Looking for beds

Something of a theme on my caseload at the moment is one of ‘delayed discharges’. I have three people in hospital medically ready for discharge and am waiting for residential or nursing placements to ‘pop up’.

It’s a warped kind of waiting game with no beds being available locally and people increasingly being shipped further and further out of London or at least towards the suburbs as the hospitals become desperate for beds and the lack of resources becomes painful.

One of the three has been on the waiting list for a local residential home for months. Another has a devoted wife who has constantly cared for her husband for decades through his progressively deteriorating dementia and another – well – the hiccoughs are proving to be way too many to detail succinctly..

But the result is the same – people who have strong local attachments, families and spouses are having to be placed outside the local areas.

It’s a subject matter that I have personally brought up again and again – going directly to commissioners when necessary but there is no aspect of my work where I feel ‘less heard’. Of course, placements can’t spring up overnight although some people imagine they can – and the brutal truth is that a placement usually only becomes available when someone dies.

That’s why the dementia residential placements locally have been so sparse – often they are taken up by people who could be very well physically and this means that those who need the beds are waiting longer and longer.

A part of the problem is that there was a feeling that ‘Extra Care Sheltered Accommodation’ – namely sheltered accommodation with additional 24 hour support on site – would ‘divert’ some people from residential care. In fact, the extra care sheltered properties, which we were told when they were established would be an ‘alternative’ to residential care, are not – at least in the local area I work (and it really could change from borough to borough) – not geared to meeting the needs of those who have 24 hour support needs. This is a particular issue at the moment as they seem to be incredibly reluctant to take anyone who doesn’t fit in to the ‘kind of person they want and would be ‘easy’ to manage’ making it more of an alternative for sheltered housing than for residential care.

I would love for there to be a widespread rethink of residential and nursing care provisions in the context of meeting individual needs. Prior to my qualification, I worked for about 7 years in a small group home for adults with learning disabilities and there was a massive focus on individuals and meeting particular needs. Of course, the funding is massively different level and that will always be the ‘sticking point’. There are vast amounts of funding available for younger adults compared to over 65s – simply because there is not the money there to provide the same levels of funding. Local authorities are not able to pay high care fees and the cheapest fees often involve large care homes. That isn’t to say they can’t involve personal care but more often than not they don’t – and certainly not where they need to be.

For every problem I find though, money is the answer – unfortunately – and in these times of shrinking budgets, we are left to provide what constitutes poor outcomes. I’d love to imagine a world where some kind of charity or donor could set up some smaller group-home like care structure for older adults too but the costs are way too high.. maybe that’s a project for the future..

Working in central London probably exacerbates the problem in some sense that the housing prices and land costs in the area that I work are particularly high – definitely favouring residential redevelopments for bankers as opposed to more substantial community resources.

But there is something incredibly cruel about ‘shipping out’ the older and the frailer to outlying areas. I know there is a move towards less residential care services but that isn’t the answer as there will always be some need for the provision.

The Court of Protection

There was a curious headline in the Mail on Sunday yesterday. I was not curious enough to buy the paper but curious enough to investigate on the Mail website. Apparently, according to the journalist,

Secret court seizes £3.2bn from elderly… and even forces furious families to pay to access own bank account

Without any reading, I knew the reference was to the Court of Protection. I know I am in a slightly specialised area but I hadn’t considered it was a ‘secret’ court. I suspect that in mail-speak that means that they cannot sit in on its hearings but I had honestly thought it wouldn’t be something that most people would be interested to see covered as much as anything – let alone the fact that as all its hearings involve people who lack capacity, obviously the people in question are not often in a position to give permission to have the details of their lives and finances plastered around in public.

image Archway Tower (where the court is based) by markhillary at Flickr

Now, I am no great supporter of the Court in its current manifestation, not least because, since the Mental Capacity Act 2005 came into force with its adjustments to the court processes, the time lags in making a referral have been horrendous –  but – it does provide an important safeguard to those who lack capacity and I was surprised at the vitriolic and sometimes plain incorrect language of the article in question.

The court and the system in place is a crucial protection to those who lack capacity to make decisions about financial decisions although it is not solely restricted to financial decisions – that is the basis of the article.

It can be very long-winded and involving. Basically when someone loses the capacity to make a decision regarding the management of their finances, a power of attorney can no longer be taken out, and although a lasting power of attorney can be registered – that can only be done if the decision and the person taking up the ‘attorneyship’ had been made in advance of the loss of capacity.

Otherwise, a lengthy application is made to the Court of Protection. Often it is just a matter of extensive forms and there is an application fee – which the Mail rails at. I expect the Mail would rail more if the all fees were paid from the public purse but, for the record, these fees are means-tested – meaning they are paid only if the estate can afford it – otherwise, they are waived.

The Mail article of course, concentrates on some individual matters where it has been so difficult for families to access the money of their loved ones – but, and this is a crucial matter, the court is bound to make Best Interests decisions and some families’ ideas of the best interests of their relatives’ money is not the same as an independent solicitor or judge.

For the most part, in uncontentious matters, the court appoints a family member as an ‘attorney’. Indeed, that is by far the most favoured options. Deputyships are used when there is either no family member or sufficient concern about the money in question and how it might be used by the family member.

The Mail, using it’s obviously sharp reporting skills, quotes some users of an internet forum set up to gripe about the Court of Protection. I would venture a guess that any story they write about anything, they could drum up some anonymous quotes from random internet forums to concur with whatever they wish us to believe.

I can’t defend everything the Court does. It is slow without doubt and it is very far from transparent but a body such as it is, needs to exist. All that is needed to avoid its role is for a more widespread knowledge of Lasting Powers of Attorney which can be set up at any point prior to the loss of capacity as, in a sense, a ‘living will’ and there would be no need for these processes (except, and I know of at least one case, where these LPAs have been challenged on the basis of some adult protection concerns).

The Court of Protection is tightly wrapped in the processes of protecting those who cannot advocate for themselves. It is very very far from perfect but it has a crucial role. I’m both surprised and not surprised that the Mail is blaming the existence of this court on the Labour government saying

The first Court of Protection was set up by Labour’s 2005 Mental Incapacity Act, which for the first time formalised the arrangements for dealing with the assets and care of people suffering from dementia and other similar illnesses.

Before this it was left to families and social services to make arrangements – but it was argued this ad hoc system was open to abuse by both family members and by officials.

That’s blatantly false, for the record. The Court of Protection existed long before 2005 Mental Capacity Act (note – NOT Mental INCapacity Act), its form has changed somewhat and if anything, I’d say it is more transparent rather than less although by the comments on the Mail article, you’d think it was all some evil plan by the Labour government to ‘rob’ people of the money their family members are rightfully entitled to spend on their behalf..

Perhaps I have a distorted view due to the levels of financial abuse of older and incapacited adults that I have seen, by family members, due to my job. Of course, most people can be trusted completely and most want the best for their family members but money and greed does strange things to people, even some of the closest of families and it is vital that these checks and balances are in place in the form of an independent body.

Ultimately, in the words of a ‘spokesman for the Department of Justice’ quoted in the article

The OPG (Office of the Public Guardian) recommends that every adult considers making a lasting power of attorney. This enables people to choose someone they know and trust to make decisions about their property and affairs or their personal welfare, should they become unable to make decisions for themselves.’

And with that, I would have to agree. I try to tell people again and again to use the Lasting Powers of Attorneys while they can to avoid any difficulties in the future. I share that advice out of the ‘work’ environment as well as I think if there is anything to be taken from this article – apart from shabby journalism by the Mail – it is that point that no-one knows what may or may not be around the corner and if there is someone who you know and trust to make decisions on your behalf – appoint them formally..

Saving DLA

It looks like Andy Burnham, the Secretary of State for Health, has ruled out any use of DLA (Disability Living Allowance) to fund a ‘national care service’. DLA is one of the few non-means tested benefits that is provided to people aged under 65 who have ongoing mental or physical health difficulties over a long term.

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There have been campaigns to protect DLA and Attendance Allowance (the equivalent benefit for over 65s) but, worryingly, no mention has been made about Attendance Allowance and I can’t help thinking this is either because it is proving too expensive or that those who receive it have quieter voices to engage when shouting.

It was suggested earlier in the year that funding for a more comprehensive and ‘fairer’ system of paying for care would leave DLA at risk however this might have proved to be just too politically sensitive at a time when it has been to be fair game to pick on benefits for those who are sick.

I remain concerned about the lack of commenting on Attendance Allowance though. Already those who are over 65 receive less in payment for exactly the same presentations of disabilities as those under 65 and it remains one of the more obvious ‘age discriminations’ in the ‘system’. We are told that the costs would escalate if the same criteria and funding were applied to those under 65 as those over 65 but it becomes something of a game and a reason for more inequities across the board.

If someone applies for DLA before their 65th birthday they retain the higher rated allowances for the rest of their lives whereas if they wait and claim one day after their 65th birthday, the receive the lower Attendance Allowance for life.

I remember one woman I worked with whose daughter was furious that she was only advised to claim a month or two after her 65th birthday, meaning she had lost out on the higher ‘lifetime benefit’ she would have had under DLA. We are advised to recommend making applications for these benefits as soon as we become involved but often this is after 65.

I hope very much that the differences between treatment of Disability Living Allowance and Attendance Allowance will be addressed. Especially as, in the same speech, Burnham vowed to abolish age discrimination in the Health Service.

Personal Budgets – Some thoughts

I attended some training on Personal Budgets a while ago. It was fairly comprehensive training that was surprisingly well-presented (it isn’t that I don’t always expect good training but sometimes it can be something of a curate’s egg.. ).

It leaves me in the position of being able to now set up pilot Personal Budgets, having a greater awareness of the process. I immediately, during the training, thought of two people whom I felt that this new system could benefit but first to the details.

Individual budgets or personal budgets as they are also known, are a key part of the programme of ‘Personalisation’ of adult care services. It is detailed in the ‘Putting People First’ paper but was first mooted in the 2005 Green Paper, Independence, Wellbeing and Choice. The idea is that the cost of the services will follow the individual and will involve different sets of choices about how that money is spent.

There is no doubt that the moves towards a more fine-tuned way of meeting needs opposed to making resource-led decisions about services that can be provided is a wholly positive outcome.

The idea is that you would start with a Self-Assessment Questionnaire which is completed either independently or with the support of either a care manager or an independent advocate (I am using ‘care manager’ broadly to mean an allocated employee of the local authority/health trust who would usually be setting up the care plan).

This questionnaire is then ‘validated’ by an employee who needs to ensure that the dreaded (in my view anyway) Fair Access to Care Services criteria are met and then a RAS (Resource Allocation System) defines an indicative  budget.


This budget is used to discuss a personal care plan with the service user and the idea is that the budget should not be a ‘cookie cutter’ type care plan but should indicate the person who needs the service within the financial constraints, of course. Care can be provided via a direct payment or the indicative budget can be used to purchase ‘in house’ services and a wide variety of mixtures in between. The people that I am considering taking through the process, as a part of the pilot stage, both really would benefit from more mainstream day time activities rather than going to the provided day centres (which are great, in their way, for people who enjoy them – and many do).

One person wishes to do some computer training and keep in touch with family all over the world as his daughter is on the verge of emigrating to Australia and he already has family there. One of the examples given to us during our training referred specifically of someone who wanted a computer and internet access to ‘keep up’’ with the times and I think there is a good case that this would provide this particular man with a much richer life if it were to be provided.

The other person is a woman whose husband is providing substantial care for her. She is subject to very low moods but has expressed an interest in pottery and she is very experienced and skilled in various art mediums. Although the day centres offer art activities, she wants to be challenged and we are looking at a lot of courses across London – however this has financial implications. I am hoping that we can use individual budgets in these contexts.

So we can see how wonderful they could be – however, my fear remains the quantity of paperwork they have generated around them. There is no question that the idea is positive and would provide better services but they are, at present, very far from simple and straightforward. My hope, in my ever-positive light, is that the pilot scheme will iron out and streamline the process – my fear is that in the system that is local government bureaucracy, paper is seen as a good thing and forms as positively exciting! Even in these days of ‘paperless’ offices.

Our trainer assured us that we wouldn’t find the process too draining on our time and days of increasingly caseloads as the people who were able to complete their self-assessments independently, would balance out those who needed a lot of support – however, I think she was gearing that comment towards those who work in general adult teams. My main worry about the new system is that it will be very difficult to plan the time to put together these budgets, although in the back of my head, I am remaining positive overall.

Like Direct Payments the focus seems to be on younger adults with disabilities, those who are able to advocate well for themselves and adults with learning disabilities. My thoughts on returning from the training was that little thought and time seems to have been spent on the consideration of people who may lack capacity in some areas to make judgements about some of the choices that are expected in this process.

I hope very much I am being overly cynical and am proved wrong. Today, David Brindle in the Guardian writes about RAS and its more helpful nature towards informal carers, whose contributions are recognised.   He makes some excellent points and it restores some of that positivity about the process.

I have some niggling doubts in my mind though – perhaps it is reminiscent of the introduction of the 1990 NHS and Community Care Act – when we were promised that ‘Care Management’ would be needs-led rather than resource-led, however, the fact is that those needs became more and more narrowly banded into large block contracts involving very little choice or flexibility.

Plus ca change..

Taking Back our Profession

On 12th November, BASW (British Association of Social Workers) is holding a rally starting at 10am at Friends House at Euston in London to support social workers and the social work profession. The rally is titled ‘Taking Back our Profession : Time to Challenge the Politicians’.

Confirmed current participants are Moira Gibb of the Social Work Taskforce and Tim Loughton, the Conservative Party Spokesman for Children. All political parties though have been invited so the list may grow.

This will be followed by an Additional General Meeting of BASW to discuss some additional clauses, the content of which I haven’t investigated fully but are available online.

It is certainly heartening to see more activism growing from BASW. It might be a case of needs must because the dangers of over-compliance with career politicians have been seen first hand. Social Work easily falls into the ‘politicking’ sector because so much that concerns the work that we do can be ranted and raved about by over-excited press railing at all of society’s failings or seeking to shift blame to the less politically sophisticated and poorer edges of society that are easier to challenge than the bankers and middle class mid-managers who wave their copies of the Daily Mail angrily at their local MPs in outrage.

I hope to be present although it depends a little on my work and capacity. I have a sneaky feeling it won’t be possible for me to take the time off – which is unfortunate as it is very easy for me to get to otherwise. I suppose it would be unrealistic for these events to occur outside of work time.. but in any case, I can be there ‘in spirit’!

Looking forward to retirement?

Yesterday, I was at a meeting with a few of my more senior colleagues, and I mean that in terms of age. A couple of them were joking together about looking forward to early retirement. Although I’m at least (depending on government policy!) a comfortable 30 years away from retirement age as it stands at present, I was able to wistfully dream along with them, only half-jokingly, about my wish to retire early as well.

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So I found this article in the Telegraph today and thought it related an interesting point. Basically, it highlights some research made that retirement can affect both physical and mental health adversely.

Truthfully, although I can dream of days when I don’t go into work anymore, I know it’s the case on a very non-scientific study of people whom I work with. I have been allocated and worked in a few men who, just past 65 have retired and then have been dogged by significant and debilitating depression.

The article relates to financial difficulties faced in retirement. I’d venture a guess that there is also a relation to a loss of a significant role and social environment that work can give. With men, in particular, ‘of a certain generation’, there is an expectation to work and to provide for the family. There is significant time spent out of the house working and away from the spouse that when both can be together day and night can lead to tensions that might not have previously been apparent.

Of course lower spending power is an issue but also not having the same structure to the day and purpose to respond when people ask ‘what do you do’ to mean ‘who are you’ in social settings.

The study claims that some of the answers can be found in part-time work and perhaps voluntary work, even in an area completely unrelated to that in which the career had been focused.

You know, I’d take that kind of retirement. That’s when I think I’ll start my flower-arranging course.. (I know, I know, but honestly, it’s something I’ve always wanted to do!).


Yesterday I visited G, a woman with anxiety and depression. . She had been very well for a good few months but of late, I’ve stepped up my visits a little as I can sense a downturn in her mental state. She is beginning to feel very low in mood.

We talked about benefits together. She receives Attendance Allowance. I see lots of people who claim Attendance Allowance and she falls right into the ‘absolutely eligible’ category, but she is concerned that before her health fluctuates, she is not entitled to receive the payments when she is ‘well’.

This has been a cause of great anxiety to her and in the context of politicking through the conference season targeting those who claim benefits for disabilities, she is feeling not only anxious but guilty. She is worried and concerned that she will be checked and discovered ‘on a good day’ and that her entitlement to these benefits will be rescinded.

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There is no way that that would happen in my opinion because I have seen so clearly the effects that her illness has on her over a long term period.

A part of me though can’t fail to feel angry that both the government and the opposition are targetting those with the lowest income levels and with the highest level of needs in their ‘benefit fraud’ campaign. In my experience, those who do not claim that which they are entitled to, WAY outnumber those who fiddle the system but the scare tactics and villifications have led to a real fear among some people who have every right to claim from the ‘system.’

The DWP (Department of Works and Pensions) report that

In 2007-08 benefit thieves stole an estimated £800 million from public funds

While the BBC report that

Up to £10.5bn in income-related benefits went unclaimed in Britain in 2007-8, government figures reveal.

I wonder if the amount of fear and terror that is placed in the hearts of those who are rightfully claiming benefits is considered by the DWP. Believe me, I don’t condone benefit fraud, not in the slightest, but the focus of press attention needs to be brought onto those, like G, who feels terrified that she is claiming a benefit she is more than entitled to. And the many others who don’t want to claim because they fear the stigma attached to hand-outs, even though the option is abject poverty.

It makes me angry that the politicians who without any exception are, by definition of their salaries, living very comfortably with their juicy expense-claims, see fit to target those who can least afford it rather than just raising taxes at the higher echelon wage-earners.

World Mental Health Day 2009

Today is World Mental Health Day and this year’s theme is ‘Mental Health in Primary Care’.

I think the idea is to think about integrating mental health care with physical health care and needs and to think about some of the marginalising attitudes which exist specifically in relation to mental health services and trying to bring them more into the mainstream.

Mad World has a good run-down on different events taking place today (in the UK at any rate) but I couldn’t let the day pass without a mention.

So here’s to healthy mental health and if not health, then as much understanding of it and those who suffer from mental ill-health as is possible.

And meanwhile, away from some of the worthiness, an interesting article at the Huffington Post about stigma and awareness and how useful these campaigns might be.  Certainly made me think and then think some more, I’m not sure I wholeheartedly agree with all the points made but it’s definitely a point to consider.