Fighting Monsters

Today is the 60th anniversary of the founding of the National Health Service.

There has been a lot of coverage over the last week in every kind of media source to commemorate this.

From finding people born on the same day to relive their lives through access to the health system to much polemic and debate about restructuring and restructuring again.

A look at the past - and a look at the future in the face of the recent reviews that have come out.

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I don’t think I can add anything new to what has already been said - but in some ways, having been born into and grown up with the system as is, I find it hard to imagine things any other way.

I expect to go to the doctor without thinking of cost.

I expect to get a prescription for medication that I need (and still pay my fixed fee for it!).

I expect to be referred to secondary medical services if and when I require.

I am fortunate to be and to have been in good enough health that I can’t  ever remember  having been in a hospital overnight - a few visits to casualty here and for minor stitching ups really is about as far as it goes.

I have family members who have been recipients of a great deal of care of an exceptional quality - and of course, now, I work within (although not for) the health service.

There are likely to be many changes in the future as the health needs of the population change. Introduction of ‘market forces’ has already started. Management layers are added and exist to increase the drive towards efficiency.

Always new restructuring, always new developments.

Expectations of what a health service can and should deliver are changing too - and this monolithic structure - oft-quoted as being the third largest employer in the world - does need to adapt.

But I think she’s not been doing at all badly, when all’s said and done.

And here’s to another 60 years and many many more beyond.

Happy Birthday - and at some point today, I’ll raise a glass to Nye..

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And in other, marginally connected news, The Guardian in its Work and Careers section, spotlights a Social Worker (marginally connected because she is a hospital social worker!).

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

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

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

But just putting a few pieces of very rudimentary information together

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

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

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

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

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

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

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

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

‘tighter local authority spending’

seems more than a little churlish.

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

The Times quotes the Chief Executive saying

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

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

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

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

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

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

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

The stock fell to 130p yesterday.

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

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

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

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

At, yes, a Southern Cross Home.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now, she just wanted to a break.

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

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

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

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

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

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

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

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

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

EVERYDAYLIFEMODERN @ Flickr

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

As the article points out

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

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

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

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

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

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

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

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

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

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

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

She looked at me glacially.

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

National Archives via pingnews.com

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

The Giro is on its last legs.

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

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

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

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

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

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

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

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

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

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

The National Pensioners Convention has picked up on these changes

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

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

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

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

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

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

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

Respite care (£150m)

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

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

Focus of young carers (£6m)

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

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

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

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

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

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

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

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

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

Rethink approaches some of the proposals from a different angle asking

‘What does £15 pounds buy you?’

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

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

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

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

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

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

Bert 2332 @ flickr

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

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

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

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

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

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

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

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

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

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

stephmcg @ flickr

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

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

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

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

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

This frustrated and continues to frustrate me.

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

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

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

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

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

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

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

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

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

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

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

I first saw on the news over the weekend about the report produced by the Institute for Public Policy Research related to  Personalised Budgets for Carers and it baffled me a little bit.

Don’t get me wrong, I completely think that carers need, deserve and are entitled to a lot more support than is available presently.

The Carers Allowance is, quite frankly, an insult to those who put in so many hours and whose lives are changed by the amount of care that is put in (as well as, on a less emotive level, the amount of money that is saved by both the NHS and Social Services). Also (for what its worth) it’s linked to Disability Living Allowance/Attendance Allowance and is means-tested. All of which contribute to its inefficiency.

But the call for personalised budgets seems to be, as far as I can garner, more or less the same as Direct Payments for Carers - which is explained much better on the Worcestershire County Council site (thank you, Worcestershire - and no, I don’t work there - actually, I don’t think I’ve ever been there!) as follows

‘Support for Carers

A Direct Payment can be provided to enable family and informal carers to purchase the services they are assessed as needing as carers to support them and to maintain their own health and well-being.

A Carers Assessment and Support Plan should be completed to identify the impact of caring on the person’s life along with the support they require to continue caring or to take a break from their caring role.

Carers are able to use Direct Payments to purchase support in any variety of ways including:

• Short breaks for themselves and/or the people they care for;
• Personal assistance within the home;
• Sitting services;
• Social, education and leisure activities;
• Transport costs;
• Equipment
• Relaxation, stress management and holistic therapies.

Some of the intended outcomes of using Direct Payments for carers are:

• Promoting social inclusion through greater opportunities for carers to actively participate in family and community life;
• Greater opportunities for the personal development of carers;
• Promotion of the carer’s health, well-being and coping skills;
• More responsive, timely and consistent methods of providing support, with greater opportunities for creativity;
• Values the essential contribution carers make to family life and the wider community.

Under the service, young people, aged 16-to17-years, are also eligible to receive Direct Payments to support them in their role as young carers and to minimise any difficulties or isolation they may experience in undertaking their caring responsibilities’.

psd @ flickr

I have to say I like the direct payment scheme as it works for carers because it is incredibly flexible. Indeed, I’d say it is the easiest way to provide direct support to carers and in the most visible way - so I’ve got a fair amount of experience using it.

In a lot of ways, it is a lot more flexible than the direct payments provided for service users because it can be used for ‘anything that would support the carer’ - so gym membership, travel costs, parking costs, washing machines - there is the ability to be much more creative. ‘

And it exists now - today and has been used with frequency.

So that’s why I didn’t really understand the call by the IPPR for personalised budgets with no comment about what is actually happening in social services departments to support carers today. Maybe they are calling for more money to be a part of the personalised budgets (a good thing) or more control (although the control can be basically in the hands of the carer themselves), more exposure to issues that matter to carers or less scrutiny from local authorities who provide the funding.

I suppose I’ll have to actually read the whole report rather than just the reporting of it!

I noticed that Sophie Moullin from the IPPR wrote about this in the Guardian and from what she says, I can’t see any difference in the new system she proposes to what is actually, legislatively in place at the moment.

I am absolutely in favour of anything that will help though and if the proposed system will ringfence more money or provide more exposure or utilisation of services then I’m the first person to applaud it.

But to promote the new system which has a lot of links with Carers’ Direct Payments without discussing the failings of that particular system and to look at the issue as if this system didn’t exist, seems not to be giving a true picture of the situation as it is today. Perhaps more needs to actually be done to increase awareness of the system as it exists today and promote use and access to it.

Yesterday I was called to an ‘emergency’. Well, as I don’t operate strictly in a crisis setting, it was more to act as a gatekeeper to the ‘real’ emergency services.

In essence, did Mr A need to come into hospital?  It wasn’t a formal assessment - more like  a pre-assessment and an attempt  to establish levels of risk.

Mr A was homeless. Not ’street’ homeless but as near as possible to that as could be. He had been evicted from one hostel following allegedly ‘disturbing’ behaviour. He had been moved by the Housing Department of different council to another hostel  in our area where he had been for a few days, and was due to move to a more permanent place (a bedsit) but it was again in a different local authority.

The housing officer was concerned about him. She was concerned about how he would manage in a more independent setting as he felt that the hostels had been providing more informal support. So she called us to see if Mr A needed to come into hospital.

Mr A appeared unwell. It would, of course, be wrong as well as unlawful to use the Mental Health Act to solve housing issues. Mr A was unwell enough to need support though.

He was agitated but I’d also be agitated if I had strange people trooping in to see me when I didn’t know where I was going to be spending the night. There was no way he could be said to lack capacity, at least from the history and interaction that I had access to.

So what to do?

I told the housing officer that we couldn’t refer for a compulsory admission as Mr A did not warrant it. Yes, he probably needed to see a doctor and could definitely benefit, possibly most of all, from some kind of care coordination, someone to help him and guide him to tie some of the pieces of his life together, possibly some medication - but not compulsory admission to hospital.

But I felt a bit empty on my way home. It’s likely that Mr A moved to a different area overnight. I don’t know if he would have got into the taxi to take him or not (he was fairly adamant that he wouldn’t when I left), but I think it’s one of those situations that might be on its way to deteriorate.

The housing officer will contact us later to tell us where he is, and we can contact the local team there to try and ask them to make contact. I think its unlikely that he’ll want anyone related to Mental Health to go and see him. Already when I told him (and it was the first thing I did ) that I work in a Mental Health team he became visibly more anxious (again, understandably - he has had a string of compulsory hospital stays in the past).

I have a feeling things will get worse for him before they can get better - and that is frustrating.

Sometimes, I just want to -do- something,  but have to walk away. I think those are always the hardest situations and those are the people that sometimes I think about when I’m going to sleep at night.

I know I shouldn’t. I’ve been given and have given out the advice a million times about not taking work home with you - but I suppose there must be a way to stop thinking without stopping caring.