National Care Service?

The Secretary of State for Health, Andy Burnham, wrote a piece in the Guardian today about his vision for a ‘National Care Service’

‘ providing personal care and support to adults on the basis of need and free at the point of use, will ensure that an ageing society remains a decent and fair society.’

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Andy Burnham and Ed Balls..

It’s hard to argue against that as a positive. Everyone wants good care and noone wants a price attached to it. All well and good so far.

He focuses on the disparity in the current system which places a burden on those who have property and savings and there is no doubt that there the current system is not ‘fair’ although the way that ‘fair’ can be interpreted is wonderfully flexible.

As for me, the rhetoric is pleasant sounding and hard to argue against. The fight will be in the details and don’t get me wrong, I’d love a system like this for all run on the basis of the National Health Service – but there is a real price to pay and trying to hide behind that fact or ignore the necessity for payment will just build unrealistic expectations.

People have different ideas about ‘fairness’ and ‘equity’. Personally, I think there is more of an obligation to help those who have the least resources to pay for the care that they need. I think if there were more focus on the money and the way the funding is divided, more money could be saved through properly thought through preventative services although there seems to be a tendency to veer from crisis to emergency at present and only providing care for the highest defined needs buys into this system – when a more substantial base of care at lower or ‘moderate’ needs may well prevent a more expensive longer term role for formal care.

On one element I do agree with him though, that the system that is churned out should not be voluntary – as the Tories ‘optional insurance’ suggests – if there is an inherent fairness, it needs to be universal. I know I’d happily pay a premium or increased tax if it were to produce a good quality system of equitable care for older adults and those with disabilities.

But there are more statements to be made and more talking to be done. Until the rhetoric morphs into concrete plans – which I have to say, I’m very much looking to – it’s a matter of waiting and seeing – and playing at politics until the election guides us to the way it might be taken forward.

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Cutting Costs

Public sector cost cutting is very much a theme of the moment. I suppose in my narrowly focussed view, I thought that we would be struggling but wouldn’t necessarily see any immediate changes – at least as far as front-line clinical work is concerned.

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I was too complacent. Already, changes are being felt and all agency staff have been given their notice to leave our team – which will leave us short of a few full time members of staff across the service and it really isn’t that big a team in the first place.

There’s a fairly bleak outlook in the office at the moment.

Not simply because those who are leaving are extremely competent, experienced, valued and just overall pleasant members of staff, but because the effect on service delivery and quality of care is going to have an immediate impact.

Already we are bursting at the seams in terms of workloads.

My frustration at the moment is that I feel I’m not able to work in the way that I would like to and it seems almost verging from crisis to crisis.

The true frustration though lies somewhat in not being heard from above. We are issued many many diktats about performance indicators and targets that we are slipping on and how we need to make sure we document and record various parts of the work that we do leaving less time for actual clinical work.

Last week, the Service Manager cornered me. He is a very pleasant, affable and jovial chap. Honestly (and perhaps surprisingly) I feel quite confident and supported generally in my management structure.

He asked me about some outstanding reviews that needed to be logged or it would ‘look bad’ on the system. As it turned out, most of them I had actually done but hadn’t logged properly so it wasn’t as infuriating a conversation as it might sound (and another I had genuinely scheduled for later that week!) – but I couldn’t resist a pop about understaffing and expectations that were increasingly being made on our time by administration and non-functioning snazzy computer systems that have been installed.

I am also possibly fairly rare in that I don’t mind the paper light systems we have moved to which mean that case notes are all logged online and documents uploaded instead of filed. For me, the less pieces of paper floating around randomly that can potentially be lost, the better – but sheer frustration has resulted when the wonderful systems fail to actually work – as will happen with any technologically based system.

So at the moment, the office seems to be caught on a bit of a downer – to say the least. Hopefully, well, it’s hard to know where the hope is to come from. The work is not going to decrease as staffing decreases. Perhaps we will all find more efficient ways of working – or at least, that’s the ‘management speak’.

A few years ago, in a different team and different department, I  had an Assistant Director follow me round for a half day to ‘see the work that we did ‘on the ground’’. I quite enjoyed it because it gave me a good opportunity to expound my thoughts on the service and although one of the visits was straightforward, the other was a matter of a user asking for resources that just did not exist within our service. We had a frank and full discussion about commissioning, resources and the choices that we have to make and explain on a daily basis. It was almost cathartic!

I do wonder sometimes how detached some of the higher tier managers have become though. I know cuts have to be made but it is so tempting to suggest that some of the ‘project managers’ be shaved off the services as opposed to front line clinicians and vital admin support.

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The Recovery Model and Dementia

Every week, in supervision with my student, we pick a theory, article, piece of legislation or policy, to discuss at length. Last week, we spoke briefly about the recovery model in mental health services and she asked that we discuss it in more depth this week and particularly if and how the model can be used when working with people who are suffering from a deteriorating dementia, particularly when there are organic causes.

Recovery is about ‘getting better’, ‘functioning better’ and how can this allay with an illness that is chipping away at cognition.

It was an interesting question and one that I’ve looked at in various ways at different stages. I did a brief literature search and found a couple of useful articles that both seemed to suggest a similar approach.

Recovery is not necessarily about ‘cure’. ‘Getting better’ can have lots of meanings and it doesn’t always mean getting back to place where one was before diagnosis or deterioration. It shows though how narrowly sometimes the models are perceived and how some of the workings within older adult services are ignored or bypassed when they might not ‘conveniently’ fit.

Recovery then in this sense can be used to work towards an optimum – but that figures as it should be what we are doing in any situation!

The article that we were able to discuss was ‘Recovery Approach to the care of people with Dementia’ (Martin G ‘Journal of Psychiatric and Mental Health Nursing’ (16:7 2009) which unfortunately is not available free but can be accessed through university journal collections or libraries.

It linked the recovery model to the person-centred approach which is more commonly used in different format and worked the model into where a person is at, empowerment through advocacy (and much broader advocacy than the legal provision of IMCAS (and IMHAS)) and talked a lot about the models presented in Kitwood’s ‘’Dementia Reconsidered’ which emphasises the importance of ‘personhood’ and retaining an individual and personal approach to people who have dementia (which shouldn’t be coming as a surprise as this is a basic tenet of human dignity which is so often forgotten in some care settings).

I wonder how much it is an attempt to fit a group who have not traditionally been able to meet the criteria of ‘recovery’ in some of the most obviously apparent settings into a hole and whether it is a fair jump to make from ‘recovery’ in the sense of putting the person at the centre of their own care and decisions to moving to the issues that arise when that person lacks capacity.

There are useful lessons to be taken. I think social work sometimes suffers by trying to fit all situations into previously presented ‘models’ and that sometimes is at odds with the need to think creatively and individually. That is partly a reason for my preference for postmodern models and strengths-based perspectives on social work theories.

It doesn’t matter what area you are working with, you can find strengths to draw on and that allows for a more individual approach.

In some ways, links can be made (and were in the article) between medical and social models with the medical models seeming to put the disease around the person and the social models putting the person in the centre with a corner of disease. In some ways, this can be paralleled as far as perceptions of dementia are concerned and can be seen clearly in the NHS’  new campaign to show individuals with dementia and emphasise the personhood rather than the disease – the tagline being ‘I have Dementia, I also have a life’.

I think it’s interesting to see how the move towards the social model or perhaps, in this context the ‘recovery’ or person-centred model is now being broadened to a media campaign and likewise to a move towards individual budgets.

To those who say that theory has no place in social work training, which should be ‘practical’ or those who may say that the theory is ‘out there’ and not used in day to day practice – I present two very real examples of ways that a theoretical model and approach affect our day to day working – obviously we would hope that it happens on an individual basis but the extension of Individualised budgets (in an ideal world, in any case) which put the person rather than the ‘need’ at the centre of support planning and the campaigns which focus on personhood, we can see the practical implications of shifting paradigms and uses of theoretical bases.

Incidently, I had a copy of Kitwood’s book knocking around in the office. I hadn’t opened it for a while, but I came back to it when preparing for the supervision session. I can’t recommend it highly enough – since first picking it up, I’ve come across lots of books about ways of working with dementia, approaches etc. I haven’t come across anything that comes close to it though. Maybe (and I still am reading it!), I will come back to a full review at some point.

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I just noticed that my 500th post was posted last week. I don’t usually measure my blog anniversary because I had a bit of a false start into the blogging ‘game’. But I think it’s a useful point to look back over the couple of years since I started and make a few reflections.

I think the blogging has improved my knowledge base and practice. It allows me a little space of my own to comment and think about wider policy as well as issues that come to me in practice.

As is understandably the case, a lot of what I do at work –  I’ll never write about and that includes some of the assessments that have challenged me the most, some of the work about which I’m most proud or some of the situations that would seem to have arisen straight out of a work of fiction – simply because I don’t wish for anyone to be even remotely identified on the blog. And sometimes the nature of the work is that those would be the ones that would be most identifiable.

One of the massive differences from when I started is a blooming of the social work blogging community. Mostly internationally, as can be seen by the Social Work Blog Directory and its exponential growth.

When I started, I wrote about things that I wanted to read about. I couldn’t find another UK social work blog. So I started one. That isn’t to say there wasn’t another one out there – just that I hadn’t been able to find it!

Now, I’m really excited to find blogs like Wall, Social Worker to Be, Active Social Work , The Masked AMHP – taking up the reins.

When I think to the start, I recall some of the first ‘connections’ I made, particularly with the writers of Trench Warfare, Amy’s Life in Brief, Anti-Social Social Worker and Awake and Dreaming and a couple of others who have retired long since. It seems like such a long way has been made since those days.

Sometimes I have wished I could be more amusing, more witty, more informative, more skilled in writing but I think I have arrived at a point where my writing style has developed around me and I know I can be ponderous but I spend very little time editing these days, compared to the earlier halycon days!

I have contemplated bringing things to an end over the last week, I have to be honest. Things have been hectic at home and at work and I am refreshed by the freedom not to feel the obligation that I had set upon myself to reflect and account for the different things that have been happening around me. Like others,  I’d considered a more personal, non-anonymous blog to collect together my wider thoughts and allow me space for discussions more related to politics (as the election approaches), sociology and just random TV programmes I might have been watching last night..

But then I feel pangs about leaving the blog behind. I know without updates it would become stale very quickly and I might regret it.

I like what I have created. I make no allusions to it being anything spectacular or for anyone except me really.

I am thinking about slowing down a little though. Perhaps. Let’s see if I can resist!

Meanwhile, I’d like to thank everyone who does stop by and engage with discussion. I know I’ve been a little less on the ball with responses that I was – mainly because I’m trying to spend more time away from the computer – but, I’m not going anywhere.. for now!

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Personalisation and Anti-Racist Practice – A SWAN Event

I was sent the following information by SWAN (Social Work Action Network) London Group whose aims I wholeheartedly support – to publicise an event that they are holding in London on the 24th April.

‘The London group of the Social Work Action Network (SWAN) is holding a half-day seminar and discussion around Personalisation and Anti-Racist Practice which will take place on Saturday 24th April.

This will be an opportunity to critically explore and discuss these two highly topical issues for social work today: the former in the context of the general election and talks over how to fund and deliver social care, and the latter with the rise of the BNP and Islamophobia in Britain.

The event will take place from 10am-2pm at Finsbury Library, 245 St John St, London EC1V 4NB (nearest tube: Angel). The event will be £5 for waged, £2 for low/unwaged. To register for this event please send an email to:

The seminar includes the following speakers: Pat Stack (Chair, London Self-Directed Support Forum), Mark Lymbery (University of Nottingham), Surinder Guru (University of Birmingham), June Sadd (Equalities Consultant and SWAN National Chair) and Weyman Bennett (Unite Against Fascism).

We hope to generate a strong and energetic debate that will reequip and reinvigorate all those involved in social work.
Finally, please feel free to forward this message to colleagues who may wish to participate.

Kind regards,
Social Work Action Network, London’

I am not sure at the moment if I’ll personally be able to attend due to some date clashing that I’m not sure I’ll be able to ‘unclash’  but I’d definitely recommend attending as it sounds fascinating!

And if anyone reading this does attend, I’d love to have a write-up covering it afterwards!

P.S Massive thanks to Natalia of Active Social Work for helping with the new header (helping in the sense of completely designing!).

Happy World Social Work Day!

I know, I was having a break and all but I could barely let the day go by without note!

Today, the focus is on Making Human Rights Real.

Oh, and did I mention it is the day to give all your social worker friends lots of chocolate and other useful gifts.. I expect my desk to be overflowing by the time I get to the office!

bee on flower

Random Sentences

I mentioned our use of MMSE (Mini-Mental State Examinations) to provide a rough guide to cognitive levels – and I’ll emphasise the ‘rough’ part of that as really they can only be considered in conjunction with other tests and assessments of daily functioning.

One part of the MMSE we use asks the respondent to ‘write a sentence’. This can be any sentence, often the first thing to come to mind. Some of these sentences can provide interesting insights in their own right.

I have had a few ‘I love you’s. A few ‘I love (insert random object/thing/person)’ – I love flowers, I love Bob (where Bob is name of spouse).

A lot of ‘The cat sat on the mat’. ‘It is sunny today’, ‘I am tired’. ‘There is nothing wrong with my memory’. The kinds of things you can well imagine.

Sometimes you get an imperative like ‘Go away!’. ‘Leave me alone’ occasionally with a choice swear word thrown in.

One of my favourite sentences remains

‘XX (insert  name of local authority I work for) social workers are harassing me’.

To be fair, she hadn’t been wrong. It was one of those ‘is it too risky to go home’ situations that had led to lots of hand-wringing assessments of risk..

But at least she got her point across in no uncertain terms and so it remains, safe and filed – a true snapshot of her feelings and ability to express them.

Sometimes the sentences are banal and sometimes poignant. Sometimes you get a glimpse into a different part of someone. I wonder what it is that might make someone able to write what they feel they can’t say.

Most times though, it is genuinely the very first thing that comes to mind.

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