What Price Care?

Today the Institute for Public Policy Research publishes a study about adult social care on the cusp of the publication of a new Green Paper next month.

As they claim, the study

seeks to generate public debate about the future of social care; and consider how the social contract between the state, organisations, communities, families and individuals may need to fundamentally change to ensure that the future of social care is based on principles of fairness and sustainability.

Quite a substantial task!

It does make interesting reading though – especially as the gap between expectations which have possibly been raised to unrealistic heights by a free health care system and realities which are that the costs of social care in a society which is ageing can only increase – possibly exponentially.

What is clear is that no-one wants to pay for services. No-one wants to have to sell a property in order to fund care services. No-one wants family members to be obliged to pay for care services. No-one wants higher taxation levels to pay for care services. But everyone wants high quality care services that are not means-tested and are, like health care, free at the point of delivery.

So looking back to the study, the main points raised were that

  1. Low awareness and uncertainty: confusion about the nature of social care services

There was shown to be confusion on where the barrier is drawn between health care and social care. One only has to see the balance that is drawn by continuing care funding to see how difficult it is to judge at times. It is also something that is rarely going to be seen to be  equitable.

There was a general wide understanding of the most obvious social care provisions like directly provided home care, residential care and day care but this tapers off when provisions like support for those who are homeless or support for substance misuse services or even direct payments for carers are considered.

– Misconceptions about social care funding

    When it came to asking about how social care is currently funded there was a large proportion of people who just didn’t know that the services were means-tested. Unsurprisingly, the younger the age of the respondent, the less likely they were to know about how funding was implemented!

    Which leads to the third ‘heading’

    – Lack of preparation and planning for care needs

      The vast majority of people have made no plans to fund future care needs and unsurprisingly, the younger the respondent, the less likely they were to have made plans – or as in the older age groups – feel that they wouldn’t be able to make plans in any case.

      – Reluctance towards greater family responsibility for funding and providing care

        This heading is an interesting one and one that is a model in other countries but here in the UK, there is seemingly strong resistance to any kind of obligation to fund older family member’s care with only 4% of respondents feeling that there should be an obligation on children to pay for their parents care. 14% would support a system based on means-testing to fund parents’ care however 52% believe that is fundamentally wrong to make any expectations of children to pay for their parents’ care.

        Interestingly this resistance to pay increases with age. Perhaps because of closer experiences with the caring role and the need for social care provision.

        Also, there was a preferred role for professional ‘paid’ carers providing social care as opposed to family or friends, either voluntarily or in a paid capacity, providing that support.

        Although these figures are significantly varied when related to Minority Ethnic families where there is a higher willingness to take up the costs of care for older relatives and a greater desire for that care to be provided by family members.

        – Views on the principles for future care and support for a more collective, universal system

          When asked about possible models, by far the most popular seems to be a free, universal system of care available to all and funded through taxation on a strictly need basis. I have to say I’m not surprised by this although I wonder if it would change if a proposed level of taxation had been mooted.

          – Space for change: a strong desire for more information and debate on the future of social care

            With information comes understanding and only 7% of respondents claimed to feel well-informed about the current ways and means that social care is funded, against 69% who feel they are uninformed and 11% who are somewhat informed but would like to know more.

            image mickeymox at Flickr

            In all I think it’s a study that possibly can link in to the Green Paper proposals – not because there is anything particularly new but because it reiterates the point that there is vast confusion about the current system and will continue to be into the future. People don’t like to think about getting old or needed care until these issues are sometimes quite literally, staring them in the face.

            Personally, I can only see some kind of mixed pattern of care with some kind of means testing and some kind of base free entitlement for the most critical needs, possibly with the additional of a type of insurance. The free universal pattern would be wonderful  but is not economically viable.

            It will be interesting to see what the Green Paper comes up with.

            Ginger

            My duty as an AMHP (Approved Mental Health Professional) is fundamentally to co-ordinate and carry out assessments according to the Mental Health Act (1983 – as amended 2007).

            So in the case of a community assessment, I will request the doctor’s attendance – if a warrant is required for entry, I will attend the local magistrate’s court and request police assistance if needed.

            I book the ambulance and although the Mental Health Act Code of Practice is clear in vesting the responsibility for bed finding to the doctors involved, our current practice where I work would mean that I would alert our Trust ‘bed manager’ of the impending assessment who would then inform me of the bed that I can use.

            I am obliged to accompany the patient to the ward if they are admitted under section (compulsion) to ensure that the admission papers travel with the person themselves – although this can be delegated, I have never done so – and even if it were, it would remain my responsibility as the AMHP.

            Once on the ward, I hand the papers to the member of staff whose role is to ‘accept papers’ who will then check everything is correct. I will, if I can, stay to see the patient settled but one of the other matters that I am tasked with is to under Section 48 of the National Assistance Act (1948) which explains

            (1)Where a person—

            (a)is admitted as a patient to any hospital, or

            (b)is admitted to accommodation provided under Part III of this Act, or

            (c)is removed to any other place under an order made under subsection (3) of the last foregoing section,

            and it appears to the council that there is danger of loss of, or damage to, any movable property of his by reason of his temporary or permanent inability to protect or deal with the property, and that no other suitable arrangements have been or are being made for the purposes of this subsection, it shall be the duty of the council to take reasonable steps to prevent or mitigate the loss or damage.

            (2)For the purpose of discharging the said duty, the council shall have power at all reasonable times to enter any premises which immediately before the person was admitted or removed as aforesaid were his place of residence or usual place of residence, and to deal with any movable property of his in any way which is reasonably necessary to prevent or mitigate loss thereof or damage thereto.

            Put briefly, I have to ensure the property is secure. This is usually done by enlisting a locksmith to attend the assessment so that if the lock does have to be broken it can be replaced immediately.

            ‘Moveable property’ though, also ensures that any pets are taken care of and I have a legal responsibility to ensure the well-being of any pets left behind in a property.

            And so it was that I learnt of the existence of a device called a ‘cat trap’ (obviously one of those humane traps!).

            image AmbHain at Flickr

            I had carried out an assessment a couple of days ago. It was relatively fraught, as is often the case. Mr Y though had a very timid cat. After he had been admitted I called our animal warden to see if we could arrange a cattery for the cat in question (as that is invariably what we do).

            He was happy to agree it but we needed to find Ginger. Along with Mr Y’s daughter (whose own child was allergic to cats), we went to try and find him. And we couldn’t. He is a timid cat at the best of times but the uproar and noise of strangers padding in and out of his ‘den’ must have had some kind of impact.

            That was when the warden suggested a trap. He explained that it wasn’t as scary as it sounded and just involved putting food inside a cage which would close down when kitty entered.

            And the trap was left overnight. The next morning, sure enough, there was Ginger. Looking disshevelled but rather plumply satisfied and with the warden, we waved him on his way to his own ‘place of safety’ for a couple of weeks at least.

            Sometimes you really never do know what the day will bring.

            Meals on Wheels

            We can’t escape the fact that we are growing older – it creeps up on us at first  – it is easy to ignore – and then seems to gallop alongside us a while – keeping pace, seen only went sought and then, becoming ever more visible next to us and later as we slow down, it can overtake and eventually beat us down.

            The Guardian and Observer have been running a series about Ageing Britain – it isn’t a terribly positive one either and seems to have a focus on the ways and means that the country has lacked the foresight or else the cash to manage an ageing population.

            One of the more poignant stories, to me anyway, is that of Rhona Johnson. She delivers hot meals at lunchtime in the local community.

            IMG_0920

            Working as I do in services for over 65s, I have a lot of time for the ‘meals on wheels’ service. Unfortunately, my borough doesn’t have any money for them anymore – and that’s where the poignancy comes in.

            We offer a service, contracted out, of course to the lowest bidder (the provider was changed a couple of years ago). There is a block on providing a hot meals service at the moment. Instead, we can offer a fortnightly delivery of 14 frozen microwaveable meals.

            It’s a cost thing, of course although there is a standard charge for a ‘meals on wheels’ service. It’s not always easy to sell.

            And we don’t have any Rhonas – who stop by for a chat – however brief or even a cup of tea.

            It is a false economy of course – like all the services offered, it is reactionary by it’s nature. There is no scope for prevention. Sometimes by the nature of the criteria needed to be eligible for meals delivery (even frozen ones) is that they cater for the loneliest individuals.

            In order to be eligible you pretty much have to be housebound or in the case of a couple, both housebound – namely unable to get meals by any other means – no family members popping in regularly to get the shopping.

            So what do we do? Provide carers to go in and actually make the meals – possibly at a higher cost because they times they stay at longer – although this is highly discouraged of course, because of the increased costs. So perhaps it is a better system but it seems to miss some of that human contact that is explained in the article in the Guardian.

            One of the worst parts of the job and it is a legacy of the 1990 NHS and Community Care Act in my view, is that choice for users has all but disappeared. There is some semblance of choice with direct payments packages but they barely touch the edges of the services, especially for older people.

            There are services and lists of timings and availabilities and criteria that need to be satisfied in order to access these services. There is little scope for creativity although ‘making a case for an exception’ has become something of a mission for me and has, to be fair, a reasonable success ratio.

            And the future is Individual Budgets and the Personalisation agenda promising greater choice. I remain sceptical but we can always hope.. I suppose. The Triumph of Hope over Expectation….

            Expenses

            The British Houses of Parliament, London
            Image via Wikipedia

            I have retained the general cynicism in the light of the expense claims made by MPs that have been highlighted in the Telegraph over the past few weeks.

            I don’t honestly think there is anything I can add to the debate or discussion that hasn’t already been said.

            I am though, amazed at the mealy-mouthed defence of ‘It was all in the rules’ that seems to be wheeled out again and again and again.

            Especially when they make the rules in the first place.

            There seems to be a detachment between professional politicians and those whom they seek to represent in a general level. Perhaps it is the kickback of the class system and a ‘right to rule’ that permeates some sections of the Upper and Upper Middle classes.  Commentary seems to have settled around a generalised mistrust of the institution of Parliament and those who lodge themselves within her, on the inside looking out.

            One thought that has meandered through my brain though is that I wish I could take some of these MPs on my visits with me though – to highlight to them what can and could be done with additional government funding in some of the more deprived areas of London.

            I’m well aware that things don’t work like that. The money paid in expenses would not be the same money that would fund a woefully inadequate social care system. That the Fair Access to Care Criteria that squeeze all but the most highly dependent from any kind of rights to care would actually be more broadly implemented if fewer MPs had this mentality of entitlement.

            It doesn’t work like that.

            The thought that while we are being told that any criticism amounts to victimisation and that, as the BBC reports

            The atmosphere at Westminster has become so “unbearable” due to expenses revelations that a suicide is feared, one MP named in the row has warned.

            Honestly, I’m sure they are stressed and all but there’s a matter of cause and effect and actually taking some responsibilities for actions. Actually if there are any suicidal thoughts coming from a Member of Parliament they have all my sympathy and I mean that most sincerely.

            However I really don’t have time for though is self-pitying MPs. I have to say coming from a profession which has been the subject of disdain by the media and the general public – I can’t say I’m wholly oblivious to some of the stresses caused by such deep seated public resentment –  but conversely, many of these career politicians seem to be oblivious to any uninformed prejudices unless it relates specifically to them.

            The Archbishop of Canterbury calls for a return to the basic morality in the dealings of the public servants and perhaps he isn’t so far off. Rather than seeing what money can be squeezed out of a flawed system – there needs to be a wider exploration of the responsibilities of governing and representing, rather than merely a counting of the rewards available.

            As he comments, the answer is likely to be through transparency in the future. It will be a brave and foolish parliamentarian who tries to make claim for a plasma television now. . .

            Will it deter the most able from entering parliament? It depends how ‘most able’ is defined. Most highly paid? Possibly. I expect the salary without the ‘bonus extras’ will attract some but will deter others.

            Maybe I’m just working on a different level but I know I’d be attracted by a 64K salary at any rate! So does it mean that the highest earners are automatically going to be the best to govern us? Do business and industry leaders make the best Members of Parliament? I’m honestly not sure. I think the best Parliament though is made up from the sum of lots of very diverse parts from all different backgrounds and professional groups.

            So where does that leave us now? Pretty disillusioned but not beyond hope. I think a purge of current MPs who were complicit in a system of gorging would go some way.

            I wonder sometimes if the idea of public service has, in general, fallen by the wayside though and if not, a new generation will soon emerge, ready to find new ways to game the system.

            I know, I shouldn’t be so cynical!

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            Chasing Housing

            I try to avoid contact with Housing as much as possible. It comes very close to the  ‘hello, head – meet brick wall’ kind of scenario. I know they are very busy and all  but sometimes it seems like every conversation turns into a battle. Even relatively mundune ones.

            I could write reams about some of the ‘firmer’ discussions I have had with my colleagues in the Housing department. Whenever I am asked to ‘push a housing application along’ I run scared – actually I explain the brutal and honest truth – namely that I have no influence whatsoever on housing applications and although I can sometimes make a phone call or two it doesn’t really have a massive effect.

            Except in some occasions. I have been following through with Mrs S because she lives with her son and his family. They are moving to Australia en masse in a few months and she isn’t. So she needs somewhere to live.

            We are looking at sheltered accommodation as she doesn’t really have any physical care needs. It is actually plain and simple (if it ever is) about having a roof over her head. Obviously though, it would be anxiety-ridden at the best of times and these aren’t the best of times for her.

            image terren in Virginia @ flickr

            She completed the forms herself and submitted them to the relevant department but had heard nothing. She asked me to make a few calls. I agreed with my usual reticence.

            The first call was to confirm the receipt of the supporting documents she had sent with proof of identity, residency etc. They were all present and correct when I called.

            Still no word after a couple of months. She called me a couple of weeks ago beginning to panic a little with the lack of response. I made another call or two but this time didn’t manage to speak to anyone directly and rather left a string of messages which, unsurprisingly, weren’t returned.

            I knew her forms hadn’t been received by the person who manages the sheltered housing applications (because I phoned her direct as we have had a fair few conversations over the years) and I knew the forms had been received by the housing department so somewhere we needed to bridge this gap.

            A couple of days ago and no returned call my righteous indignation levels are rising dangerously high. I called the housing number and was told their computers were down and the only named person with whom I was dealing ‘didn’t take telephone calls’. So I did the only thing I know what to do in those circumstances and asked for a string of email addresses, line manager by line manager, up to the Assistant Director level.

            And I pieced  together an email detailing all my contacts and attempted contacts, with the housing department relating to this particular case. I detailed the messages I had left, the emails I had written over the months – all of which had been unanswered.

            I copied into the email the named person with whom I had been dealing. I thought that was only fair. As well as his manager.

            I got the ‘undelivered mail’ message back seconds after hitting ‘send’. I had been given the wrong spelling of the manager of the team’s email address. I’d like to think it was unintentional but at least the addressee himself knew I was more than a little peeved and willing to take this as far up as it needed to go.

            Actually his response angered me more. He thanked me for my email – explained that no, he didn’t take telephone calls any more – and that as Mrs S met all the criteria for sheltered housing, he would see she was put on that list immediately. Mission accomplished.

            My reply (with manager’s name spelt correctly this time) was somewhat terse in substance though. Basically, explaining that if she met the criteria now, she would also have met the criteria two months ago when all the documentation was sent. She has been ‘off’ the list for two months for no reason at all and had I not sent that email on that day – she would have remained off the list although everything had been completed exactly according to their procedures and all the correct documents had been sent.

            She’ll be fine now though. There is enough time for a property to show up and I’m pretty confident she’ll be housed.

            My worry related to how many other people might be thinking they are on the waiting list when, in fact, they aren’t because there isn’t anyone ranting and raving and copying all their email correspondence in to the managers of the rehousing team when they don’t get satisfactory responses.

            That makes me furious.

            A Course

            Last week I went on a training course. As an AMHP I am obliged to complete 3 (I think!) training days every year which specifically relate to my role as an Approved Mental Health Professional in order to maintain my warrant.

            So it was that last week there was a legal update course. I can’t say I was thrilled by the prospect. Generally, I don’t mind training. It’s a day out of the office and a chance to exercise different parts of the brain. I knew the course wouldn’t be oversubscribed as the levels of emails reminding us to sign up increased as the week progressed! So it was a nice, cosy group!

            As it was, and in fact, if I’m brutally honest, as it usually is – it was more engaging than I was expecting. It was a pure and simple (if it ever is!) legal update with no more specific narrow focus so we applied more recent case law and some points of confusion between the old legislation and the new legislation (as the Mental Health Act was amended last autumn) to some practical case studies and examples of our own practice.

            image limaoscarjuliet @ flickr

            Two points of interest really from the training. Firstly, it was the first time I have ever, I think, in about ten years, attended a training course for social workers (yes, I know AMHPs don’t HAVE to be social workers but we all were on this occasion!) where there were more men than women present!

            It was rather novel actually and although it made absolutely no different whatsoever to the course, the training or the dynamics – it was just a point of interest – for me anyway – because these are the kinds of things that occupy my mind when I should be thinking of recent case law!

            The other part was that with the exception of one person, all the other attendees were from Emergency Duty Teams. So it was actually lovely to meet the ‘names on the report sheets’ finally. We don’t have much opportunity to meet those who work between 5pm and 9am and at weekends and holidays so it was great not only to put faces to names but also to engage in a wider discussion about the role of the generic social worker – as all the EDT workers have to have substantial experience both of Children and Families work and specifically of Mental Health work (as they are involved in those difficult through-the-night emergency decisions that all too often involve Mental Health Act Assessments and Emergency Child Protection work).

            Apart from that the training was very well delivered and I shouldn’t really underestimate it! It reminded me how important it is to germinate ideas and case studies between us as otherwise it is very easy to grow a ‘team’ mentality and a way of working that isn’t always helpful all round.

            Contrary

            I have not been in the most sanguine of moods at work recently.  A mild and basically inconsequential altercation has put me somewhat at odds with one of our countless managers and although in my head (and this might be one of the problems!) I know I am right (!) , in retrospect, I probably haven’t been exceptionally wise about voicing my concerns and might be treading a fine line between outspokenness and ‘trouble-making’.

            So all in all, I have to consider whether I’ve reached my regular ‘two year itch’ stage of working where I have tended to move on to different jobs or roles every couple of years – pretty much since I qualified.

            I did apply for a new job a few months ago and that is the cause of some of the general grumbliness because it was an internal position which I didn’t get because I was told there weren’t enough applicants (only me actually.. )  so it will be re-advertised at some random point in the future but at the moment, I’m not inclined to re-apply.

            image bohman at flickr

            I am restless though. I feel I should be doing ‘more’. There is a strange position where social workers in the team, being seconded and therefore unbanded in relation  to our Health Service colleagues – end up on placed at about Band 6 equivalent – so we have nurses and OTs with significantly less experience being given more substantial tasks and responsibilities on the basis of their Band 7 (actually, the salary is genuinely not an issue for me but they do get paid more as well!) and the sometime obtuse situation where I am often approached for advice and support on the basis of my AMHP status and training by someone who is actually more senior than me in those strange office pecking orders that emerge.

            I don’t give it a second thought most of the time because I’m more than happy to help and I have so much to do that there’s no point pulling weight but when it is raised in the more general meetings, it doesn’t really hold water.

            It is grating particularly at present because my local authority won’t fund any PQ training for me at Higher Specialist (Masters) level unless I am a Senior Practitioner and I have exhausted all the possible training at the Specialist level (as I have a full PQSW under the old system which is equivalent to a Specialist level Award).

            I enjoy learning. I don’t like standing still. For years, I’ve wanted to take a student on placement and in fact, was told that I could only on condition that I completed the ASW (Approved Social Work) training first on the basis of a service need (I wasn’t at all keen to train as an ASW – for the record!). I have done exactly what was asked of me and postponed my more favoured training route (the practice teaching) .

            Now though, I’m being told that unless I hold a more senior position, the training will not be funded and anyway, I can’t be released for training because I am such a precious (!) resource as an AMHP (ASW as was) that it would not be possible for me to miss so many days.

            Generally I like my job. I have good, conscientious colleagues and work with some excellent consultants. I enjoy working in the service area too. I think there is so much work to be done in the field of care for older adults and I feel passionately that there is a strong advocacy and support role that I can fill. Since I qualified, I have worked exclusively with the over 65s age group too so I suppose there is an element of expertise there as well.

            I enjoy working in mental health services too as it gives me more flexibility to provide the support that I went into social work to do.

            I love that social work has a place in a multi-disciplinary team and am grateful that I can inject some of the social model of care into the team approach although to be honest, that is very much the ethos of the team as a whole.

            What I don’t love is the politics of the management and management structures. I could ignore it for a good deal of time but as I have wriggled into the team, I  have become more aware of where the priorities and balances lie – and they are firmly fixed on ‘not rocking the boat’ and almost impossibly lean balance sheets.

            Part of the reason I feel I can do this job is because I have no fear of voicing my thoughts, feelings and experiences. I genuinely believe that advocacy and giving a voice to disenfranchised is a great part of my role and that I would be doing myself an injustice if I didn’t reflect this in my own dealings too.

            But last week, in conversation with a more senior colleague, I was  urged to be more cautious in my language. A little less confrontational, perhaps. While seeing my point, she said that my approach could mark me as a ‘trouble-maker’.  That would not, she said, be useful in the longer term.

            And I can see her point too, after all, she’s been working in the service for decades. But a part of me doesn’t want to keep my head down. I might lay low for a while though – it isn’t as if I don’t have enough to be getting on with in the meantime…  but I am going to try and push for the practice teaching .

            Student Satisfaction Surveys

            Over the weekend, I came across a story in The Times which deviated from the MP’s expenses which is increasingly leaving a bitter taste.  Students across the country were asked to rate the quality of the teaching on the degrees in which they were currently engaged.

            image gwire @ flickr

            These were some of the so-called ‘top’ universities (I’m more than a little sceptical and I can say that with some marginal authority having studied – at least for my first degree – at what would be described as a well regarded ‘old’ university and for my MA at an unreconstructed ex-poly) scratching around at the bottom of the table when current students were asked to rate the quality of the courses they were attending.

            The marginally surprising aspect was though that

            The bottom courses in the country, however, are three social work degrees — at Swansea, Brunel and Royal Holloway, London, all of which receive satisfaction ratings of less than 50%.

            Now, Brunel and Royal Holloway have both suspended their BA courses as a result of criticism from students and the GSCC, as I wrote earlier in the year. So I suppose there is good reason for this dissatisfaction – but still – the worst in the country…

            And the Times article could have gone on to say that four of the bottom five are social work courses because Birmingham City scrapes in with a 49% satisfaction rating. Hardly a glowing praise of the training of social workers.

            Interestingly, it is actually Swansea that comes in at the very bottom below both of the suspended courses at a stonking 2176th!

            Looking through the actual figures (Excel chart of figures)  is marginally compelling. The top degree listed as ‘Social Work’ comes in at Kent, followed by Teeside and then Leeds. This is purely on the basis of student satisfaction but it should be an important consideration.

            I know both Brunel and Royal Holloway were criticised regarding placements so that is obviously a cause for concern among students. Looking at tables is a good distraction mechanism so I also checked out the Unistats site which pulls information together not only about student satisfaction but also about graduates who are in employment six months after finishing their courses (although the data doesn’t correspond perfectly as the Times article refers to 2007/8 and the Unistats refers to 2006/7).

            I’m a little sceptical of these figures for the reasons that I am get nagged by the universities through which I  have done my PQ (post qualifying) training to answer surveys about my employment status – which I’m sure ‘cooks the books’ a little because if they are asking work-based post-qualification students about their work status then of course they are going to get ‘higher’ levels of student employment figures!

            So with that weighty pinch of salt, it is still interesting seeing the differences in the employment percentiles for the different universities.

            I would have suspected a correlation between student satisfaction and ‘employment after six months of graduation’ but it isn’t always there.

            Birmingham City, for example, had a 95% employment rate within 6 months of graduation but a 35% satisfaction rate.

            And conversely Glasgow Caledonian with her impressive 95% approval rate had only a 20% employment rate.

            So clearly figures need to be fleshed out a little.

            It is still clear though that at least in some quarters, the quality of the degree taught is paramount. It is not cheap and a significant amount of government money is pushed in the direction of universities. We need to be satisfied that we are getting a proportion of well-educated and competent practitioners as a result.

            Going back to the Times reminds us this is not a problem which is exclusive to Social Work students by any means.

            Students complain that teaching time is being cut, classes are becoming bigger and postgraduate students are being used as a cheap alternative to lecturers to teach seminars — despite universities taking increasing amounts of money from undergraduates through fees.

            It is partly endemic and although I have no expertise in the field of Higher Education – I have teeny suspicion that if more of a qualitative rather than a quantitive approach were taken – there may be a more satisfactory outcome.