automatic checks – and of course, although this shouldn’t be an issue, the right to s117 aftercare) than the Mental Capacity Act so saying that DoLS offers a least restrictive alternative, is, I think, (whether judges agree with me or not) a false premise. One thing is for sure, there needs to be SOME legal framework and having none, certainly isn’t the least restrictive alternative.

What would work better?

I think there needs to be a streamlining of the DoLS process – perhaps more along the lines of the Mental Health Act which is better developed – certainly in terms of rights to advocacy for all and a similar type tribunal system. There needs to be much better understanding of the processes and what RIGHTS mean to people who lack capacity to make decisions. Local authorities need to provide better information and access to advocates all the way through the process – they are supposed to but it sometimes gets lost down the line.

CQC need to actually inspect and enforce when organisations are not telling them and they need to understand the processes better to judge organisations against what they should be doing.

Changing the name would help too, something about protecting rights not depriving of liberty – perhaps that’s a bit flippant but language is important.

Everyone within organisations needs a better understanding of them from care workers/health care assistants to consultant psychiatrists who seem to regard them as an optional extra if they can’t be bothered to use the Mental Health Act because ‘they don’t do that’ when people lack the capacity object in the only way that they can recognise.

These aren’t new now and they aren’t optional but too many organisations seem to write them off as ‘too complicated’. Too many supervisory bodies seem to ‘pre-screen’ referrals. There are too many discrepancies nationally to think that they are anywhere close to being embedded in our health and social care systems (despite CQC’s positivity on this).

We need access to clear information including current case law in a central space – perhaps the Department of Health can offer up some space – in easy to read language which explains rather than complicates.

I’m sure there’s far more than needs to be done. I don’t have all the answers – not by any means, but I do know we all, who have any interest in this sector, need to do a whole lot better and understand what the current law is. These safeguards aren’t an optional extra and just nice for people to understand a bit better. They are the current law and the current law is failing for as long as no one is actually checking or caring whether they are used properly or not.

Choice, Control and Obfuscation – How the Personalisation Dream is Dying

In the bold move towards a transformation in adult social care, it feels from where I sit, that control has completely overtaken any pretence of ‘choice’ in the so-called move towards more idealised ‘person-centred’ care and support planning.

I hope I’ve been clear over the years in which I’ve expressed a remarkably consistent view that I love the idea of people being able to choose the support plan they like from a wide menu of options with ‘professionals’ taking less of a role.  I am a massive fan of direct payments. I want people to have more personalised care and more creative care. Desperately. The options just aren’t there yet for people who lack capacity and that is a terrible disservice and inequity that is being served throughout the care system.

Removing care planning from my role doesn’t concern me – unlike those people on the training courses who bang the drums blindly about how wonderful and bright it looks when we allow people to choice whatever they like to put together packages of care, I don’t want ‘retain control’, I truly don’t believe that I, as a professional ‘know better’,  but likewise I know that with the user group I work with, it is rare that I can just hand someone a support planning tool and a list of potential providers and tell them to ‘get on with it’.

That is as far from reality now as it was 20 years ago in my work. While I can say that everyone I care co-ordinate who has a ‘package of care’ is now officially on a ‘personal budget’ and some even have direct payments, it hasn’t really increased choice or control for any but a couple of those people.

If anyone for a moment wants to ponder the duplicitious nature of those in policy making ivory towers who dribble down policies which they want to couch in ‘soft’ language so they are difficult to challenge, one only has to read a fantastic piece of research conducted and published on The Small Places site.

It is worth reading through the piece in detail. Lucy, the author, made a number of requests to local authorities to ask about how their Resource Allocation Systems (the link between the ‘assessment’ and the ‘cash’ – basically) was calculated.  She seemed to come up against a wall of obfuscation but it’s worth looking at her research in detail.

This reluctance for me, seems to relate to the lack and reduction in spending on care and support – the key ‘missing piece’ as to why a council can ‘reassess’ someone as needing less ‘cash’ than they did last year with a more traditional care package.

My personal experience is that the council I work in (and this is similar to things I’ve heard from people in other councils) probably doesn’t want to share it’s RAS because it’s ashamed of the utter dog’s dinner that it’s made of it. It doesn’t ‘work’. It doesn’t make sense. It is frequently changed. There is more emphasis on physical health needs as opposed to mental health needs and while there can be manual adjustments, some of the figures that are ‘spat out’ just seem nigh on ridiculous (and that works for sometimes calculating care ‘too high’ as much as a figure which is ‘too low’).  It comes down to everything needing to be qualified and fitted onto a spreadsheet when actually the needs of two people who might fill out a self-assessment with the same ‘tick boxes’ might have very different needs in reality – no RAS can account for that. One person might under-score because they are embarrassed by the process and don’t want to admit to being incontinent on an initial visit from a social worker because they haven’t been able to tell anyone other than their GP – another person might be anxious and think they can manage less well than they can. Sometimes and this is what local authorities and health services seem to find hard to account for, you just have to treat people and their needs as individuals rather than the subject of outcome measures, tick box performance indicators or resource allocation systems.

Shouldn’t personalisation be about putting the user at the heart of the system? Every user should have a copy of the RAS and how the figure was determined. Which questions are weighted and which aren’t. Without that, there flow of money and the control rests solely with the local authority.

I’m fully against ‘traditional’ care packages. Having someone anonymous and constantly changing pop in for a 30 min welfare check once a day isn’t about improving the quality, control and choice in someone’s life, it’s about a local authority doing the absolute bare minimum that they can get away with to fulfil their statutory duties of care.

The lack of openness about the ways that the RAS shows the true colours of the reasons for these pushes towards the Eden of ‘Personalisation’.

While I have no doubt that for some people, as I keep saying, those with advocates, family or who are able to voice their own needs clearly, have and will continue to benefit enormously from having direct payments – it’s worth remembering that direct payments have been available and accessible for many years now.

Forcing everyone onto personal budgets has only discriminated against those with carers by reducing the amounts of money they are entitled to through the RAS (that’s my own experience of how our local RAS works) and has discriminated against those who lack capacity by promising all sorts of ‘creative’ ways of exploring third party management of support plans but without providing any real ways of accessing it (this is my current bugbear as I have been requesting assistance with this for months for service users I work with but have been told it is not possible for older adults yet as only those with learning disabilities have budgets large enough to make it cost effective – thereby clearing discriminating on the basis of age and type of disability).

I have changed from a fervent advocate of a system which was supposed to be so much better for everyone to a bitter opponent of a system which favours some kinds of disabilities over others, some kinds of service users over others, some kinds of carers (those who are willing to put a lot more time in to manage and support plan where necessary) than others and all to provide fewer services under the guise of choice.

No wonder Burstow is pushing everyone towards direct payments. He is pushing everyone towards a system which masks the way that payments are determined and discriminates openly against people who lack capacity or who have the ‘wrong’ kind of disability or family support.

Now we know that the local authorities can hide the way they make financial calculations, it becomes much more obvious to see behind the facade of the ‘Wonderful Wizard of Oz’ who promotes choice as the final goal to achieve at all costs.

I feel tricked and betrayed by the implementation of the personalisation agenda and the lack of any of the services around it to tackle directly with the problems at it’s heart.

I was deeply disappointed, for example, that the Mental Health Foundation’s ‘research’ and work with people specifically with dementia only focussed on people who either had capacity or had family.  Their advice talks lovingly of setting up trust funds, appointing brokers – well, that is a fantasy rather than a reality and exists only on paper as a choice. They merely replicated a lot of work which was done when direct payments were rolled out around lack of take up for people with dementia and they hadn’t said anything new (I happened to write my dissertation about the lack of take up of direct payments for older adults so did actually do literature researches at the time..).

Anyway, I’m getting ahead of myself.

For now, I think it’s important that we who see through the cosy policy makers congratulating about a ‘job well done’ speak up and speak up loudly for those for whom the system is a further barrier for true individualised care because these self-same policy-makers see them as ‘too difficult’.

My title explains that the personalisation dream is dying but it isn’t dead yet. To be brought back to life, all those involved need to embrace the principles of honesty and openness and not blind themselves to their successes if they can’t see the continuing barriers.

Panels

Since I’ve been employed as a social worker one of the constants in my working week has been the presence and existence of ‘panels’ in many different forms. There was a brief stage when we were told not to refer to them as ‘panels’ but rather meetings but it’s all the same thing at least, in the setting in which I’ve been working. They are groups of managers and professionals of a variety of provenances making funding decisions on behalf of the local authority or health service.  Of course sometimes they say it is about joint decision making (which is why the word ‘panel’ is frowned upon now) but that’s really a facade. I make recommendations but I have little authority over funding decisions.

Different local authorities often have different mechanisms so my explanations of the panels that I might attend come with the proviso that things are arranged and organised in a variety of ways.

We have panels which primarily make decisions about packages of care that exceed a particular baseline cost. That baseline has changed a variety of times but generally managers in each team are given a certain ‘threshold’ to which they can approve funding requests but above that and any application for funding for residential or nursing respite or long term care have to navigate a ‘panel’.

We have separate panels for high cost personal budget packages which would be provided for care at home and those which approve residential and nursing care/respite and continuing health care (which authorise applications for long term payment for care by the NHS )

Going to panel generally involves the transfer of reams of paperwork. I’d probably say it’s the most obvious way though that I provide the function of advocating for a particular service user or family member when I ‘present’ the situation to those who make the ultimate funding decisions.

Contrary to what some people might think, I have absolutely no vested interest in the local authority or NHS ‘saving’ money by not agreeing to a particular package – indeed, I won’t tend to bring something to the panel if I don’t wholeheartedly agree with it myself. I am a great advocate of money being spent where it is needed.  I have a general wish to see public money well-spent of course and I understand the need to ration resources but if I bring something to the panel and authorise an assessment, it is because I believe that that is what is needed according to my professional  judgement and as far as that’s concerned, balancing the rest of the local authority’s budget is not an issue I consider (which is obviously why these panels exist!).

Similarly with the Continuing Health Care Panels  I cannot conceive of a situation where I would bring someone to that panel if I didn’t absolutely want and believe that they should get that funding.  If I attend and collate a report it is because I and the multi-disciplinary team behind the report, believe in it.  I absolutely want people to get what they are entitled to and have no ‘secret instructions’ to try and deny the funding. The rules though are not altogether clear but it suits the funding parties and the governments to keep the rules complicated and unclear. There’s a lot of money at stake.

The panels are open to service users and carers but for me, personally, it’s very rare that service users or carers attend with me.

I have more often  had family members attend Continuing Health Care Panels with me and found it is a much better way of working as it allows a lot more transparency and removes one of those bars between me trying to put the words of others in my mouth.

By now, I know the people who sit on the panels and they know me. That’s a massive advantage in being able to persuade and cajole. It makes me realise how useful it is to have built up links and a reputation among the more senior management. I like to think that a trust develops.

Panels used to scare me because I’d be questioned, often in detail about the proposals that would have a substantial monetary implication for the local authority. My paperwork and assessments are examined in great detail and a level of scrutiny applied. Now that I’m more confident, I tend to take pride in presenting my reports and welcome the questioning as I know what to prepare, what to highlight and what to expect.

I’ve had panels where paperwork alone is assessed and where we are not required to attend in person.  I prefer being there ‘in person’ especially when there are any question marks that I feel I can clarify.

One of my favourite tasks in my work is feeling that I am genuinely able to advocate and navigate a person or family through the muddy mired waters of local authority funding streams and decisions. I wouldn’t say I enjoy the panel process although there is a satisfaction in having something approved especially if it is something you feel might be hanging in the balance, but I don’t dread them as much as I used to.

As for now though, it’s just another part of the process of seeing a paper ‘plan’ through to fruition.  I know they work differently in different areas – indeed, I’ve seen them in different forms in the local authorities I’d work for – but that’s how they work – whether they are called meetings or panels, the effect is the same.

And that’s the explanation of what the panels are – the other side of each discussion I have and each decision that is made by the faceless ‘management’ that I sit in front are that they are desperately important decisions to each person who is reliant on the authorisation of that funding to allow them to life their lives more fully, to allow their family to have access to respite services. My job as I see it, is to bring the paperwork and paper assessments ‘to life’. I am not only writing about a person on a pro forma, but I’m able to flesh out the requested questions and documents with a person, with a family, with relationships.

That’s why I don’t mind attending  these panels as much as  I used to. I’m not frightened of them anymore. I see them as an opportunity to take a crucially important role in someone’s life and to speak for them and not  just about them.

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

iPad con dock y teclado inalámbrico

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Perspectives, Students and Ageing

I enjoy having students around. It helps keep me fresh and enthusiastic and to see my job through the eyes of someone coming into it rather than through the occasionally blurred eyes of someone who has been working for a while.

I had a student shadowing me for a period yesterday. It was a  fairly standard visit as far as my work goes. The person we went to see (who I’ll call Mrs J) was someone I’ve been working with for a few years. While I endeavour to do my best in every aspect of my work, I can’t deny that Mrs J  is someone I have a soft spot for.

I started working with her about three years ago and to say she is isolated is an understatement. For obvious reasons I can’t go into the details but suffice to say since my first encounter with her we have both come a long way. She has had a lengthy compulsory hospital admission during this period and has lived in three different flats (and two different hospitals) in that time. She is now living in a beautiful flat and has a secure tenancy. She is ‘settled’ for the first time in many many years.  She even has a fairly interesting personal budget to pay for a support worker.

I thought it was quite a good visit. We got through a lot of things that needed to be done and things that needed to be discussed.

As we left the student said to me how sad she felt after the visit. She asked me if all the visits I made were that ‘depressing’ and wondered if I worried about ‘getting old’.

It took me by surprise because I thought it had been quite a positive visit and wasn’t feeling remotely ‘depressed’. Then I remembered the perspective I had and the perspective she has. She doesn’t know, apart from the words that I filled her in with, where my ‘starting point’ with Mrs J was. I can explain and expand but it isn’t the same. My ‘starting point’ needs to change and as long as I consider where Mrs J was three years ago, I wonder if I am becoming complacent about the further routes to enrichment and recovery in her life.

It made me think about the way that new eyes can improve the work that I do and shatter some of that selfsame complacency. I shouldn’t look at where I am now necessarily in the context of where we’ve been but rather where we are going.

As for the sadness in my work, I don’t feel it. I feel it some days and in some situations, of course. It’s hard not to and a part of compassion is empathy but I remember a conversation I had a few years ago when I wasn’t long in the job with a colleague who reminded me, while I was expressing my own concerns about age in general, that we only see a small proportion of the population and to constantly remind myself that most people age well. I try to remember that. I wonder if that is one of the reason for prejudice against older people and a lack of respect in the care system.  We just don’t like being reminded of the fact that we will get old. It personalises the work in a way that working in other areas of social work might not. We all hope to grow old. We owe it to those we work with and for to provide the most assistance and to make what can be the unpleasant task of ‘dealing’ with public services as painless and as accessible as possible.

Food for thought.

Rankings and Musings

Quick post today as I have a few things on the go.

So, Wikio sent me their top 20 UK Health Blogs and again, I’ve made the list. Thanks to everyone for your support and do check out the other sites there – there are some real gems and it’s a pleasure to be among such fine company.


1 PsyBlog – Psychology Blog
2 Sarah Boseley’s global health blog
3 A boy with Asperger’s
4 Dr Grumble
5 Maternity Matters
6 Bad Medicine
7 Where Are My Knees?
8 Confessions of a Serial Insomniac
9 Fighting Monsters
10 Purple Noise
11 frontierpsychiatrist.co.uk
12 National Death Service
13 The Voyage
14 Aspergers, family life and me
15 Bah! to cancer
16 PlanetOutreach-ASD
17 the DeafBlog
18 Carers blog
19 Lake Cocytus
20 DPAC

Ranking made by Wikio

I also was interested in this post from Community Care about crafting in care homes.  I wish there were more personalised activities (or any activities beyond the ‘singalong’ and ‘bingo’ ). It does raise important issues about the sense of self and differing interests and pursuits that one has when one might need residential care and why we make assumptions that what is enjoyable for one person would be enjoyable for the next, just because they are the same age.

With the move towards self-directed support in care provided at home, I wonder when residential services will also pick up.

On a related issue, I caught this link yesterday on Twitter about a care home which has installed touch-screen computers. For me, it’s an obvious step to take but its’ a shame it had to be provided by a grant and not by the provider service themselves – seeing how much they charge for placements!

I wonder how much these private companies are subsidised by these types of grants…

Still, it is good to see some different ideas about ‘activities’ in care homes and a challenge to the assumption that older people just want to sit around and sing ‘Knees Up Mother Brown’.

Age Discrimination and Language – or why I don’t like ‘The Elderly’.

What is age besides a classification? When do we become old? What language is used in relation to people who reach certain points in their life cycle. Does a child become an adult at 18?  Legally perhaps but in a sense these are rough brush strokes which relate in very different ways to different people.  When do we stop being ‘young’ and start being ‘middle aged’? When do you move towards being ‘old’?

Wise Ones

maureenshaugnessy@flickr
I’ve had growing feeling over the past years really, that our society does not value older people. Just yesterday, I received a wonderful application form from a potential student social worker. It was a positive picture of a hardworking and ethically sound potential practitioner. It warmed my heart.

But the student, although careful to detail their work with people with disabilities and children with special needs, felt that it was entirely appropriate to comment alongside this that they had worked with ‘the elderly’.

I presume this wasn’t discussed or mentioned by tutors at the university but it made me wonder how ‘the elderly’ has become more acceptable than ‘the disabled’.

I will put my hand up at any accusation of oversensitivity. I am acutely aware of the importance of language vis a vis power.  I am also aware that language shapes thoughts and reflects thought processes. If that makes me politically correct, I am proud to reclaim that label as a badge of honour.

Maybe in a society that needs to compartmentalise obsessively, it becomes more important to define someone by their age rather than their humanity but it also made me question what we mean by ‘elderly’ or ‘older people’.

Are we merely describing someone who has reached a certain age? I have worked in older adults services for a long time and some have called themselves ‘older adults’ and others ‘over 65s’ teams as a way of providing a context of age.

I read so many stories in the papers about the ‘problem’ of an ageing society and the costs of managing more dementia in society and it saddens me that age becomes another negative label and a problem for the wage-earning society to ‘deal with’. Perhaps that is the key to the perceptions that we have.

It’s natural that our perceptions of age and what ‘old’ is change with time as we and our parents, colleagues and friends move into ‘older age’ and it becomes less of an us and them type discourse and it becomes more personal.

I wonder why we, why society demands we differentiate between disabilities which are ‘age related’ and conclude that it is predominantly a cost issue. Social Security is determined by how economically productive someone is or could potentially be and when someone is past ‘working age’ their needs for social interaction and stimulation must automatically decrease?

Where is the ‘personalisation’ in the determination of Disability Living Allowance as opposed to Attendance Allowance. Look at the differences in those names.

Disability LIVING Allowance is paid to adults of working age (and children). Attendance Allowance is paid to those who are over 65. To be ‘attended to’ or ‘dealt with’. Not to live. Independent Living Fund monies were always restricted to those up to 65 (ok, now they are being wound down but the idea behind them was age-biased).

I wonder how much the Equality legislation will help? Perhaps it will but mostly I will only notice a difference when I stop seeing the ‘problem’ of an ageing population referred to and blame being assigned to people on the basis of their age.

As for me, I’m still deciding whether to raise the language issue with the potential student in their first interview with me or whether it might be something that needs some time to work on..

‘The Elderly’ No, I don’t like that. Not at all.

Goodbye Southern Cross, Hello Open Public Services

So Southern Cross – the largest private care home provider in the UK will be closed.

What of the 31,000 residents who live in their properties? Well, the government has given us its assurance that they will be ok so that’s alright then.

Or not.

Goodbye, Hello

m kasahara @ flickr

On the day that the Open Public Services White Paper was published  (which can be found here – pdf) – which couched in the comfort of positive words like ‘choice’ , we would do well to heed the warnings of the way in which social care was sold off in chunks, from public to private and reflect on whether it is better to allow care homes to ‘fail’ in order to prove that the strongest will rise to the ‘top’.

The problem is that Southern Cross WAS the strongest. It did rise. It also speculated on property and ownership transferred away from the core business base of providing care and homes for those who needed both.

But on a more pressing issue, what will happen to those who live in Southern Cross homes and work for Southern Cross homes.

As the Independent says

Analysis by the GMB union revealed the names of 80 landlords who own 615 of the homes, many of which are subsidiaries of larger companies registered overseas. This makes it much harder to obtain financial information about the companies as rules governing accountability and transparency, especially in “tax havens” such as Jersey, Cayman Islands and British Virgin Islands are significantly more lax.

In addition, the GMB was unable to trace more than 120 landlords, which mean thousands of people are living in care homes where the identities of the owners and directors are unknown.

In the absence of full company accounts and other relevant information, such as the names of directors, it is “nigh on impossible” to assess whether they are suitable to run care homes funded in large part by public money, according to Andrew Craven, GMB statistician and researcher

At least the ‘Department of Health’ spokesman says

“Whatever the outcome, no one will find themselves homeless or without care. We will not let that happen. Today’s announcement does not change the position of residents. The Care Quality Commission will continue to monitor the services provided… We have been in constant contact over the course of discussions and remain ready to talk to all parties.”

That’s reassuring. Or not. Would that spokesman or anyone in the Department of Health want that level of uncertainty lying over their head or the heads of one of their parents? The residents of the homes will not know who their landlords are or whether they are fit to run care homes at all. Of course no-one will find themselves homeless – it will be the local authorities, the elected local authorities who will have to spend and fret themselves out of this one – nothing to do with the Department of Health’s reassurances – unless the Department of Health is going to compensate those local authorities for the time and cost they spend to ensure the welfare of residents of Southern Cross homes that may close.

As for the CQC, I think we have established that it is unfit for purpose and unable to regulate a care industry that has grown too large and too costly to be regulated efficiently. How about an idea? The Department of Health invests very heavily directly in the CQC so that they can provide at least twice-yearly, unannounced inspections together with a host of lay visitors attached to every single residential and nursing home?

No, the Department of Health is weedling out of this crisis as it will weedle out of the cost of ensuring that the residents of Southern Cross Care Homes are not made homeless.

Now, I want to link some of these issues to the Public Service White Paper that was published yesterday and particularly one or two sentences I picked out.

Firstly

In the context of rolling out more extensive ‘choice’ in other areas of government, the paper says

‘We will ensure that individual service providers are licensed or registered by the relevant regulator for each sector (e.g. the Care Quality Commission) so that those choosing services can known that providers are reliable, without stifling cost”

Does that not lead to a tiny little shiver down ones spine? The CQC is being held up as a reason to trust in this extension of ‘choice’.  Has noone mentioned the cost of good quality regulation, either.  It’s worth reading this post at The Small Places for more consideration of the way the CQC regulates social care services. The CQC has failed to regulate and the care sector is failing to deliver on personalisation so far. The care sector has had time to learn as well. We had direct payments for many years and before that the ILF (Independent Living Fund) which allowed payments to be made directly to adults with disabilities to choose care. The system should be sophisticated enough by now to deliver good quality, equitable services but it has taken many years even to reach this point. There’s a long long way to go.

Secondly

“The wider public sector has much to learn from local authority successes in commissioning, for example, in adult social care”.

See, look at us, government, we’re a success! Success. This is the end-result of success. Adult care commissioning is not a success. It has not extended choice unless of course (and I think I’ve found the key) success is based on the principle of privatisation and provision of contracts to the those who deliver at the lowest cost regardless of quality. That is the adult social care ‘success’ that the government is lauding in the Open Public Services White Paper.

We are dazzled by words such as ‘choice’ and ‘open government’  but they have no meaning outside ‘lowest cost’ and ‘discharge of responsibility’.

Think of Southern Cross. Think of Adult Social Care. It’s coming to our homes, our hospitals, our high schools and our highways.

So much for my week of positivity!

Elaine McDonald, Kensington and Chelsea and Dignity

Yesterday, the High Court ruled in the case of R (on the application of McDonald)  v Royal Borough of Kensington and Chelsea. This was a further appeal by McDonald against a previous decision at a lower court.

Elaine McDonald is 68 year old woman who worked as a ballerina in her younger days. The press seems to be a little fixated on her former career, and she does have a more glamorous background than many who come to rely heavily on social care so perhaps it is no surprise. Ms McDonald suffered from a debilitating stroke in 1999 and had a further fall in 2006 which led to very poor mobility.  Although not medically incontinent, she required assistance to use the commode during the night.  She had been provided with overnight support to meet her assessed needs related to continence during the night however Kensington and Chelsea were suggesting that this need could be met by substituting this assistance with the provision of continence pads during the night which would, by their nature, demand that Ms McDonald remain in these pads until carers could come in the morning and at intervals to ‘change’ her.

sulle punte

frabattista @ flickr

I wasn’t surprised by the decision by the High Court because there are precedents that led the access of local authorities to resources to be a factor in relation to the provision of services.

In my own working experience, it is impossible to access any kind of home care support overnight except in some very specific cases where there is very high need support and even then, it is much much more likely to be provided to younger adults with physical disabilities. I can count on the fingers of one hand the amounts of times I’ve come across local authority funded overnight support in the last 10+ years of practice.

Sometimes I have to take a step back from what I regard as ‘normal’ practice to understand the outrage at this decision. I realise how I become attuned to ‘local authority’ think and ‘budgetary’ think and that’s quite an uncomfortable thought.

We get used to applying different definitions of ‘dignity’ and what is acceptable because we are aware of the thousands of Ms McDonalds that require support and the existence of a  finite resource. So do you support the Ms McDonalds and assist them to provide a fuller and more dignified life at home or do you provide 8 Ms Smiths with respite care over the year. These are the realities of the decisions and it shouldn’t have to be so.

Perhaps that’s why I’m less surprised by the McDonald ruling and less surprised by it.

There are though horrendous inequities in our system of the provision of social care. Where Ms McDonald in Kensington and Chelsea may be receiving a vastly different service from a parallel Ms McDonald in Newham.  I would venture a guess that there are thousands of potentially very similar cases to Ms McDonald bubbling under the surface ‘in the system’ but because they are not ex-Prima ballerinas and don’t have the will, way and means to bring cases and involve solicitors, we will never know about them.

If anything is, quite literally, the ‘dirty secret’ of social care and health care provision particularly for older adults, it is this.

We have different standards of what we class as being ‘dignified’ for ourselves as for others. What might class as dignity to an older adult has less value and invites less spending to an equivalent younger adult with exactly the same care needs. Those who shout loudest get the most – as far as care is concerned and as far as public interest is concerned.  The shame and pity of the ‘personalisation’ agenda and the flawed implementation of personal budgets in social care have exacerbated this problem further rather than provided a channel to allow for a more equitable system of care delivery.

It sometimes feel cruel and harsh, because it is a cruel and harsh system that it perpetuated by discriminatory systems. Would the warehouse-style very large residential and nursing care homes with 100+ beds be acceptable for younger adults with similar care needs? I don’t think so.   I don’t mean to imply that every large care home is bad and every small care home is good. That isn’t the case. It’s about a fundamental reassessment of what is acceptable in the provision of care for older people in our society.

Lucy at The Small Places covers the issue of dignity through caselaw, in an excellent, thorough and educational post.

I make no apology for my less erudite post and thoughts.  The more I work and the more I reflect, the more interplay I see between the basic conceits of ethics and ethical judgement in the role that I play as a part of this system that condones this mealy mouthed interpretation of human rights merely on the basis of cost and resourcing issues.

It is accepted because our society is inherently ageist. We don’t want to think or pay for the care of older people. We care more about our collective inheritances and potential house prices than the more collective thoughts about where the boundaries of an acceptable level of care and dignity lie.

If anything, this has impressed on  me the importance of constant reflection on my practice and my work. I can advocate to an extent, from within the system, for the dignity of those like Ms McDonald and I try to. Some I win and some I lose but as long as I make my voice heard through every step of the process I can help to feed the voices ‘from the front line’ back to the more senior managers.

I make judgements and I am the mouthpiece of the local authority. I am an employee but the second that I become complacent, the  moment I stop reflecting on the effects the decisions I make have and the instant that I join that local authority ‘group think’, I lose my ethical compass and my professional judgement.

I talk a lot about important qualities of social workers and social care workers. Respect, empathy and to that I’d add advocacy. It might not always be seen in the internal battles that we fight, but we have to try to fight so as not to accept a ‘normal’ that is defined on the bank balance sheets of the local authority accountants.

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