Category Archives: socialcare
(Note – I wrote this for something else where it was not used but thought, I’ve put the work in and might as well see if anyone else finds it useful/interesting! That’s why it’s a slightly different style from my usual rants and definitely drier#.. and why there’s a bibliography!)
Personalisation policy and the principles of developing person-centred care have promised a great deal in terms of increased choice and control for service users, and a change in focus towards greater user participation in services. While putting people at the heart of services is fundamental to a progressive and ethical social care culture, the gap between practice and policy in relation to the personalisation agenda can look like an insurmountable chasm to the practitioner. This is an area where promises have bounded ahead of practice experience.
What is personalisation?
Personalisation is a process which puts people who use services at the heart of decision-making about what is right for them and how their care and support needs will be met. The opaque jargon of social care can be a barrier to communicating key concepts, and defining ‘personalisation’ is crucial as the term is used in different ways and attracts meanings which can depend on the agenda of the speaker. Sometimes personalisation can be used as a synonym for person-centred practice and support. Gardner (2011) explains that ‘personalisation’ incorporates “different strands of ideology, theory, policy and practice”(p2). Not all definitions are inclusive of the groups of people who may lack capacity to make decisions for themselves about their care needs so it is easy to see how the rhetoric can overtake the reality.
The ‘personalisation’ agenda as it has been known is more than moving people to ‘personal budgets’ and the roll out of direct payments as a default mechanism for delivering social care. It is about moving the paradigm of ‘power’ away from the centre and towards the individual. The development of this personalisation agenda took place in the context of a great deal of excitement and promise. In the early stages where the Independent Living Fund (ILF) was created in 1988, allowing for the first time people who used services to directly commission and purchase their own services. This continued through the various configurations of direct payments (initially introduced through the Community Care (Direct Payments) 1996 Act) as they made their way through different user groups and the scope extended, leading to Putting People First (2007) which pushed through the ‘transformation agenda’ in adult social care to move towards personalisation for all.
It is important that we don’t confuse ‘personalisation’ with ‘direct payments’ nor ‘personal budgets’. Different models of providing people with more choice and autonomy over decisions which are made regarding their care can be done in many different ways and in some ways, the handing out of money and telling people to get on with it – with or without the requisite support – is a very narrow attitude to take in terms of allowing choice. Choice has to include a choice in the way that we can choose about what we receive, but there has been a political emphasis on direct payments as the gold standard of choice and that leaves some at a much greater disadvantage than others in terms of having control over their own support packages. The jargon and language attached to the change in adult social care creates a layer of professional knowledge so that in itself, it removes elements of knowledge and control from people who use services.
Gardner (2011) states that “Personalisation reinforces the idea that the individual is best placed to know what they need and how these needs can be best met. It assumes that people can be responsible and make their own decisions but people need information and support to do so” (p34).
Personalisation is about far more than ‘cash in pocket’. The system embraces models for establishing different routes to choose but in practice some of these are scarcely developed. For example, using individual service funds to buy support for older adults and people with mental health needs. This focus on the individual being at the heart of the process of choosing and having more control over the care that they are provided with and establishing a framework for person-centred practice lies at the heart of the ‘personalisation’ agenda. However, the path towards a goal that it is impossible not to support wholeheartedly has become muddied with the realities of spending cuts, local authority processes and challenges which have been continually ignored rather than addressed.
The policy has been driven by the wish to overpromise in terms of extending personal budgets (and hence the ‘personalisation’ agenda) to all within specific time frames where the reality has not been able to keep up. So we have seen the reinterpretation of ‘personalisation’ to represent care and support packages that in reality look no different at all to those which were delivered 5 or 10 years ago but with a different layer of language and bureaucracy layered on top of them. This creates further disillusion within the profession, especially as the social work profession is committed to increasing person-centred practice and empowerment of individuals in the face of the ‘system’ which can sometimes be oppressive and dictatorial.
The implementation challenges for the personalisation agenda have been extensive. While this is to be expected in any process involving widespread changes behind both the philosophy of a system and the systems themselves, the agenda of promoting user involvement, choice and co-production has moved at different rates for different user groups. For example, while the roots of the personalisation agenda lie in the Independent Living Fund and the processes built on driving forward choice and control for adults with physical disabilities and learning disabilities, SCIE report 40 (Newbronner et al , 2011) explains that “There is a risk that people in later life are being squeezed into a ‘one size fits all’ model of personalisation designed with and for younger people with physical and/or learning disabilities”.
Practitioners on the ground who are often the key to success of failure of these policies in practice perceive that there is little interest in addressing their experiences or hearing their feedback.
Personalisation is an important policy aim and it is important that it works. The idea of self-directed support (or personalisation) has been a process and direction through which policy has been travelling for decades. It touches on the fundamental aims of what social work is about and how it is used in practice. There have been many changes in the way adult social work has operated since the NHS and Community Care Act (1990) was rolled out and particularly as ‘social work’ developed into ‘care management’ through this period. So why was ‘personalisation’ needed? As local authorities disavowed themselves of delivering services directly, the logical step, as purchasers of services would be to ask people who used those services to have a greater input and role in making decisions about which services were commissioned. That, at the heart of it, is personalisation. One of the main criticisms within the care management model of services and care plans being written by social workers with services being defined by block contracts was that there was that this was very much a ‘one size fits all’ attitude which left people with little choice apart from accepting or declining the services which were on offer (Maclean, 2011).
The policy move to change this and to shift the ‘power’ from the provider to the user has been wholly positive. There is no professional expertise in deciding what meets the needs of individuals that cannot be trumped by the individual deciding for themselves. For this policy to move into practice, there have been accompanying bureaucratic and process-driven changes, such as the introduction of self-assessment processes and attempts at rationalising resources with some transparency (with mixed effects) around the amounts of money spent on care so that people can make their decisions about the services which best suit them. While the direct payment model is the most touted, there are also routes through local authority managed budgets and individual service funds (ISFs) where budgets are shifted to service providers to deliver as required by the service users.
How is personalisation?
The barriers to extending personalisation have been addressed in numerous research literature. There is much evidence which seems to repeat the same conclusions that the progress of different models of delivering care, because ‘personalisation’ is about more than direct payments. This leads to frustration among practitioners that the current barriers are exactly the same barriers which were identified to the same groups of people as those to direct payments five years ago with little progress in some areas.
SCIE carried out research (Newbronner et al , 2011) focusing on people with mental health needs and older people which were the groups of people where the take up of personal budgets has been slower to gain traction. They looked at the different ways that personal budgets were offered: namely those which were directly commissioned and managed by the local authority, third party managed accounts, direct payments or a mixture of these things. They found that there was a risk that inherent processes to assess and allocate resources such as the RAS (resource allocation system) and the assessment process which may be initially a self-assessment or a facilitated process of assessment depending on the local authority and the individuals’ needs, needed to be tailored more finely towards the relevant user group.
“Where a generic system [for RAS] was used it highlighted inequalities for resource allocation between client groups. Older people, especially those with high care needs, appeared to be the most disadvantaged.” (Newbronner et al , 2011) p9
This lack of equitable access through the ‘front-door’ leads to increased disillusionment with a process which is supposedly designed to be enabling and supportive.
Another barrier is that of attitude of social worker and organisation, which is mentioned in an Age UK report “Personalisation in practice” written in 2011.
“There was a concern among support providers and some LA/Trust staff that many PB (personal budget) holders, especially older ones, were being steered away from direct payments and towards managed accounts or services by the LA (local authority” p9.
This indicates that some of the ‘blockage’ on progress and implementation is within the systems which are meant to promote it.
The intransigence of social workers and the lack of desire to embrace new models of service provision which move the locus of ‘control’ away from the professional and towards the person who uses the service has often been argued as a reason for the poor take up of direct payments first ( (Littlechild, 2002) where they say, in relation to direct payments, the forebear of the current personal budgets “it is not disabled people making informed decisions to reject the idea of a direct payments package, but their social workers effectively depriving them of access to direct payments by failing to provide information and support” (p138). This is a harsh judgement to put at the feet of practitioners but it is one that is popular among policy drivers as it is easier to blame the attitudes of practitioners than to evolve methods to promote and simplify the methods of delivery of the personalisation agenda.
Unfortunately the ‘blame’ agenda took hold early in the development of policy making and has led to greater alienation of practitioners who do want to try and make things work. There is a sense of being blamed for not embracing personalisation when the system is flawed, not because they are negative but because the processes are inexorable and have been built to reflect the needs of particular service user groups whose needs, priorities, and abilities are not universal. Effectively, policies are designed to fit some service user groups at the expense of others. Glasby (2012) states “one danger [of the roll out of personalisation] may be that current policy rhetoric is so strong that it is difficult for people with legitimate concerns and questions to raise these in an open and safe environment. Speaking to front line practitioners, some feel as if expressing doubts can be seen as ‘heresy’ and they are reluctant to say what they are thinking. While this may not have been the intention of policy makers, it could be a significant barrier in change if people feel concerned about a policy but don’t feel comfortable exploring this further, and simply disagree in silence.” (p8)
In some of the legitimate concerns, (Newbronner et al , 2011) explains that there is an inherent biases present. Referring to resource allocation schemes (RAS) the study found that “Where a generic system was used it highlighted inequalities in resource allocation between client groups. Older people, especially those with high care needs, appeared to be the most disadvantaged.” (p6)
There are therefore, many legitimate concerns which have been evidenced through research into ways that personal budgets have been used with different user groups has shown. It is vital that the cautions voiced by less enthusiastic practitioners and service users are embraced by those who are guiding policy, rather than being written off as being ‘negative’ without having the chance for their voices to be heard and for lessons to be learnt as a result.
Another challenge that is faced in practice is one of time. Quality support planning needs the investment of time. In the ideal world, presented by those who ‘run with’ the agenda, everyone is able to take an active part in making decisions for themselves and choosing their own care to meet their needs, as defined by themselves. The reality is that some groups have not been able to engage in the process of taking an active role in their own support planning; they are effectively excluded. This may be because they lack the capacity to manage a direct payment or organise a personal budget themselves, or because they lack support systems around them, such as family to help them do this.
SCIE report 40 (Newbronner et al , 2011) emphasises the fact that older people are more likely to need care during a crisis. People undergoing a crisis are likely to be less able, at least initially, to engage in the process of planning and organising their own care. Intermediate care teams typically assess and set up a temporary interim care plan and budget. Support planning then takes place a second time once the person is in a more stable situation and able to take stock. The time taken to set up a more personalised care plan in terms of the administration hoops to jump through are a significant barrier to some people and some ways of providing support.
Where does Personalisation go?
The ideology behind personalisation is sound and needs to be embraced wholeheartedly.
As practitioners we want work to support, involve and include people who use our services. The future must involve a stronger focus on services and delivery of services in conjunction with people who use them, but in order to get there, we need there to be a realistic, no-blame space for discussion between those who make policy and those who implement policy, as well as those who use services who lie at the centre of the social care system. There is still a disparity in terms of those who are best served by current practice. People who have benefited most from personalisation are those with the best advocacy and loudest voices. For the policy to embed itself in practice, it needs to offer the same quality and opportunity for flexibility to all user groups including those who are not able to raise their voices and who don’t have family advocates to speak for them. That’s where the role of the social worker has scope to be established to a much greater extent. As practitioners on the ground they have some of the most acute understanding of the challenges faced by people they work with, particularly people who are not able to best articulate their own concerns. If personalisation is going to work for everyone, we need to hear the voices from practice.
Age UK. (2011). Personalisation in practice : lessons from experience. London: Age UK.
Netten et al (2012). Personalisation through Individual Budgets : Does it work and for Whom? . British Journal of Social Work , 1556-1573.
Gardner, A. (2011). Personalisation in Social Work . London : Sage.
Glasby, J. (2012). The controversies of choice and control – why some people might be hostile to English Social Care Reforms . British Journal of Social Work 1-15
Littlechild, J. G. (2002). Social Work and Direct Payments. Bristol : Policy Press.
Maclean, S. (2011). Personalisation and Person-Centred Care. London : City and Guilds.
Newbronner et al . (2011). SCIE report 40 : Keeping Personal Budgets personal : learning from the experiences of older people, people with mental health problems and their carers. London: SCIE .
Frontline is a scheme dreamt up by the IPPR who published a report – which has since been embraced by the government and opposition – which builds on the Step Up to Social Work model of social work training and Teach First which has proved to be a popular want to pull graduates into teaching, focussing on ‘difficult’ schools.
The idea behind it, based on research done with a focus group made up of people who had been teachers on the Teach First programme saw that there was ‘something wrong with social work’. A part of me says ‘tell us something we didn’t know’. Seriously. There have been proposals to change in the way that social work is taught which have stemmed from the Social Work Taskforce and then the Social Work Reform Board.
So what is it that will make ‘Frontline’ different? The initial paper linked to above, makes reference to Oxbridge and Russell Group graduates who aren’t choosing to go into social work and seeing that as a ‘problem’ for the profession.
According to the Frontline website
The Frontline training programme will last two years. Specifically
- An intensive five-week residential summer institute;
- The first 12 months as intensive on-the-job training and education;
- At the end of the first year participants will be qualified to practice and then undertake a second year as a newly qualified social worker.
Participants will be paid over these two years and will be based with the same local authority. Participant will complete a Masters over the two years of the programme.
The 12 months will be when people go to local authorities to be trained by a ‘consultant social worker’ who is basically a glorified practice educators who have their salaries augmented by ‘Frontline’ – which, incidentally, is either a charity or a social enterprise – depending on what you are reading. The social worker trainees will be working in ‘tough’ environments.
The idea is that these people will be ‘qualified’ social workers after one year and the second year will be the AYSE year. One year (or 13 months, I believe cos these whizzy geniuses sure can count).
So who is Frontline looking for?
Frontline will look for two key features in recruits. The first is high academic ability required to be an effective social worker. Social work practice requires analytical thinking, assessment skills, critical reflection and excellent written and spoken communication, which is why applicants must have a 2:1 degree or higher.
The second feature is the attributes, skills and values to be a successful practitioner. These range from emotional resilience, respect, good judgement, inter-personal skills, and humility
I love the intense irony that humility is written right at the bottom. I’m not one to rubbish academic rigour. I’m all for it but I think it’s interesting that it is the first thing they emphasise. People develop intelligence in different ways and having a 2:1 degree from a Russell Group university is only one indication but that’s their standard so fair enough. Just interesting emphasis.
So that’s the scheme and what’s not to love? I have a number of issues that have concerned me, none of which have been addressed by Frontline PR machine. I’m concerned that while they have said they want to engage and talk to social workers about this, there has been no evidence of them speaking to anyone except on their own terms, without actually answering questions of substance. Meanwhile, the PR machine flounces around the press with the ‘they just don’t understaaaaaaaaaaaaand’ us referring to social workers who don’t ‘get’ their new model without actually addressing the very real criticisms.
So what are the criticisms?
1) It is based on an elitist model where some universities are ‘better’ than others. The initial document refers to lack of entrants to social work training from Oxbridge and Russell Group universities being evidence of its lack of appeal. I’m not sure about ‘evidence’ for this. I don’t think the university you go to defines your quality of potential for social work or your intelligence and ability to critically analyse and reflect. Sometimes it’s based on income and family circumstances. Sometimes we go to the university that is nearest home. Sometimes we go to the university that offers the best course which may not be a Russell Group. It shows an enormous amount of assumptions (which, incidentally, are very bad in social work) to take otherwise
2) Lack of involvement of social workers in developing the model. Now Josh MacAlister, the so-called ‘brains’ behind the scheme has recruited some social worker managers and academics to ‘support’ him but that doesn’t refute the lack of involvement in the initial research of social workers. Yes, spokespeople from the College of Social Work and BASW have involved themselves but they have shown no effort to engage views other than those that agree with them or work on the base of the Social Work Reform Board which particularly looked at social work education and build the new professional capability framework. This falls outside that. It also hasn’t built on the Step Up scheme which makes no sense.
3) Compressing social work education into a year, even if the practice days are similar to the amount they are now, ignores the process of learning that needs time. There is a great post which I highly recommend which covers this far better than I can. Social Work is not analogous to teaching and somehow I think the model of Teach First doesn’t ‘fit’ as nicely as the government ministers would like to think it is. It displays a lack of understanding of social work. Teach First replaces a PGCE which is a one year course in a specialist subject (which is taught).
Social Work is a generic qualification. One does not ‘train’ as a child protection social worker or even a children and families social worker – but as a social worker who then specialises in working in a particular sector. This model doesn’t allow space and time to gain an understanding of what social work is. The fear is, it will breed process-driven staff who are able to fulfil functions within a child protection team but without a deeper understanding of social work as a profession which touches the lives of adults and children in different ways and at different stages.
Moving initial social work training – not least in an organisation which doesn’t understand social work, clearly, is, I fear a mistake. One of the figures behind Frontline told me that this was a poor argument as ‘there had always been arguments about genericism’. In my view that doesn’t mean we can’t still have the discussion. We need to have an understanding of personhood and social work as a whole profession because if we don’t it becomes two, or three professions. Does that matter? I think it does because we can’t work in isolation. Mental Health, for example, covers all areas of social work. Families don’t exist in isolation. Is one year (13 months) enough time to do this alongside placements? Personally, i don’t think so. I’m consistent in this as I also don’t have a lot of time for the Step Up programme.
4) Evidence base – why wasn’t there a hold on developing a new scheme until there had been a few years running of the Step Up Scheme? I was a sceptic of Step Up and I’ll accept that the first evaluation of the first two cohorts was more positive than I was assuming but there were some issues raised and what we really need to understand is retention rates which will need a few more years of evaluation. I’m willing to change my mind in the face of evidence but developing a programme before we had some data seems foolhardy but entirely consistent with government policy making. The one issue which did arise from the Step Up scheme was access and success rates of people from minority ethic groups who were disadvantaged. The Frontline team looks very white and very male. I wonder how this will be addressed explicitly.
5) There is no mention at all of user voice in the development of the programme of education. This is a massive gap but I will wait for details of the programme. It’s all about developing leaders. Frontline’s website says
Since the start of 2012 we’ve undertaken extensive consultation with the profession to inform the Frontline proposal. Employers, universities and professional bodies were included in the process and much of their feedback is directly reflected in our plans.
No mention of people who use or have used social work services, children who have been or are involved with social work or their parents and carers. Nothing. That evidences a lack of understanding of social work education and ethos as, quite rightly, user involvement is crucial to all social work education programmes.
6) Leadership. There is a focus on this being about ‘leaders’ and developing leadership. I have a bit of a difficult relationship with the term and with some of the ‘leadership’ training. We all want and need to be ‘leaders’, don’t we? But who are we leading. Here are some of the statements made on the Frontline site.
Frontline is focused on transforming the life chances of vulnerable children by recruiting and developing outstanding individuals to be leaders in social work and broader society
So is this about fast-tracking people through the actual ‘frontline’ work as a stepping stone to management and management consultancy? I rather suspect it is. I want to know more about what they see as leadership? Ah, they heard me, look at their FAQs
18. WHY DO YOU CALL SOCIAL WORK A LEADERSHIP PROFESSION?
We describe social work as leadership because it needs people who are able to bring together a wide range of agencies, set out a vision for a family and convince them to act. The ability to adapt and deal with change, set clear priorities and deliver action for children under extreme pressure demands leadership qualities which we would like to see recognised more widely in society.
Note: There is no understanding or explanation of social work that happens which doesn’t involve working with children. It’s about ‘convincing’ a family to act? Really? Is that leadership or is that using statutory power to impose. There is nothing in this bumpf about power that a social worker has and the understanding of the use of power. No, they emphasis ‘leadership’ and ‘leading’ but as a statutory social worker in child protection, you have all the cards in your powerful little statutory hand and I’m not sure it takes much ‘leadership’ to ‘convince’ families. Again, it’s a complete misunderstanding of the social work role and selling an untruth to those who take on the role. So if Frontline ‘breeding’ leaders or are we all leaders? Bit fuzzy but then this is to sell social work to people who would otherwise consider Teach First.
7) The rhetoric of those involved with the PR has been very much ‘we need excellent/better social workers’ ‘social work education is failing’ and it’s interesting how many academics have jumped on this bandwagon. Er, guys, you’re the ones doing the training?!
Seriously though, it’s not exactly going to endear you to a profession by saying that current social workers and social work students aren’t adequate. I see that they’ve backed down a bit from that but that was definitely the initial thrust behind their PR campaign – we need ‘better’ social workers. What they are creating, I fear, are people able to work through processes in particular local authorities effectively. Is that social work at all? Does doing social work tasks make one a social worker? Unfortunately I suspect the answer is yes because that’s what employers want.
8) Local authorities should take a greater responsibility for the ‘failure’ of social work training. They want ‘cookie cutter’ ready-to-practice social workers immediately from university without investing in the process of training on-the-job. In my view, and I say this as an ex-practice educator, placements are training to be a social worker but should not be used to train for a particular position. Students need space around the placements to understand processes, power and to analyse their own changing roles as they move between being students to being practitioners with power. What local authorities want, and through this scheme they get, is more akin to apprenticeships where social workers will be trained in their own systems. There’s an advantage to that. There’s also a potential disadvantage as one of the things I found most valuable in moving from being a student to a practitioners was being exposed to different systems, different organisations and different people who had different views about the same statutory function.
9) This has shifted the focus away from post-qualification training and towards pre-qualification training without any evidence about retention. It seems to me that a better focus would be to invest in training and retaining social workers who are qualified already. I say this with a little bitterness as a social worker remained in local authority/NHS practice for 12 years before moving away. I think there needs to be more thought specifically for post-qualification training in child protection with perhaps, a course akin to the AMHP training in mental health with better pay and status – and a need for greater experience before going into these roles.
In my opinion, one of the failings of the social work system we have is that often newly qualified social workers go into child protection work. Surely it makes more sense for there to be career progression and more experienced workers to be in this field but no one wants to stay so there is a rapid turnover. Maybe that’s something that should be addressed with the money Frontline generated instead of making the problem worse.
10) Frontline seem obsessed with social work’s ‘professional status’. They want social workers to be one of the most respected professions blah blah. By focusing on ‘leadership’ and recruiting ‘top graduates’ this will happen. Right. I’m more sceptical. I think it will only happen when social workers don’t obsess about their/own status and when we speak up for people who use social work services – without our job role and outside and show how useful we are. We don’t need validation and we don’t need to be ‘loved’. We don’t need documentaries so people ‘understand’ us. We need to do our job well and not wait for others to find the respect for us. If we tell people what we do well, if we concentrate on developing a profession where we can respect ourselves, then we will be respected and some people will always hate us because we use state powers to control behaviours. That’s life.
I hope someone from Frontline will respond to these ten points in turn. I wait with interest.
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.
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.
Yesterday, while most of the media, fixated self-referentially on the Murdoch hearings and Cameron was flying back into the country, Lansley began to dismantle the National Health Service.
In the first wave, beginning in April, eight NHS areas – including musculoskeletal services for back pain, adult hearing services in the community, wheelchair services for children, and primary care psychological therapies for adults – will be open for “competition on quality not price”. If successful, the “any qualified provider” policy would from 2013 see non-NHS bodies allowed to deliver more complicated clinical services in maternity and “home chemotherapy”.
So we are led to believe that being open for ‘competition on quality not price’ will act to pat us on the head, reassure us, and direct us back to the ‘big media story’.
It worries me and it worries me for a number of reasons. Lansley’s words are couched in the words of ‘choice’ but I wonder exactly whose ‘choice’ it will be to make these commissioning decisions for which, no doubt, large amounts of money will change hands and profit-making publicly listed and private companies will be able to partake.
I admit to a bias having been exposed and having experience in the adult care sector which was subject to a similar rollout of competition which was supposed to increase choice and quality.
I’ve written many times about the end result and how it is one that has inherently favoured larger providers and companies that have been able to deliver on economies of scale rather than the poetic vision of small scale providers delivering local services. Those small scale providers were quickly priced out of the market and I fear this will happen again.
But wait, I hear, ‘quality not price’ Lansley says.. to which I reply, ‘nonsense’.
Why? Because there will probably be minimum standards of ‘quality’ that a service has to reach and beyond those, it will be a price competition. That’s what is supposed to happen in care – but who checks the standards? who will check the standards? How can we have confidence in a well-resourced and well-delivered service when regulators are so weak.
I do not want any private company to make a profit on my potential need for services for my back pain, my hearing or a child’s wheelchair.
Of course, making the publicly delivered service is clearly both too expensive and veering against the government doctrine of handing the healthcare to private companies.
I am sure the first few providers will intersperse local voluntary organisations with large multinational corporations in their delivery methods. Again, I point to the adult social care sector. We started along the path with the NHS and Community Care Act (1990) having a lot of local providers together with a few Southern Crosses and Care UKs. The local providers were eventually priced out.
Of course in the case of podiatry and hearing services as well as primary care psychological therapies, we can see these as almost discreet services. The ones that will potentially be easy to deliver and it will always be possible to find wonderfully successful outcomes for people choosing Boots rather than the local NHS for their podiatry appointments because it is more convenient. And I’m sure it seems to pave the way for Individual Health Budgets where people are given the money to ‘spend’ on the services that they need. Choice you see. Choice is what it’s all about.
I turn back and look at what has happened in social care. Choice has been extended in wonderful ways to those with the loudest voices but in some ways those with the highest needs have been left behind. That is my main concern about the introduction of private into public.
For some people, the people in the comfortable middle classes of Chipping Norton, this is fantastic news – they can access their IAPT (or equivalent) by a local provider when they are feeling a bit down. They can have their feet checked in a local branch of Boots instead of having to travel into Oxford. All’s well.
Those will be the areas where both competition and choice are the highest.
My concern is that people who experience the degradation of poverty will have quieter voices and less choice because there may be higher multiples of health difficulties and choice is determined through power. I can’t help but think of people who are restricted in their choice by issues of capacity. Will they be given advocates to assist with the process or will they just be ignored? Will the choice by made by GPs who are courted by these private companies, just as they are currently courted by drugs companies?
How equitable will the ‘new’ system be?
If we are extending choice, we have to extend safeguards and checks.
If we are extending choice, we have to extend quality.
It hasn’t happened in social care – there is no reason to believe or trust that it will happen in healthcare.
It does make me wonder – Are we all in this together? Really? With the impact analysis projects that are carried out to ensure equality, I know there are provisions to look at ability and disability, gender etc but are social class and income level also considered?
And think – Lansley considers putting ‘quality’ in as a concession – he was happy to go ahead with the Bill and with a pure ‘cost’ factor. This is his so-called concession but it is no concession at all if we don’t have a definition of what ‘quality’ is. After all, the CQC – too look at the Health Care regulator – defines ‘quality’ on the basis of paper documents and paper inspections given to them by provider services.
If that doesn’t wave any red flags, I don’t know what will.
This is a government of interests rather than representatives. The shame is that the last government was too and likely all the future ones will be as long as we allow our heads to be turned more quickly by celebrity gossip than the tragedies unfolding in our adult care services.
- Private sector firms invited to bid for £1bn slice of NHS (independent.co.uk)
- NHS services to be opened up to competition (guardian.co.uk)
- More competition planned for NHS (bbc.co.uk)
Yesterday, the High Court ruled in the case of R (on the application of McDonald) v Royal Borough of Kensington and Chelsea. This was a further appeal by McDonald against a previous decision at a lower court.
Elaine McDonald is 68 year old woman who worked as a ballerina in her younger days. The press seems to be a little fixated on her former career, and she does have a more glamorous background than many who come to rely heavily on social care so perhaps it is no surprise. Ms McDonald suffered from a debilitating stroke in 1999 and had a further fall in 2006 which led to very poor mobility. Although not medically incontinent, she required assistance to use the commode during the night. She had been provided with overnight support to meet her assessed needs related to continence during the night however Kensington and Chelsea were suggesting that this need could be met by substituting this assistance with the provision of continence pads during the night which would, by their nature, demand that Ms McDonald remain in these pads until carers could come in the morning and at intervals to ‘change’ her.
I wasn’t surprised by the decision by the High Court because there are precedents that led the access of local authorities to resources to be a factor in relation to the provision of services.
In my own working experience, it is impossible to access any kind of home care support overnight except in some very specific cases where there is very high need support and even then, it is much much more likely to be provided to younger adults with physical disabilities. I can count on the fingers of one hand the amounts of times I’ve come across local authority funded overnight support in the last 10+ years of practice.
Sometimes I have to take a step back from what I regard as ‘normal’ practice to understand the outrage at this decision. I realise how I become attuned to ‘local authority’ think and ‘budgetary’ think and that’s quite an uncomfortable thought.
We get used to applying different definitions of ‘dignity’ and what is acceptable because we are aware of the thousands of Ms McDonalds that require support and the existence of a finite resource. So do you support the Ms McDonalds and assist them to provide a fuller and more dignified life at home or do you provide 8 Ms Smiths with respite care over the year. These are the realities of the decisions and it shouldn’t have to be so.
Perhaps that’s why I’m less surprised by the McDonald ruling and less surprised by it.
There are though horrendous inequities in our system of the provision of social care. Where Ms McDonald in Kensington and Chelsea may be receiving a vastly different service from a parallel Ms McDonald in Newham. I would venture a guess that there are thousands of potentially very similar cases to Ms McDonald bubbling under the surface ‘in the system’ but because they are not ex-Prima ballerinas and don’t have the will, way and means to bring cases and involve solicitors, we will never know about them.
If anything is, quite literally, the ‘dirty secret’ of social care and health care provision particularly for older adults, it is this.
We have different standards of what we class as being ‘dignified’ for ourselves as for others. What might class as dignity to an older adult has less value and invites less spending to an equivalent younger adult with exactly the same care needs. Those who shout loudest get the most – as far as care is concerned and as far as public interest is concerned. The shame and pity of the ‘personalisation’ agenda and the flawed implementation of personal budgets in social care have exacerbated this problem further rather than provided a channel to allow for a more equitable system of care delivery.
It sometimes feel cruel and harsh, because it is a cruel and harsh system that it perpetuated by discriminatory systems. Would the warehouse-style very large residential and nursing care homes with 100+ beds be acceptable for younger adults with similar care needs? I don’t think so. I don’t mean to imply that every large care home is bad and every small care home is good. That isn’t the case. It’s about a fundamental reassessment of what is acceptable in the provision of care for older people in our society.
I make no apology for my less erudite post and thoughts. The more I work and the more I reflect, the more interplay I see between the basic conceits of ethics and ethical judgement in the role that I play as a part of this system that condones this mealy mouthed interpretation of human rights merely on the basis of cost and resourcing issues.
It is accepted because our society is inherently ageist. We don’t want to think or pay for the care of older people. We care more about our collective inheritances and potential house prices than the more collective thoughts about where the boundaries of an acceptable level of care and dignity lie.
If anything, this has impressed on me the importance of constant reflection on my practice and my work. I can advocate to an extent, from within the system, for the dignity of those like Ms McDonald and I try to. Some I win and some I lose but as long as I make my voice heard through every step of the process I can help to feed the voices ‘from the front line’ back to the more senior managers.
I make judgements and I am the mouthpiece of the local authority. I am an employee but the second that I become complacent, the moment I stop reflecting on the effects the decisions I make have and the instant that I join that local authority ‘group think’, I lose my ethical compass and my professional judgement.
I talk a lot about important qualities of social workers and social care workers. Respect, empathy and to that I’d add advocacy. It might not always be seen in the internal battles that we fight, but we have to try to fight so as not to accept a ‘normal’ that is defined on the bank balance sheets of the local authority accountants.
Tags: Age Discrimination, ageism, agism, dignity in care, elaine macdonald, elaine mcdonald, health, Home Care, kensington, local government, mcdonald v kensington and chelsea, nursing home, r v royal borough of kensington and chelsea, Royal Borough of Kensington and Chelsea, social work
Scheduling and exhaustion meant I didn’t have time to look at the Dilnot proposals in detail yesterday so this morning I have fired up my browser and am going to make a few initial comments on the baseline main recommendations and hopefully over the next few days can look at some of the details.
The Dilnot Report on Funding of Care and Support runs at 82 pages. It attempts to forge a solution for the currently antiquated and inequitable system of care funding that is currently in place. Much talk has been made of the current threshold of £23,250 of assets, at which people currently become responsible for paying for their own care services but little made of the current discounting of homes in certain circumstances and the ability to raise a charge on a property to postpone payment of costs for care services. Nevertheless, this threshold was deemed as being too low. People who own houses like to keep houses for children. People don’t like those who ‘haven’t worked as hard’ or ‘saved as much’ getting something for free.
The system is broken though, don’t get me wrong, I just think the focus of the discussion has been too much around middle class fears of actually paying for something they believe should be free. Now, I’ve got that off my chest, back to the report.
The main recommendations are
- to cap lifetime costs of care between £25,000 and £100,000 – with a suggested threshold (which is used throughout the report for ease) of £35,000
- means-tested assistance will be extended to those who have between £23,250 and £100,000 of assets.
- Those who ‘enter adulthood’ with support needs will not be means-tested and care will be provided free.
-Universal disability benefits will continue but may be some differences in names regarding Attendance Allowance. (erm.. DLA?).
- There will be a cap on so-called ‘hotel costs’ in residential care between £7,000-£10,000
-There should be a national, portable eligibility framework which is more transparent.
- A government awareness campaign about planning ahead and preparing for potential age-related disabilities. And their costs.
- There should be a new information and advice strategy to help people through the confusing forest of knowledge.
- Better carers support and information.
- More health and social care integration
Of course, these recommendation run alongside the Law Commission’s report for changes in adult social care law. Together they could create a much better and clearer system than we currently have.
The ‘lifetime cap’ allows for insurance policies to be generated and probably very profitable ones too for the insurance companies. Most people do not need high level social care provision but the fear generated by the media is enough to drive right minded people into the arms (those who can afford it and who have substantial assets) into the arms of the insurance companies. I’m not sure how comfortable I am with the lifetime cap on care costs. It means the more wealth someone has, the more they are protected. I understand the logic behind it in that noone chooses ill-health and disability but the more than government spends on those who do have substantial assets, the less there is for those who cannot afford it and the higher the criteria to access support rises.
I just have a few queries which may be answered in the details. If Mrs Smith has a house worth £300,000 and she lives alone with no other substantial assets – say, for example, she has savings of £10,000 – is her house sold to release the asset worth up to the cap of £35,000 – assuming she doesn’t have an insurance policy? If she chooses to live in a care home which is private, but then the money runs out, will the local authority still move her? Will she ‘top up’ the local authority fees, paying above the ‘cap’ to do so? What is she lacks capacity and has no family? I suspect all these answers are in the report but they will be questions I will be looking for. The system of deferred payment is mentioned and I’ll hunt around for clarification.
The cap though, seems to be there to protect middle class votes.
I do, however wholly support the increase in the level of means-testing. I think it is entirely right to continue to means test up to £100,000 and I’d even go further than that. I don’t have a problem with mixed funding, I am just not entirely comfortable with the capping.
Again, the clarity of the coverage of those who ‘enter adulthood’ with care needs is entirely right. There is a necessary distinction between working age adults with care needs and older adults with care needs but quite rightly it is wrong to have a distinction fixed at a specific age. Indeed, Dilnot proposes that those who develop long term care needs before the age of 40 should continue to have a zero cap and costs should be met fully by the state. Above the age of 40 there will be some kind of tapering of the cap up to retirement age where the full proposed £35,000 cap would be reached.
Regarding the accessibility of universal disability benefits, Dilnot clarifies that he does not propose any reform that would lead to anyone losing their disability benefits and that attendance allowance will continue. I do wonder though how this ties in with the government plans to remove 20% of DLA claimants.
There are some recommendations though to change Attendance Allowance (AA). Firstly to change the name to something more understandable and an appreciation that many who are eligible for it do not claim it. That absolutely reflects my experience. People who reach the cap when the government takes over payment will not continue to receive Attendance Allowance (or whatever it will be called) because the government is fully paying for their care needs – which makes sense to me. The Personal Expenses Allowance (PEA) is proposed to continue – this is the payment that is made to people whose costs are met by the government in residential care and is currently about £23 pw – there is a suggestion that it should increase but not a recommendation.
The cap on hotel costs is excellent news in my view because I saw this as a potential ‘get out’ clause for residential homes. I do want to know how some of the private homes will adapt to these new systems though and what the cap will mean for overall quality of care provision.
The idea of clearer, portable assessments is a good one and long overdue. Eligibility criteria interpretation can differ wildly and there needs to be more transparency. The minimum threshold would be applied at the ‘substantial’ level of care so I wonder how this portability will work for those who live in areas that meet lower levels at present. It seems that there is some kind of recommendation to do away with FACS over the longer term.
Can’t be soon enough – a new assessment framework will be developed ‘with experts’. Please please please can front-line practitioners be involved in these developments – not just people who professionally develop policies and have never needed to use assessments in their lives. This is why we end up with unusable systems. There is also a way of building self-assessments into these new models. That’s the idea anyway.
The last recommendations about building awareness and improving quality of information seem to be sound all round. Nothing to argue about there.
I am interested in the recommendations as they relate to carers. As far as I am concerned, I want more than just an assessment for carers, I want the provision of more services. Supporting carers very well both financially and with practical and flexible support is probably the one aspect which can potentially save the government more money in the longer term than anything else – but more than that, it is an issue of ethics and morality. I know that doesn’t often come into government services but it’s something I feel very strongly about.
I also recommend Arbitrary Constant for links and discussion about Dilnot.
Tags: Andrew Dilnot, british politics, care and funding, dillnot report, dilnot report, dilnot report on funding of care and support, dilnott report, Funding, funding of care, health, local authority, long-term care, Means test, nursing home, old age, social care, social work
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)
The ‘Hardest Hit’ Campaign is has been organised by a number of disability charities which form the heart of the UK Disabled People’s Council which is an umbrella group for many organisations across the country and Disability Benefits Consortium which is another umbrella type body which includes a lot of well known major UK charities and organisations.
Between them, these two bodies substantial weight and experience of disability in the UK and the campaign which has organised a march tomorrow, is intended to highlight the cuts which are being focused on people with disabilities by the government.
Tomorrow, 11th May, there will be a march in London. The details of the march can be found here and will culminate in a lobby of Parliament between 1.30pm and 5.30pm. Unfortunately, I won’t be able to attend myself due to work, however, in the spirit of inclusiveness there is a joint online campaign for those who are not able to attend. There is both an option to write to your own MP (if you are in the UK!) and/or to send a testament to the campaign so that experiences, worries and issues can be collated. It is worth reading through some of the testimonies already sent in.
So what changes are being proposed? Why is disability targeted?
Well, as the Hardest Hit website states, the government (and let’s not forget that the Labour Party are also backing these changes) proposes
- Cutting 20% from the budget for Disability Living Allowance (DLA)
Putting a percentage figure of cuts necessary only means one thing. It means raising the bar to access DLA. It is not an ‘easy’ benefit to apply for. I know because I’ve filled in many many DLA and Attendance Allowance (the equivalent benefit for over 65s) forms in my time. There are many faults with the system of DLA at the moment but being too lenient isn’t one of them. My own criticism would be about the way that applications are made and the emphasis on physical ‘ability’ and ‘disability’. I genuinely think that more trust should be placed in GPs and teams that are working with the claimants rather than form filling. It’s important to remember that DLA helps disabled people to WORK.
Disability Living Allowance is also a ‘gateway’ allowance for Carers Allowance. Carers’ can only claim Carers’ Allowance when the person that they care for receives either DLA or Attendance Allowance so a cut would have a substantial effect on carers as well – even though carers’ allowance is pitifully low, it is better than nothing.
- Taking mobility payments away from disabled people living in residential care and children going to residential schools
I think the government may well be backing away from this one already. Campaigns and demonstrations can work.
- Cutting off payments of contributory Employment and Support Allowance after a year to people struggling to get back into work due to disability or serious illness.
This, I think, will have a massive effect as well as ESA (Employment and Support Allowance) is the benefit that is paid when someone cannot work due to ill health or disability. There are so many issues regarding ESA but this one is likely to cause substantial hardship and limiting contributory payments for a year when the effects of the illness or disability are not time-limited will merely serve to reduce payments to those who do not meet the criteria for the income related ESA.
Remember, contributions based means that the person has worked and paid their National Insurance – this is not a ‘layabout charter’ that the government (and opposition) seem to think that ‘hardworking people’ imagine is in place for ‘scroungers’.
Our system should support people who are not able to work due to sickness and disability. I don’t doubt there are problems in the system but I don’t see how employing a private company (ATOS) to make perfunctory tests based on predominantly physical health needs rather than asking GPs and consultants to validate (or not) the claims of their own patients makes sense.
On the one hand the government is saying how trustworthy and fine our GPs are and how they can carry the ‘commissioning’ task as they know their community best but on the other hand they are not trusting GPs to make honest assessments of their patients’ ability to work or not as regards assessments for ESA.
So as for the campaign, I want it to succeed or at least to change some of the distasteful discourse that exists at the moment around benefits and people who rely on them more broadly.
In order for it to succeed, it needs widespread support and the people marching need to know that they are supported.
If you aren’t able to attend tomorrow, go to the website and see what you can do to lend support. Anyone who has a belief in social justice needs to be involved in building a fairer society for everyone. That’s what social work is about as I see it.
- Thousands to march through London in protest over cuts to disability benefits (guardian.co.uk)
- Making Work Pay – Thoughts on the Welfare Reform Bill (fightingmonsters.wordpress.com)
While awaiting the details of the court judgement, there was an important ruling yesterday that Birmingham Council’s attempt to limit eligibility to social care services to those who have ‘critical’ care needs is unlawful.
Drawing out some of the definitions to what this actually means and could mean requires a look at the details of those who brought the case to court.
There were four defendents which the BBC explains include
a 65-year-old woman with severe learning difficulties who receives 24-hour care in a home paid for by the council
25-year-old man with a rare genetic disorder and severe learning disabilities who receives overnight respite care, also funded by the council
30-year-old deaf, autistic man with severe learning disabilities who is prone to self-harm. His specialist day care would also have gone under the plans
a 36-year-old woman with severe learning difficulties whose day care centre will close and who is also set to lose respite care
It’s useful to go back to the definitions of what ‘critical’ and ‘substantial’ needs are to understand fully the implications of councils moving the eligibility criteria from one stage to the next.
Critical needs exist where -
• life is, or will be, threatened; and/or
• significant health problems have developed or will develop; and/or
• there is, or will be, little or no choice and control over vital aspects of the immediate environment; and/or
• serious abuse or neglect has occurred or will occur; and/or
• there is, or will be, an inability to carry out vital personal care or domestic routines; and/or
• vital involvement in work, education or learning cannot or will not be sustained; and/or
• vital social support systems and relationships cannot or will not be sustained; and/or
• vital family and other social roles and responsibilities cannot or will not be undertaken
Whereas Substantial needs (those that Birmingham are stating they are no longer able to meet) exist where -
• there is, or will be, only partial choice and control over the immediate environment; and/or
• abuse or neglect has occurred or will occur; and/or
• there is, or will be, an inability to carry out the majority of personal care or domestic routines;
• involvement in many aspects of work, education or learning cannot or will not be sustained;
• the majority of social support systems and relationships cannot or will not be sustained; and/or
• the majority of family and other social roles and responsibilities cannot or will not be undertaken
A couple of things to be noted here. A differentiation is made between ‘abuse’ and ‘serious abuse’ so that one will be covered and the other won’t. What kind of ‘legal’ test would there be to determine when abuse counts as ‘serious’ or not? Can we see children in similar cirumstances being subject to a differentiation of level of care available depending on whether abuse is ‘serious’ or ‘not serious’? And who is doing the judging? Well, I can answer that last question. It is the social worker involved as I am asked as a matter of course to ‘band’ people according to these criteria.
The obvious glaring point is the lack of thought of any kind of preventative work that sticking so closely to the criteria will create. Where is the hope of creating those very creative personal budgets when only the very bare minimum of essential needs are being met.
I can’t claim anything other than relief that Birmingham case was challenged in court. These criteria and these levels of need look at people as lists of what they cannot do. That goes against everything that we know and the ways in which we practice by looking at strengths and looking at people as individuals. However, the reason the criteria were brought in in the first place was to end some of the ‘postcode lottery’ of care provisions and to bring consistency to who was offered what nationally. Of course, the problem remained that interpretations of these criteria vary so the consistency which is objected by ticking boxes (the only way the officials seem to know to apply it) depends, as mentioned previously on the social worker who is doing the ‘judging’.
Back to this case though, it was brought under the Disability Discrimination Act and hopefully the judgement will be available soon. Hopefully too, local authorities around the country will be leafing through it and realising that the wholesale and slapdash cuts that they are imposing are not legal.
As for the government of millionaires, none of them will be reliant on social care support from the council. They can buy in any support that they might potentially need and cannot understand the distress of those who are totally reliant on the availability of services. They cannot understand the implication of their gung-ho ideological cuts and the thought of Cameron, Clegg and Osborne claiming ‘We’re all in this together’ sticks painfully in the throat.
Although I fully expect Birmingham to challenge this ruling, I hope that the case is held and that some of the trigger happy cutting is stopped and the very real effect of the cuts agenda is shouted out more loudly and more clearly – not just for those of us who are personally losing services but to raise our voices with those who cannot always shout so loudly.
That is what social justice is about and that is what social working is about.
Tags: BBC, Birmingham City Council, Disability, England, learning disability, local authority, local government, personal, personal care, respite care, social care, social services, social work, social worker, uk, United Kingdom