Category Archives: personal budget
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.
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.
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.
I caught this article a few days ago on the Huffington Post by a Social Work academic, trying to explain away another aspect of the riots and cashing in on his status no doubt as an ‘authority’. I don’t have much time for the body of the article.
He starts by saying
There is much of merit in the Prime Minister’s speech concerning the riots
and I’m afraid he almost lost me there as I found absolutely nothing of merit in the Prime Minister’s speech. Not even a single thought that I would deem worthy of merit.
He also states that
Social work has developed, importantly, its commitment to people made vulnerable, marginalised and disenfranchised by social, political and economic circumstances. However, it has constructed an edifice of anti-oppressive practice sometimes decorated with the inanities of political correctness that hampers its position to mediate and negotiate a pathway that re-engages individuals with their society.
I dislike the way the author picks the intellectually soft targets of ‘PC gone mad’ brigade to cast aspersions on the profession and to attempt to construct a criticism of an over-reliance on ‘anti-oppressive practice’.
Perhaps I’ve had the theories ingrained into me after years of practice but I maintain that it is absolutely vital that social work retain a fundamental commitment to language of inclusion, equality and equity and I have strong objections to the theft of ‘political correctness’ as some kind of negative stream that is acting to society’s detriment. I believe very strongly that challenging oppressive language and offensive language is the first stage to changing assumptions and removing labels.
It seems to be desperately sad that someone who purports to be teaching social work holds these ideas and I have to wonder if his goal is simply to gain more ‘status’ for himself.
His criticism comes a lot closer to home when he states that
Perhaps for too long social workers have been content to stand outside of the policies and workings of society when it suits, whilst still being employed, in the main, by local government.
and I honestly have to claim I’m not sure I know what he means. I wish he had written in a less emotive and a more explanatory style. Shame, if he considers himself to be a so-called ‘teacher’ that he can’t express his ideas in a clearer way and come out with exactly what he means by ‘content to stand outside of the policies and workings of society’. To whom is he referring this comment? I take it personally because he goes on to refer to those of us employed in local government, like me, but I wouldn’t by any means see myself as being ‘content to stand outside the policies and workings of society’ and I would say, if he is doing his job properly in teaching and training social workers, he isn’t doing very well at it if those are the kinds of social workers he is producing.
Every single day I go into work (and many I don’t) I consider how the impact of my work affects the society I work around and live in. I have never been content to ‘stand outside’ and take the proverbial government dollar. I challenge from within the system and criticise from without. That is what the reflective and critical analysis that we are taught trains us to do.
If you are not happy with it, Mr Parker—oh, sorry, I mean Professor — teach it better.
But there was one aspect of the article which rang a bell for me while he is having a dig at the provisions of the welfare state and buying into the tired government rhetoric of the ‘something for nothing’ benefit claimant as he says
The rise of neoliberal, de-humanised market-driven approaches have encouraged a version of Government that has removed personal well-being from the economic. In the middle is the third level of action that is dependent on social policy and legislation and individual ‘buy-in’. It is the area of social welfare. We have a system in which a person’s expectations have reached a point at which there is no need for reciprocal action themselves. There is an important social welfare cushion that rightly protects vulnerable people. However, it allows some to play that system, to refuse to engage with training, work or socially responsible activity and to believe they have a right, not simply for protection, but for continued support regardless of lifestyle, behaviour and willingness to contribute to society.
When I first read this paragraph I thought he was going to go off into a far more interesting angle of discussing the way that personalisation has led to a commodification of resources and the reduction of care to money and cash but no, he went in the far more predictable tub-thumping ‘let’s bash benefit claimants’ way.
Well, I’m going to take the ‘neoliberal, de-humanised market-driven approaches’ in another angle.
Let’s think about what personalisation means. Of course it means choice. Choice is good. Choice is a word that abounds in economic theories relating to consumers.
Service users are now consumers so, the argument goes, they will have more equality in the market system. They can buy with their money what they choose.
That is the ideal but it is very very far from the reality for all. The agenda of choice is all very well and I heartily back it but it has been deceitfully delivered first to those who are most able to exercise choice (adults with physical disabilities, those with involved family members). We can see some excellent examples and many charities and organisations have whole-sale bought into the wonderful possibilities of opening up markets to more social enterprises and small providers.
The research evidence from the roll out of direct payments which proved that adults with mental health problems and older adults (particularly those without carer support) had a very poor take up of direct payments was COMPLETELY ignored when new systems of delivering personal budgets were developed. How those involved int he implementation were and are allowed to ignore swathes of evidence and plough on with the process in the way they ‘knew’ and the way it ‘suited them’ and this has somehow been interpreted as ‘successful’, I’ll never know.
As someone who actively advocated for those user groups who were ‘harder to reach’ to be targeted FIRST by personal budgets roll-out, I stand by what I said then. We have known what has worked for direct payments for a long time, why not look at new ways of managing them for those who lack capacity and don’t have family or informal support - but then, as now, I was completely ignored.
So we have a care delivery system which is very much couched in the biases of the market and insurmountable inequity that no-one is interested in challenging because it does not meet the needs of the narrative that relentlessly drives this as a wholly positive change. I completely accept it is a mostly positive drive. I want people to have better services but I see some people having much better services and some people having fewer, worse services and amid the wave of positivity, the difficulties are ignored.
We have commodified care needs and quantified them. Our work as social workers is about allocating resources and not supporting and providing a service ourselves.
An assessment becomes a mere conduit for an allocation of resources rather than an attempt to actually work to combat and counter inequities.
So has neoliberalism ‘won’ in the battle for the soul of social work? We become functionaries of the state for the most part and are reduced ad infinitum to processors and glorified data systems entry folk.
I don’t think so – not entirely. There is a real danger of it happening but we need academics to actually support us not attack us. We need people who are engaged in research to help us by providing information that will highlight what is lacking as government policy pushes forward relentlessly towards devolving responsibility and couching it as an increase in choice.
I am in favour of direct payments. I’m in favour of personal budgets but I am not in favour of the whitewashing that has taken place of the real problems, challenges and lack of choice which is the reality for the majority of people I work with.
I am more hopeful than Parker and his somewhat mealy-mouthed, confused ‘article’. I think we need to seize the opportunity to make social work something more meaningful in the face of neoliberal pressures to commodify everything.
Yesterday Think Local Act Personal (TLAP) published the results of a National Personal Budget Survey.
Is any of this a surprise though? We know that people who can and are able to manage (or have family members to help them to manage) personal budgets delivered through direct payments (where money is paid directly to users) prefer them to less flexible local authority provided care packages – particularly when the scope of local authority care packages is limited to agencies with block contract arrangements.
In Control – which publishes the survey – highlights the following ‘implications’ from the findings. The bold is a direct quote and the italics are mine.
Other implications that can be drawn from the survey results include:
- Personal budgets work better for older people than you might expect and direct payments work just as well for older people as everyone else.
Who said we were not expecting personal budgets to work for older people? Does this make an ageist assumption and lump together all ‘older people’. Of COURSE they work as well for people who are 65 as they do for people who are 64 but what about people without capacity or who don’t have family or friends involved? What about a more subtle distinction between 65 year olds and 85 year olds rather than a blanket ‘old people’ response.
- The processes used for delivering personal budgets are more difficult than they need to be and that impacts badly on carers and on personal budget recipients.
Did this seriously need a survey over three months to discover? You could have asked me three years ago and I wouldn’t have charged consultancy fees.
- More work needs to be done to make direct payments more accessible generally but especially to older people.
This could have been written 6 years ago. We KNEW this from the roll-out of direct payments initially so why was NO WORK WHATSOEVER done around trying to work with more difficult to reach groups when personal budgets were being ‘piloted’. I really can say ‘I told you so’ as I begged our Personal Budgets roll-out team to allow us to pilot or be involved in the initial processes and they said our user group was ‘too complicated’. Heh.
- There is a need to simplify and clarify the rules and regulations surrounding personal budgets.
So those are the ‘implications’ and forgive me my cynicism. I love the idea of personalisation. I want it to work. I want to work in more creative ways or outsource my work if necessary to other third sector organisations but this is not ‘different’. This is not ‘new’. I fail to see the value of reports and surveys that tell us exactly what we already know again, and again and again instead of actively trying to work with people who actually understand and know what is happening ‘at the sharp end’ to try and work out ways to improve outcomes for those who are not receiving direct payments currently.
So back to the report – which used a Personal Budget Outcomes Evaluation Tool (POET)
in total, 1,114 personal budget holders completed the POET survey, including 832 returns from the 10 local authority demonstrator sites and returns from at least 76 other local authorities. 417 of these personal budget holders also wrote in a comment about their experience of personal budgets.
In total, 950 carers completed the POET survey,including 782 returns from carers in the 10 local authority demonstrator sites and returns from at least 66 other local authorities. 434 of these carers also wrote in a comment about the impact of personal budgets on their own lives
Almost half of people responding to the survey were aged 65 years or more (43%); the social care needs of working age adults (aged 16-64 years) were largely split between learning disabilities (17%), mental health needs (8%) and physical disabilities (25%).
I don’t want to play too many games with statistics but it would be interesting to know what proportion of people who meet the FACS criteria in total are over 65 and whether 43% is a proportionate figure in relation to total recipients of social care services. I think as well, to class ‘older adults’ as ‘over 65s’ is a little disingenuous although I know it is done because that is the basis on which statistics are given but it shows some of the ways that systems restrict and inhibit knowledge. It would be far more interesting to know the differences of take up of personal budgets between 65 year olds as opposed to 85 year olds for example.
And to some of the headline figures, that can catch the press attention – most people who receive personal budgets find there is a ‘positive effect’.
Looking through some of the figures, it seems that older people were much more likely to be receiving council managed budgets – you know, that ‘easy’ way of just switching around a bit of paperwork and making it look like there is now more ‘choice’ when in fact, the services and delivery is almost exactly as it was before the ‘change’.
As for the outcomes the report says
In terms of social care need groups, older adults tend to report less positive outcomes than other social care need groups in six out
of the 14 outcome domains
I find the report to be honest, a bit of a whitewash in itself. It is only accentuating the positives and like all discourse related to personalisation and personal budgets, seems to be going over all the same ground again and again.
People like choice, people like flexibility. Yes, and rabbits like to eat carrots. It doesn’t need a survey to tell me that. What action and money and research needs to be concentrated on is the HOW.
HOW is there going to be an improvement in service delivery to those who are marginalised in this process.
HOW are we going to wriggle out of the sham that is council-managed budgets while allowing those who need to have others to manage their budget and support their care to have the same access to quality care and personal assistants that those who are able to choose and decide have.
I’m rapidly coming round to the view that personal budget support planning needs to be moved out of the hands of local authorities who currently have no interest in the process except for meeting the government targets. Where is the innovation within local government for change? Sure there are people, and I hope to be able to count myself among them, who want to do a better job and provide a better service but the constraints of the type of job I am doing means that I can’t devote the time necessary to truly inclusive and supportive care planning so Mr G whose support plan I am writing up (he doesn’t want to be involved in the process as he ‘doesn’t like forms’ and can generally only tolerate conversations with people for between 5-10 mins maximum and that’s only if he’s known you for at least a year) does get a rushed service because I have to carry out Best Interests Assessments, do Mental Health Act Assessments, complete reviews and CPAs, liaise with other professionals, arrange discharges from hospital for other people. Yes, it’s a little bit of wallowing in self-pity and I wholly accept that. We are all busy but local authorities have no idea if they want a quality support plan without changing the ways of working in any other respect. Where is the time to devote to Mr G’s creative support plan? Oh, well, we’ll just do a regular care plan and a managed budget. Should it be that way? How has the march towards personalisation helped people like Mr G? Mr G wouldn’t complete a survey about a personal budget even if he did get a letter. Letters worry him and he doesn’t have a phone. I don’t want the Mr G’s that I work with to be forgotten in the rush towards direct payments.
When I first attended training we were told that any additional time we might be spending in our day to day work on these awful process-driven systems would be made up by the amount of time we would save by people completing their own support plans and assessments without any assistance. That may work for some people and I hope it does but for most of the people in the team in which I work it is unfeasible due to the amount of people I work with who have high support needs and who don’t have the capacity to make decisions about their own care needs.
The survey angered me, in a way that is probably irrational. Partly because it seemed to have taught us nothing at all. And partly because again, I see no new thoughts and ideas about developing systems that will be truly inclusive.
HOW can social care improve for everyone. That’s everyone. Even those who don’t want direct payments. Even those who don’t have advocates. Even those who are self-funding their own care packages as the criteria for receiving government support rise higher.
Those are the questions I want Think Local Act Personal to answer.
I have my own ideas. I think there will be a movement to roles for professional ‘support plan advisors’ who aren’t necessarily based in the local authority – perhaps individual social work consultancies but there has to be a separation between planning and delivery and the cost of these services shouldn’t need to be met out of the personal budget itself.
First and above all, there has to be a consistency and a transparency in the way resources are allocated and if necessary a weighting towards people who need assistance to access the same kinds of services who have been excluded from the process and the benefits in the past.
A survey of the skills-base of professionals who do implement support plans needs to be undertaken to establish what is needed and what is important to have.
Maybe it is a professional type qualification or maybe not. There is not much discussion about what the role of the social worker should be in the process. Should we be the ones support planning? I think there’s a argument that a social worker is well-placed to look at building plans together in conjunction with a user and family member if necessary and setting up things like trust funds or managed local authority budgets but only if the social worker is removed from the local authority talons. Maybe some kind of team of people with different kinds of experience and expertise working together with some background and training in non-directive advocacy for people who do lack the capacity to organise their own support plans. Perhaps the social worker or support worker in these new roles could have longer term relationships with the users and carers and wouldn’t feel so pressured by management if freed from the local authority reins.
But who is going to suggest and discuss the new ideas? Where do they go? Who will collate them?
While I see lots of discussions around me about personalisation, I see little that says anything other than it HAS to work because it is best for ‘people’.
I genuinely believe that is has potential to deliver a much better system but and this is a big but, there has to be more creativity and different kind of research that looks at new models and methods of delivery and consults people – yes, like me – who while being critical really really do want things to work better.
My criticism isn’t because I want to bury my head in the sand and ‘retain the reins of control’. I really don’t. I want to relinquish control but I want more than anything an equitable system that doesn’t fob off ‘more difficult’ service users with a second class service.
- Personal view of personal budgets (fightingmonsters.wordpress.com)
- Should private companies be looking after the elderly? (telegraph.co.uk)
I read on the BBC website among others that there is a report suggesting that care provided in the home by local authorities to older adults may be overlooking human rights issues.
An inquiry into this was initiated by the Equality and Human Rights Commission in November 2010 and will report in December 2011 but some interim findings have already been published.
I think the context in which the inquiry is taking place is crucial in times that Cameron trying to pretend that he invented the personalisation agenda and rebrand it as a version of ‘Big Society’.
The scope then of the Inquiry as to determine where the responsibility of the ‘public authority’ under the Human Rights Act actually lies and I’m going to quote directly from the EHRC (Equality and Human Rights Commission) as I think this is a crucially important point in the progress of personal budgets and home care provision (n.b. the underlining is my own).
The nature of social care is changing rapidly with a greater emphasis on personalised services and choice. The majority of social care services are already delivered by private sector agencies, either via contract with local authorities or directly with individuals through a mix of public and private funding.
This complex web of transactions is combined with a narrow judicial interpretation of the meaning of ‘public authority’ under the Human Rights Act. This combination has created a confused picture concerning the duties and obligations of the various groups involved in respecting, protecting and promoting human rights.
Further, an increasing number of care transactions are likely to take place at the margins of, or even outside of, regulated care. There is the possibility that these transactions are beyond the present human rights obligations of the State.
We are also seeing the emergence of new on-line care marketing and brokerage services aimed at people purchasing social care with either ‘individual budgets’ or private funds. These marketing and brokering services are currently completely outside of the regulatory system with no means of monitoring the quality of the advice and services they offer. The Government wants to accelerate the pace of reform even further. While personalised care and support has many potential benefits, this is uncharted territory. There are concerns that human rights protection (and other issues) could fall between the gaps.
I’m going to come back, I’m afraid, to my perennial bugbear of people who lack capacity to make choices regarding care provisions and care delivery and wonder again how this group of people without family members, friends or advocates will be able to secure their own well-being in a world where responsibility of the state and the public authority is being discharged to private individuals. Will it become the responsibility of an advocacy service to determine that the support package and the provider of the support package are of a good quality? Or the carer/family member? Hardly the same as a protection under the Human Rights Act.
Food for thought and while I am extremely happy with the forward march of personal budgets and direct payments to those who are able and happy to manage their own budgets, the way that local authority managed budgets provide ‘more of the same’ regarding cheaply bought, block contracted social care remains floating fairly close to the edge regarding what is acceptable and what isn’t.
My fear is that the roll-out of personal budgets has not led to choice for all. It is a false choice and a false impression of the so-called ‘success’ of the roll-out. It has led to great benefits and more choice for some, yes, but I worry that this is actually at the expense of those without the louder voices to shout who have, again, been pushed to the bottom of the pile when quality services are being distributed.
So back to the reports findings so far.
Back to the BBC report
The Commission describes cases of people being left in bed for 17 hours, or more, between care visits and a failure to wash people regularly.
It received reports of people being left in filthy nightwear and bedding after a homecare visit, or without a wash or hair wash for several weeks.
Visits are sometimes so brief, the report says, that people have to choose between having a cooked meal or a wash.
The short visits also mean that staff have to rush tasks like washing and dressing, which frustrates elderly people and care staff
That doesn’t even bat an eyelid with me. This is what I have dealt with for the years I have been working in adult social care. Complaints and apologies about the time we can allocate for specific tasks due to budgets. Apologies on behalf of private agencies who have block contracts that cannot assure any kind of continuity of care. That’s not even mentioning the missed visits, the non-payment to staff of travel costs so they are cutting short visits in order to make it to the next ones. This is the reality of social care for older adults in the UK. Not the ‘season tickets to football matches’, not the ‘let me choose nice Mrs Walters’ daughter who I know from church to be my home carer’ kind of idyll that we are presented in the personalisation literature.
The reality for the people I work with and for is increasingly rushed visits and yes, choosing between a cooked meal (but only if it is a microwave meal because there is never ever time to cook a meal more complicated than tinned soup or beans on toast from ‘scratch’) and a shower.
The way to solve this problem and promote dignity is to increase and not reduce budgets for social care in the home. But budgets are being cut and cut hard.
Local authorities use block contacts with private care agencies to save money. The private care agencies generally pay staff at minimum wage. There are some fantastic carers and some fantastic agencies but they are penalised if they don’t offer their services at the very very lowest cost.
As for personal budgets? It is a wonderful reality for some but for most of the people I work with and for, it is a pipe-dream for people with a different kind of disability and with different kinds of support needs from the ones which are mostly promoted in our training programmes and in our policy documents.
If the government truly and genuinely means what it says about increasing and drawing out the personalisation agenda and increasing personal budgets delivered by direct payments there have to be ways clear and research undertaken to help us to create protective and interactive systems for people who are not at the forefront of the march because they don’t realise how much they are being penalised for not having a family member who is able to help with choosing and designing a care package and because they are not able to do this for themselves.
There has to be money spent on developing ways to allow those who at the moment are most at risk of vulnerability to be protected and cared for.
There are so many problems with a society that treats older adults or, in fact, anyone in the way that older people who are in need of care are treated currently. No-one wants to address it because no-one wants to pay. And it will cost.
No-one wants to lose their homes. No-one wants to lose their savings. No-one wants to pay higher taxes. No-one wants to lose weekly bin collections. No-one wants to pay insurance premiums.
The people who hold the reins of power will never be subjected to the humiliations which become a part of daily life for older adults who have need of support that is provided because they’ll be able to buy in their own ‘help’ privately.
Older people in need of assistance are less noisy than younger adults and less emotive than children in poverty and need. Ultimately we shouldn’t ration compassion and there’s no need for a choice to need to be made between one group or another
In the roll out of direct payments and then personalisation and personal budgets, it is the more able younger adults who have led the march and those who have been setting the policy and agenda seem to have completely forgotten the group of older people who don’t have involved family members and who might not have the capacity to take decisions about care needs for themselves in the rush towards pushing the responsibility for support planning and choice of care routines. They have forgotten amid the wonderful stories of attending football matches instead of day centres that some peoples’ reality is more about choosing a microwave meal or a shower.
Until those issues are addressed and the protection of the most potentially vulnerable groups of people is managed, the new system will not be equitable and it will not be fair. But perhaps that suits this government that wants shift responsibility from the state to the individual – which is fine to an extent but there are some people who really need that protection.
I look forward to the final report of the EHRC in December.
- Should private companies be looking after the elderly? (telegraph.co.uk)
Posted in carer, carers, dementia, direct payments, Disability, discrimination, elderly, health, local authority, mental health, old age, older people, personal, personal budget, social care, social work, work
Tags: direct payments, ehrc, elderly home care, equality and human rights commission, government, Home Care, home care and human rights, Human Right, Human Rights and Liberties, human rights of older adults, individual budgets, local government, old age, personal budgets, personalisation, report into home care, social work
Recently, I’ve been working with a service user and his carer (daughter) to put together a support plan or rather two support plans – one for him and one for his daughter . The two live together and without his daughter’s presence, there is no doubt at all that the man, G, would be in residential care so the personal budget is relatively substantial. G has advanced dementia. His daughter who is a strong advocate for him and a devoted carer has given up her job in order to care for her father. She receives carers allowance which is a pitiful £55.55. Think about that – for constant care (yes, she gets respite but that is sparse and shrinking).
As for creativity with G’s support plan, it isn’t particularly, because he has quite specific personal care needs and there is no scope for much creativity regarding tasks apart from the ability to potentially employ someone from outside the usual agencies. Oh, we can choose the time and the ‘blocks of care’ but the type of care needed is specific so we can’t ‘skip a shower one day so there’s more time for a bath the next (seriously, that was suggested in one of the training sessions I attended!)’ as health reasons determine the need for regular visits. G’s support plan is, what we call a ‘managed personal budget’. That means that a virtual budget is assigned to G and I make the arrangements for agencies to cover the specified hours. I don’t get a choice of agencies. The agencies that are employed are those that have won ‘bidding’ contests with the local authority and are party to block contracts.
This ‘counts’ as a ‘personal budget’ for the purposes of the local authorities’ ‘figures’ even though the effect is exactly the same as it was prior to the ‘personalisation agenda’ – no, wait, there is a difference. I have three times the amount of paperwork to complete. Am I working in a more ‘person-centred’ way – well, I hope that I was ALWAYs involving service users and carers in care planning. That’s not to say that direct payments haven’t been enormously liberating and positive for a lot of service users. I absolutely don’t believe that everyone should have ‘managed’ personal budgets but it is a fallacy to believe the ‘hype’ that this personalisation agenda has brought the same benefits for all service users.
So we move to the idea that Burstow promotes that all support plans should be delivered by direct payments. We discussed delivering this package via direct payments, when I promoted even a slither of interest, I invited someone from our direct payments team round to meet the family (because they can ‘sell it’ better than me and can answer all the detailed questions about implementation and finances that sometimes I can’t) and we stalled. Why? Because G’s daughter felt genuinely stressed and frightened at the thought of employing someone directly – the agencies that accept the direct payments amounts are limited and don’t include her preferred agency and if she went with the preferred agency, her father would lose vital necessary hours of care. She has little enough time to herself as it is and spending more time managing and planning her father’s care processes was something she felt that we should be doing.
Her father has very poor cognitive functioning to the extent that communication is very difficult. The direct payment option, was, she saw, a way to push more stress onto her as a carer.
This is a reality that some of those who are implementing the wonderful new world of everyone receiving direct payments type personal budgets really have to address.
However I do have a more positive story to follow up on. That is that she, (M’s daughter) has a carer’s personal budget for herself which is delivered via a direct payment. While I won’t go into the details about what has been provided, you’ll have to trust me on this as I say we have been able to be incredibly ‘creative’ with the support planning of the carer’s personal budget and it will have an immediate positive effect on her quality of life. So all’s well that end’s well.
Generally, I have had a lot of success with carer’s personal budgets being implemented and I think that has been because the money provided (although not very much) is money in addition to the core care needs for the cared-for person. There is a scope for more interesting ideas of things to use the money for.
It’s hard to see how more creativity can be instilled without more money and as long as the figures allow ‘managed’ personal budgets to be ‘counted’ we won’t have a real idea of how ‘ground-breaking’ these programmes are.
I don’t know the answers to these problems – I hope some of those consultants who are paid multiples of my salary and can spend all their days in discussions and consultations are able to come up with some genuinely practical responses rather than the usual ‘try harder/work harder/involve users (as if we don’t do all this already’.
And on a final unrelated point, I saw a link to this blog yesterday on Twitter. It is written by the 18 year old son of someone with Alzheimer’s and I found it excellent and insightful.
- Personalisation in Mental Health and Older Adult Services (fightingmonsters.wordpress.com)
- Personal view of personal budgets (fightingmonsters.wordpress.com)
Tags: budget, caregiver, carer's direct payment, carers allowance, carers personal budget, dementia, direct payment, direct payments, health, Home Care, individual budget, local government, personal budget, social care, social work, uk
Earlier this week, Community Care picked up on a report from Public Concern at Work which related directly to whistleblowing in the care sector. It makes for chilling reading and displays the problems which are inherent in adult social care.
As the article states
Public Concern at Work, which runs a helpline for employees who witness crime or wrongdoing in the workplace … revealed figures showing half of all calls from social care were about the abuse of vulnerable adults. In half of all cases where other staff knew about a risk, they were too scared to speak up
When you put this in the context of the CQC abandoning random spot checks and initiating increasing systems of ‘self-regulation’ in care homes and you have an extremely dangerous combination.
The article goes on to give an example
In one case, a social care worker witnessed a carer hitting a resident across the back of the head. He raised his concern with his manager but no action was taken, so alerted the care regulator. In the meantime he found himself ostracised by colleagues after the manager had revealed the worker’s identity. A subsequent investigation by police and social services took place but was inconclusive. The care worker said he felt unable to return to work.
There are a number of things that made me audibly sigh when I read this. Firstly and perhaps most tellingly, it didn’t shock or surprise me. That is a sad indictment of the sector as a whole. I’ve worked in the adult social care sector for more years than I’d like to say and come from a background as a care worker in residential home. I was fortunate to work in a great home with a fantastic ethos but I know how easy it is to become socialised into careless models and how dictatorial some management regimes can be. The other part was that the investigation proved ‘inconclusive’. Often they are when people close ranks and what does that say about the ways that abuse is investigated? Well, I make no secret of my disdain for the policies and ways that these investigations take place with little legal backing. Things are better than they were and I know locally great efforts are made to improve safeguarding procedures – indeed, a new London-wide policy has just ‘gone live’ but I hope the legislative procedures firm up.
Back to the report though, which Public Concern at Work publish here.
The organisation states that the largest proportion of calls that they receive come from within the Adult Social Care sector and relate to vulnerable adults (15% of the calls that they receive) and in their report ‘Speaking up for Vulnerable Adults : What the Whistleblowers Say’ they use some of the data gathered over an 8 year period to look at some of the issues raised to them by whistleblowers in the sector. The report as a whole is quite short and easy to read.
My main concern is the lack of involvement by the regulatory authority (namely the CQC or its predecessor body, CSCI) and lack of involvement. The report takes a sample of 100 cases, 27 of which detailed physical abuse and the respective care regulator (CQC or CSCI) was only involved in 12 of these cases which considering the role of the regulator and the seriousness of the issues raised, is surprising.
Even worse, the statistics related administration of medication where issues such as mixing up medication between residents, failure to administer medication or administering medication incorrectly – where only 3 of the identified 15 cases (from their sample) involved a regulator.
It’s worth reading through the relatively concise report. It doesn’t make for much cheer which is unsurprisingly given the subject matter but emphasises the importance for care staff who often are employed by private companies and may not have redress to a union for advice and support to be better supported by local authorities who commission their services and by the regulatory body (CQC) in raising concerns in a safe environment.
It seems obvious to note but the care worker ‘on the ground’ is the person most likely to be able to spot abusive practices in care settings and particularly in residential and nursing homes. This must be a resource that is utilised and they must be afforded protection through not only well-intentioned whistleblowing policies but well implemented and well known ones that are able to be drawn on and protect the workers involved.
As we move towards more direct payment funded personal budgets and home care settings change, the relationship and responsibilities of care workers and personal assistants that may be directly employed by service users rather than through agencies also should be addressed through policies regarding raising safeguarding (adult protection) alerts.
Until training and awareness around adult protection is as widespread as it is around child protection, we can’t afford to be complacent or make assumptions about what may or may not be reported.
Yesterday the CQC published their report ‘The State of Healthcare and Adult Social Care in England’.
I have to try and put my criticisms of the CQC and their increasingly lax regulatory process to one side, although I couldn’t help a snigger when they claimed in their statement on the front page of the report to ‘Act swiftly to eliminate poor quality care’. Not exactly my experience when they rely on members of the public to actually alert them to poor quality care rather than carry out their own random and regular ‘on the ground’ inspections but it is the only report we have and there are some useful pointers in it.
The CQC inspection remit is very broad and obviously the quality of their inspections vary. This report relates specifically to the 2009/10 year.
The report covers four distinct areas – safe care, choice and control, person-centred services and standards of care. All the areas are very broad in their scope.
In summarising the report, I’ll look at it in those same areas and highlight some of the issues that arise. I will also focus on the areas in which I have a particular interest – namely adult social care and mental health but there are lots of pointers and lessons for healthcare outside this remit – I just don’t have time to comment on them all!
This covers physical safety such as safety from infection risks as well as safety from neglect and abuse.
The first ‘headline figure’ that the CQC lauds is that 80% of care homes met ‘safe working practice standards’. It does make you wonder about the other 20% though and add this to the fact that this is a self-reporting standard. Those care homes which met the ‘medication’ standard were 72% for older adults compared to 79% for adults under 65. I wonder what the variation would tell us about the different ways of management and attitudes towards older adults.
In the ‘maintaining dignity and care’ standard which includes responses by local authorities to safeguarding alerts, there was a growth in ‘better’ outcomes as there was an increase in local authorities performing ‘well’ as opposed to adequately (from 89 to 113). There were still 3 LAs performing poorly though on this fundamental duty. Unfortunately they aren’t named.
Safeguarding alerts increased over a third to 103,030 nationally across all client groups but the largest part of these referrals came in relation to older adults. No surprise there. No surprise at the increase either if you’ve been working in adult social care. We’ve noticed a real tightening up of the procedures and ways that we report and investigation abuse allegations. There was though a significant increase in the reports relating to adults with mental health problems (up 34% – same as older adults).
There was a fairly low response rate for users of Community Mental Health Team services (17,000 patients in all). Only a third were asked about physical health needs over the last year. I suppose I have a slightly different attitude as in an older adult’s CMHT we have a lot more interplay between physical and mental health so it’s something that might be more obvious for us to discuss.
Surprisingly only 56% of users had an out of hours telephone number to use.
There was a large increase in detentions under the Mental Health Act over the last year and the CQC report that only 21% of wards visited met the Royal College of Psychiatrists recommended 85% occupancy rate. 29% were over-occupied and 7% had a 125% occupancy rate. I’m not surprised by this. My own experience is that wards are closing at a fairly rapid rate and have been over the last couple of years. They cost a lot of money. This will get far worse and it is worth holding Trusts to account over this. I hope the CQC does this.
Choice and Control
This banner is about increased knowledge for users about options available to them as well as greater use of personal budgets to choose care needs and use of advocacy services as well to promote choice.
The number of residential care home places fell but the numbers of nursing home places rose nationally and particularly there has been a growth in provision of places for people with dementia. This is patchy at best across the country with the highest proportion of additional beds in the North East and the lowest in the South West.
I was concerned that the base figures of people on personal budgets was the indicator of how ‘good’ a council was at providing choice. My experience of implementing personal budgets is that all too often it seems like an empty ‘paper exercise’ in upping the councils’ figures for surveys such as this rather than a real and concerted change in mentality towards providing choice to those who require additional professional support to seize more ‘creative’ outcomes.
According to the report, which remember is dated 2009/10, only 3 councils are proposing to increase their eligibility criteria for services this coming year from substantial to critical and one was planning on reducing the eligibility criteria from substantial to moderate. I find that really hard to believe but figures are figures.
In relation to mental health service users, 48% of users said they definitely understood what was in their care plan. That’s a fairly shoddy figure! And 53% felt that their views had definitely been taken into account when putting together care plans. Perhaps we can see some of the potential difficulties for self-directed support in mental health arena when these figures are already so low but it is important to note that the low response rate of users is possibily another variant.
Regarding medication and information about medication 29% of respondents said they were not told about the side effects of medications that they were on.
Regarding inpatients both those detained under the Mental Health Act and those ‘voluntary’ patients, the CQC identified that the hospitals had been increasingly focused on security and ‘rules’ and that, more worryingly, more ‘voluntary’ patients were being held on locked wards and potentially were being deprived of their liberty. The report mentions that they were held neither under the Mental Health Act nor the Deprivation of Liberty Safeguards but the use of the Deprivation of Liberty Safeguards in psychiatric hospitals is generally not done. It may and should lead to a greater number of patients detained under the Mental Health Act for their own protection. I wonder if there will be any affect on numbers from this report.
A couple of interesting trends to pick up in this section which will no doubt, be a sign for the future. Firstly that less people as a whole accessed community care services – a fall by 4.7% from the previous year (that’s 83,930 fewer people). The report suggests that in the face of research showing an ageing population, it could be due to increasingly stringent application of criteria for assistance. Add this to the fact that people who benefited from help from grant-funded organisations (often those people who fall short of meeting the council ‘criteria’) also fell, there is a potential for a large unrecorded unmet need to be ‘falling through the gaps’ in service provision between the statutory and the third sectors.
Generally though there was satisfaction with the way that assessments were picked up and the involvement that people had in planning services.
The provision of telecare has grown over the last year, again, unsurprisingly – and I expect it will grow for many years to come and technology and care overlap in more creative ways.
Demand for the provision of ‘extra-care’ sheltered housing – which is sheltered housing with additional care services attached – was growing, sometimes beyond the provision of some local authorities. I see this as a potentially massive growth area and am often frustrated by a lack of provisioning particularly for those with mental health as well as physical health needs. If I were to be able to approach our commissioners with any one piece of information it would be that.
Worryingly only a quarter of councils demonstrated a strength in supporting people with complex needs and only seven displayed a strength in specialist services.
Regarding services for carers, there has been a large increase in carers taking up direct payments. This reflects my own personal experience as I have done a lot more carers direct payments this year and this amount grows every year however, the report worrying raises issues regarding money which was provided to improve the outcome for carers and was not ring-fenced and wonders aloud where this money might have gone. Sign of the times with the elimination of ring-fenced funding.
Standards of Care and Support
It’s interesting that the CQC explain how they judge that a care service is of a good quality or not. Their ‘evidence base’ is interviews of providers and users of services, information given to the CQC by the service, surveys given to staff, users and professionals (I have only once ever received such a survey), a key inspection (how often? Announced? I know a lot of services that haven’t been inspected for over a year), and information held about the history of a service.
My scepticism shines through because some services can ‘game’ the systems by having all the information required by the CQC written up perfectly but how they perform on simple human care levels differs enormously. I strongly believe that frequently (at least twice-yearly) unannounced thorough inspections are the way to truly judge quality.
Unsurprisingly the highest quantity of top level ‘excellent’ services were provided by the voluntary sector and the local authority. Private providers lagged behind. A sign of the times, perhaps as the government pushes the purchaser/provider split into the health service. Look to the care sector and be warned. Today it’s the care homes for your parents and grandparents. Tomorrow it will be your hospital services for you and your children. Perhaps then, we as a society, will care more.
Smaller care homes were more likely to be judged highly than larger care homes. Care homes for younger adults were more likely to be judged highly than care homes for older adults. No surprises here. But anger, a lot of anger. It’s about money, of course and there is less money available for the provision of care for older adults on a per capita basis. So larger homes and poorer quality care is the message given to providers.
The problem as well is the way that ‘good’ and ‘excellent’ are defined by the CQC as well though. I know poor ‘good’ homes and great ‘adequate’ homes. That was always the failing of the ‘star’ system but worse, to have no system at all and out of date ‘stars’ still on the website to give a wholly inaccurate view of what the level of care is like at any given home. The CQC should be ashamed of the way they have destroyed robust and transparent regulation and the previous government should be ashamed of how they allowed this to happen.
Finally and perhaps one of the most telling figures to take from the entire report is the one in the final sentence of the last page.
Only 16% of councils demonstrated low absence and vacancy rates and high recruitment and retention rates, which confirmed staffing issues continued to be an issue for 2009/10.
We can only imagine what the effect will be on these figures for 2010/11.
The use of these reports is that it brings to life the importance work that is done in local authorities and the effect that good quality support and provision has on peoples’ lives. Yes, of course service provision is essential and too frequently, commissioners are detached to an infinite level so they have little idea about what is needed ‘on the ground’ but often to, it is the human contact, the ‘being listened to’ and having views acknowledged that also makes a difference and that is dependent on quality staffing, quality training and having the time to spend with people.
My own experience in a pushed, under-staffed team is that I am spending less time instead of more time with people as I chase from emergency to emergency and the outcomes for those people who would otherwise had more intensive face to face contact is falling. This leads to sharper deteriorations, more likely readmissions or admissions to hospital that could have been prevented and eventually higher costs.
But with councils and NHS Trusts looking towards the immediate cost cutting of the next year and not at the longer term costs in 5, 10 years, this is the way we will go.
We shouldn’t be satisfied with delivering lower quality care. We aren’t. We need to speak up and speak loud and build links actively with user groups and carer groups and other professional groups to ensure that the government never forgot whom exactly they are betraying and to remind them over and over again that we aren’t going away.
- Council care better than private, says regulator (independent.co.uk)
- Council care better than private sector, health regulator says (guardian.co.uk)
Usually when I’ve mentioned workloads here, it’s because they are increasing or we are going through one of the ‘peaks’ in the general ‘peak or trough’ pattern of work balances.
I’m going to do it again because we are definitely in a ‘peak’. The problem is, the peak has been pretty much ongoing for a few months.
The freeze on recruitment is biting much harder now. I suppose it was sustainable when one person, two people left. When numbers five, six, seven left it became more obviously apparent to everyone left in the office.
Our office has an empty look to it and none of us are ‘smart working’ or ‘working from home’. Sure, we have visits in the community but even at the beginning and end of the day, there is office space in overabundance that makes the thought of hot-desking comical.
So we are each working on more cases and the cases we are working on have more urgency attached to them as the allocation to a care co-ordinator have come later than they might otherwise have come.
Paperwork is being left uncompleted. Oh, you may pat me on the back for prioritising visiting service users and carers at the expense of ‘filling in forms’ but each piece of paperwork I don’t complete in a timely fashion has a consequence for said service user or carer. It might be a delayed processing of an individual budget – it might be the delay to a respite admission or a carers assessment – it might be the delay of attendance at a Continuing Care Panel (lovely 55 page assessment form sitting on my desk that induces nervous twitches). I could bring the form home – but I don’t. At the moment, I honestly think it is the ability to leave things behind at work and walk out at 5pm (as much as is possible) which is preserving my sanity.
It does mean that things aren’t getting done though.
There have been a couple of recent consequences of this – not helped by a rush of Mental Health Act Assessments and Best Interests Assessments which had very time-specific periods in which to be completed. For reasons that may be obvious, I have to prioritise Mental Health Act Assessments above everything else when they come in and Best Interests Assessments usually are requested in my experience during the 7 day period that an urgent authorisation is ‘running’ so have to be completed within that seven day period (note – these seven days have no consideration for the distinction between ‘working’ days or not and they include the period that the paperwork needs to flit backwards and forwards between Managing Authority and Supervisory Body so realistically, it means the Best Interest Assessor will have 3/4 days to complete the assessment).
My desk is like the inside of a paper recycling depot with filing done in various piles of paper. One pile is ‘things to be filed’, One is ‘things to do’, One is ‘not sure where to put this piece of paper’. I have overflowed to the empty desk next to me.
Yesterday some things happened that caused me to reflect on the current work pressures.
Our service manager approached me at roughly 9.01am and asked me for the Self-Assessment Questionnaire for a service user (who has fairly advanced dementia and a distant and uninvolved family and therefore would need substantial assistance in completing it) I had taken on a few weeks ago. I hadn’t done it. She was very pleasant about it when I started listing all the other things that I had been doing. As I am wont to say when asked why I haven’t completed something ‘it isn’t like I’ve been sitting at my desk twiddling my thumbs instead of completing the work’.
The service user involved had a care package that had been set up as an emergency and it was actually working really well but we needed to create an individual budget for her. Ironically, I’ve visited her a few times to monitor the care package and ensure both that she is keeping well and to enable us to build up a relationship so she begins to both recognise and trust me. I didn’t get round to the SAQ as the format of questions was so alien to her. She didn’t want to answer questions about what she could or couldn’t do – indeed, she didn’t accept that she needed any support whatsoever and would say she didn’t understand what these nice ladies coming into her flat were doing (they were preparing meals for her!). What she wanted was to tell me stories about where she used to work (although they were framed in the present tense) and tell me about her friends (mostly moved away or died) and how they visited her regularly.
I hadn’t completed the SAQ and the Performance Indicator Monsters are chasing me down. But, service user is safe and receiving support.
For me, this makes a mockery of the process of individual budgets. Yes, she could have a wonderfully creative package of care in place. But where is the time to sit down and talk her through each stage when she is (understandably) completely disinterested in process. It can feel almost cruel to labour the point for the sake of the department completing forms and ticking boxes.
How is her service to be ‘personalised’ and where are the champions of personalisation? They are telling us about packages of care where young adults can choose driving lessons to get around. Where are the champions of the personalisation agenda in helping us with means to engage people who are frightened by the process and overwhelmed by self-assessment questionnaires?
Oh, wait, all the training is about people who take an active interest in being involved in the process of care planning and self-assessment.
I try. Believe me, I try. I have no interest in the process failing. Indeed, I held out a massive hope that personal budgets would serve older adults who lack capacity much better than the direct payments system did. I have been sorely disappointed.
Anyway having explained away my lack of action to the manager, she nodded, expressed sympathy and headed on her path.
Later in the day, I was confronted by an emergency situation. It wasn’t the nature of the emergency that caused me difficulties. I have dealt with many similar types of circumstances through my years of practice but what was different was my reaction.
I spoke to my manager and as we concluded that I needed to make an emergency visit, I asked for a colleague who was ‘on duty’ to accompany me.
The situation perhaps didn’t warrant it and there was an expectation that it was the kind of issue that I should be able to manage with my proverbial eyes closed but internally, I felt some of the panic rising. I suspect that was the combination of stress about workload issues and thinking about my next arranged visit.
My manager agreed for someone to go with me – possibly because I don’t think I have asked of assistance with a visit for about three years so she might have clocked on that something was up so we went together.
On arriving, I saw that the situation is one I could easily have managed alone. I felt almost embarrassed that my colleague had come with me but then I thought, I knew I had been right to ask. I can recognise my own reactions and needs better than anyone else.
Situation resolved successfully, I apologised profusely to my colleague for ‘wasting her time’ but she, of course, denied this and said she was happy to help.
The rest of the day, I was analysing why I had asked in the first place. Why did I suddenly feel phased by an issue that I have dealt with successfully many times before? I’m not sure I can answer that but I think I’ll put it down as a positive recognition that sometimes, we just need a little more help in the day to day work and we need to be able to recognise these moments to better serve those who rely on our services.
Even after ten years, I still have ‘wobbles’ of confidence. They happen less now as is to be expected but for a moment, it was as if I had been transported back to my early days in practice when I wondered if I would ever be like my more experienced colleagues and able to manage anything that was at the end of the telephone line.
It reminded me I’m not there yet and perhaps I never will become instinctively complacent about the work.
That’s not a bad thing as long as I’m in a team that is encouraging and supportive.
And I am.
- Personalisation in Mental Health and Older Adult Services (fightingmonsters.wordpress.com)