Personal Care at Home Bill

The Bill claiming to bring in the promised free home care for those with critical needs was introduced to parliament yesterday. There is a lengthy ‘impact assessment’ available at the Department of Health website that I don’t have time to trawl through before going to work this morning.

A brief perusal confirmed that the ‘critical’ needs to be included that will lead to the ‘free’ care will be restricted, understandably in light of the name of the legislation to ‘personal care’.

According to the document above, personal care includes

Physical assistance and prompting in relation to

-eating and drinking


-washing or bathing


-oral care

-care of skin, nails and hair

And to be eligible, as I read it anyway, there would need to be four aspects that would lie within the ‘critical’ band.

This obviously reduces the ‘access’ to the ‘free’ funding. I use inverted commas for the ‘free’ aspect as obviously there will be a payment through taxation and again, some local authorities may be attracting a higher cost than others – I am thinking perhaps of some traditional ‘retirement’ towns that perhaps might have a heavier burden on them than other districts.

The other concern about the legislation is that in an interview with The Times yesterday with Andy Burnham, the Health Secretary, who suggested that money to pay for the Personal Care at Home Bill will be diverted from funds for research into cancers and dementia.

This is hardly a popular move and one I can see the government fast back-tracking on but it goes to show how little consideration has been spent on these plans to reduce charges for homecare.

There is also to be a further focus on re-enablement and rehabilitation which, it is hoped, would reduce the ongoing care costs as it would reduce the need for interventions when more access to recovery is envisaged. This is definitely a positive outcome – I have long thought that there has been too little focus on lower level needs that progress into much higher needs if not addressed at the time. I could run off countless ‘scare’ stories about trying to arrange for some kind of rehab input when someone is discharged from hospital but they would probably not be believed. All I can say is that if it is to get better, that is no bad thing.

I still remain sceptical though. It seems like a sticking plaster to a haemorrage of a problem that noone seems to want to think through and that social care is being used as a toy to tempt voters terrified of sacrificing their childrens’ inheritance due to some kind of ‘entitlement’ to ‘things for free’ that has been created.

Whether that is the Tories and their hotchpotch policy of providing ‘insurance’ against the cost of residential care that no sensible person would take up – or the haphazard ‘free personal care for all with 4 or more critical banded needs under FACS’ that Labour are now proposing.

Personally, I can’t see the legislation being passed in the lifetime of this Parliament anyway so it is something of a moot point but if there is to be a more creative focus on re-enablement coming out of the debate, that is definitely A Good Thing.

I hope to spend a little more time reading through the proposals at length to give a slightly more cognisant appraisal over the next few days!

Moving on Individual Budgets

And so it starts. Currently we are still in ‘pilot’ phase of the Individual Budget roll-out – the forefront of the personalisation and self-directed support agenda and if that sentence made little sense to you – you can probably count yourself lucky!

Very basically there is an ideologically  welcome move towards more control by users of services around the services they receive which is a very noble and worthy cause. We are trying to work through some of the details and our local authority is trying to put systems together through the pilots that have been running. While I’d like to hide my head in the sand and pretend nothing is changing, not because I don’t think it is a worthy ideal, but rather because of the intense increase in bureaucracy and the time needed to work through the new and somewhat shaky systems being put into place.

I decided that I really needed to be positive and try to actually understand what was to be happening because it isn’t going away  and so, in conjunction with a service user and her daughter (main carer) who want to engage with the process and ‘see how it works’, I am doing what I can to work through the systems as they exist.

The main pilots so far have focussed on younger adults with disabilities, people with learning disabilities and older adults with fairly straightforward care packages.

Although at the time, I explained I felt they needed to tackle some of the more complex examples at the time, mental health services were very much left out of the ‘loop’ of information.

Currently, I have assisted in the completion of the self-assessment questionnaires and have validated them. As the service user in question as fairly advanced Alzheimer’s type dementia, there was a significant input from her family and carers and I assisted considerably myself – so the ‘self-assessment’ idea was somewhat lost through that process but I felt it was important to work through the ‘processes’ with a person who has little capacity to engage actively with the assessments and realistically, it will involve many of the users of our service.

I tackled the RAS (Resource Allocation System) although I’m not entirely confident it is ‘correct’ and so my next task is to take the documents to a meeting to discover what the ‘indicative budget’ is and then, assuming all goes well, to return to patient and carer (I am running two different applications side-by-side – one for service user and a different one for carer in her own right).

I might have messed the entire thing up of course, but as I expected to user and carer themselves, the worst thing that could happen at this point is remaining with the status quo while I spend time working things out. The positive outcome would be more flexibility to choose carers and tasks that are more appropriate to their individual circumstances and to have more input into the support packages that provide the best outcomes.

But.. and this is the big but.. so far, getting as far as we have, namely writing up all the documentation and putting the forms, assessments, resource allocations etc has taken me the good part of a couple of days. That’s not including the three specific visits each of at least an hour to work through the actual assessment forms. Which would be fine and dandy if that linked in with the time taken on other work, emergency assessments, people being discharged from hospital,  rushing to court to get warrants etc.

Suffice to say the team isn’t overly heartened by the lack of support in implementing these new systems – the local authority has put a lot of support into the Community Care teams with additional workers and weekly support groups  but in the bleak and distant mental health teams, we are left increasingly on the periphery and detached further from the general information streams and planning but my thought is that at least by attempting it, we won’t be completely left out and if I make a mess of my attempts, at least I am identifying a genuine training need!

Hopefully, I’ll be able to update the process as I go through it.. .

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Inside View

Just a quick post this morning as I had a little and completely non-serious accident involving my thumb  and a fast-closing door meeting an an uncomfortably fast speed and thus am finding typing more painful than usual..

But The Times prints a story by Edward Monkton detailing  his personal experience with depression. It’s a good piece and helpful to see the ‘male’ perspective. Hopefully more detailed coverage of the experiences of others will assist in the ‘destigmatising’ process.

The government also announced a programme of extending the IAPT (Improving Access to Psychological Therapies) programme freely available on the NHS to couples facing relationship difficulties.

The idea is that it will tackle potentially much more serious mental health difficulties by ‘nipping them in the bud’.

However the scheme is already short of practitioners and has not met targets set initially so the announcement might be a little overambitious.

Wow, I didn’t realist how much more time it took to type with 9 digits when you are accustomed to touch-typing..

On Probation

In some unsurprising but still welcome news, Community Care reports that the Social Work Taskforce is proposing a ‘qualifying year’ post degree and pre-registration to all social workers coming into the workforce from university.

It makes perfect sense and it’s amazing that it was not a check that was brought in with the new degrees which placed less emphasis on pre-qualification experience in the social care sector.

It is a useful and necessary check that does not leave the universities as sole arbiters as to whether a student is ‘good enough’ to practice as a qualified social worker.

I will, of course, be interested to see details about how the application process works for these ‘qualifying years’ and how the local authorities engage with the it. Hopefully, it will offer newly trained social workers a chance and opportunity to learn and grow as practitioners in a safer environment than being thrown straight into practice. I know I’d definitely have benefited from it although I was lucky to move straight into a supportive and large team with other newly qualified workers including others from the same university course – perhaps that made it a lot easier to ask questions and learn from each other as we went. I think it might have been more challenging in an environment where asking questions and supervision was not given appropriate time and consideration.

Looking at the people I qualified with (those that I remained in touch with!) – those of us who had the more supportive first employment experiences have certainly stayed ‘in the field’ a lot longer than those who were ‘thrown into the deep end’ regardless of pre-qualification experience. Even without my very random personal experiences, it makes most sense that the better supported newly qualified staff are, the more effective the profession will become over the next few years.

In the meantime I’m looking forward to the publication of the final report from the Taskforce – due early December according to the same Community Care report.

The Queen’s Speech and Free Home Care

Today the Queen will announce the government’s programme of legislation for the next year. It is widely reported that free home care for those whose needs fall into the ‘critical’ band will be included in the speech.

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The idea is that it will be a popular vote-grabber. We will be having a General Election within the year and the polls are indicating an increasingly unpopular government so there is a turn to these kinds of headline dominating policies.

Don’t get me wrong, I think that some of the charging policies in place that I have seen have been enormously detrimental but I’m not convinced that a universally available free access is the answer. Especially in times that budgets are being cut. Perhaps better to target broader needs, namely addressing some of the moderate, substantial as well as critical needs and if that has to be done by more stringent means-testing then so be it.

But free care appeals most to the more prosperous middle classes who suffer the most from the current means-testing approaches. Seeing people with lower incomes receiving care free, we move to the somewhat disingenous ‘why should I pay when if I had frittered away all my life-savings I would have gotten the same for free’.

But it isn’t always a level playing field – just as life isn’t. Low income and no savings doesn’t mean money has been frittered. It may mean that the opportunities to earn have not been so available. Life isn’t fair.

But back to Government’s plan. It has stymied the upcoming Green Paper , Shaping the Future of Care Together – consultation on ways of paying for care for a start.

The consultation was due to finish last week but hardly much of a consultation if the government is already planning legislation to cover the costs of critical needs.

The other thing to bear in mind is that Critical needs that the payment is promised for is a very narrow band in that the headlines of ‘free home care’ will probably strike a disappointing blow for most people whose needs will not fall within that remit. I see a tightening of belts further down the line in order to provide the money for this care and that is why I am so sceptical of the approach.

Ultimately, very little is ‘free’.

It is likely this money may be gleaned from Attendance Allowance.  The Daily Mail quotes the Conservative spokesman as saying

‘What is most worrying is that in order to pay for their new National Care Service Labour have promised to scrap disability benefits worth more than £3,000 a year for nearly 2.5million vulnerable pensioners.

‘They also do absolutely nothing for the 100,000 or more people who go into a care home each year. Labour’s plans are all about political point-scoring, not the long-term care of older people .’

There is a point in there but the Conservatives have gone the other way and made a pledge to those going into Care Homes and haven’t provided any idea for those who need care at home and ultimately,  more people will be helped by focusing on the needs of those who need help at home, as opposed to those needing residential and nursing care. It’s not right though and it shouldn’t have to be an ‘either/or’ choice.

Ideally, the policies of the main parties should provide a cohesive approach which is equal whether care is needed in the home or in residential care – rather than making one free and the other not.

Just as the Labour plan will encourage more people to stay at home when perhaps residential care may be more appropriate – so the Conservative plan may persuade  more people into residential care when staying at home with support would be more appropriate.

What is really needed is a consultation across party lines.. oh wait.. didn’t that just happen?

And the irony is that it’s unlikely much legislation presented today will be enacted if there is a government charge so it is partly political posturing in any case.

Dementia and Hospital Stays

Today, Community Care reports that the Alzheimer’s Society has called for patients with dementia to be discharged earlier from hospitals as this would save a significant amount of money.  They conducted a survey of 1300 carers of people with dementia, about 650 nurses and 500 nurse/ward managers to find that 86% of managers said people with dementia spent longer in hospital that others admitted with the same medical conditions and 49% of carers said hospital stays had been longer than they had expected.

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There are other figures there but to me there is an obvious reason for these figures. Firstly, most ward managers always think people are in hospital longer than necessary. I am working with a man who is currently in the local acute hospital’s general medical ward. He fell and broke his hip. He has been ‘ready for discharge’ four times – on each occasion as I have arranged his discharge – I have been told that he has deteriorated further and is unwell. But on each of those ‘almost’ occasions, I have received all the delayed discharge paperwork and have created no small amount of work to try and set things up for him.

Currently there is a wish to rush people out of hospital. Where I work, there are very few dementia residential placements in local homes. We meanwhile have no provision for block purchased intermediate care placements – no wonder then that there are some delayed discharges but I wouldn’t expect ward managers to say anything other than that because often they are at the sharp end and cannot understand the implications of poor commissioning decisions.

I would also imagine that with some people with dementia there might be issues of capacity to explore more fully before a discharge can be planned and possibly more risk assessment in place to ensure safe discharges home. I’m not saying it is right that people with dementia have longer in-patient stays but I’m also not sure that the Alzheimer’s Society calling for £80 million to be saved by discharging people with dementias a week early is anything other that attention-grabbing without a further look at the reasons.

I would say if there were any call for the funding that could be saved by acute hospital stays when they are not necessary, it would, in our local area anyway, be better served in more longer term planning about the need for beds specifically for those with dementia and also perhaps a more substantial mental health liaison team that works specifically with older people with dementia as seemingly the funding for the liaison work doesn’t stretch very far into the ‘older’ age group.

One of the more worrying aspects highlighted in Community Care is that

The report also identified problems with staff training with 54% of nurses saying they had not received any pre-registration training in the illness. Of particular concern to carers was a lack of help with eating and drinking which was often linked to deterioration in patients’ physical health.

We had a brief discussion in our team not long ago about care of dementia patients in general hospital wards. It is understandable that time and capacity is an issue that there is not more time but perhaps having more specifically trained additional members of staff to provide care as opposed to nursing would be a way to improve the conditions for those in hospital.

The ideal is a safe and satisfactory discharge of course but often there are many contributing factors that lead to a more thorough plan being made for discharge than some patients who are able to make those decisions themselves entirely. The lack of placements and decent intermediate care will also always be a factor in delaying discharges from hospital wards.

The Price of Stigma

It has been said that the fight against the generally felt stigma about those with mental illnesses is a vain fight. Particularly, there was an article I alluded to about a  month ago that comes to mind.

And this was one of the points that came to mind when considering Robert Enke, the German goalkeeper who had been suffering with depression since 2003 who died by walking in front of a train on Tuesday and was, according to his widow, scared of his mental health difficulties becoming public as he felt he might lose his adopted daughter, Leila, after the death of their own child, Lara.

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I wonder how much the pressure of firstly being a public figure and well-known sportsman and secondly trying to keep hidden a depression that is obviously profound, added to the distress. Obviously enough for him to be driven to act.

His wife gave a deeply moving interview with the media which brought to light some of the pain that he and his family had been suffering and had been hiding from the glare of the media spotlight.

Teresa Enke said: “I tried to be there for him, said that football is not everything. There are many beautiful things in life. It is not hopeless. We had Lara, we have Leila.

“I always wanted to help him to get through it. He didn’t want it to come out because of fear. He was scared of losing Leila.

“It is the fear of what people will think when you have a child and the father suffers from depression. I always said to him that that is not a problem.”

Stigma, shame and misunderstanding of mental illness possibly are particularly burdensome in a ‘sporting’ environment where pressure is so intense and everything revolves around supreme conditioning of mind and body.

As the Times reports,  suicide is the highest cause of death for men under 45 in the UK. I wonder how much the gender perceptions that women are more likely to want to talk through things than men play in the role of treatments. Sometimes depression can be perceived as a ‘women’s disease’ and men may be  more likely to downplay the symptoms in general conversation until crisis level is reached.

So the general perceptions of mental illness and attitudes and assumptions about those who may suffer is not just thinking of terms of ‘the other’   – it is more than sympathy and empathy – it is about regarding seeking help and treatment for mental health in the same way that we might be guided to for physical health – and while I accept that it more likely to happen if you work in a supportive environment and have a strong network to support through difficulties, it might be more difficult in competitive environments that exist in the professional sporting circles. That makes it more painful, I would expect. Moving towards a more open discussion about mental illness has to be done for the sake of the societies and communities that we live in and work among.

In the meantime and for what it’s worth, I definitely have some positive thoughts towards Enke and his family and the pain that they have suffered and continue to.