Closing Care Homes

Community Care reports that the CQC yesterday released figures stating that 42 adult care services (that would be care homes and home care agencies) have been closed over the last year following action taken by the registration authority.  A further 51 services were closed following ‘poor’ ratings.

The Guardian breaks down the figures a little more minutely. And the figures deserve examination.

Those 42 services comprised of 34 care homes and 8 agencies.

Of the ‘further 51’, that includes 39 care homes, 11 care agencies and 1 nursing agency.

The total amount of residents who have needed to move places of residence due to these closures is 1600.

How is this not a national scandal on the front page of every newspaper?

It may or may not be obvious (probably not, come to think of it) but I do haul around searches for care homes and poor practice in care homes including ones that have been forceably closed – that is active searching – and maybe 3 or 4 might have been on my radar. So that’s an awful lot of highly vulnerable people who have been subject to incredible disruption, often linked to abusive practices in these care homes that have completely slipped beneath the public radar.

The Guardian lists the reasons for these closures as being

• verbal and psychological abuse of residents;

• medicines not being managed safely, leaving people at risk of not receiving vital medication;

• lack of medical and nursing care;

• staff not legally able to work in the country;

• poor sanitary conditions;

• lack of staff training.

Unfortunately, verbal and psychological abuse of residents is always a potential danger in work with vulnerable people. Residential homes can be a rich ground for potential abuse and sometimes the ‘wrong’ people are attracted to the kinds of work which can allow for abusive power-plays. It is despicable, it should never happen, but it has and it will, unfortunately. The only way to stamp on it really is strong regulation and good management.

All the other issues though seem to point to potentially money-saving measures related to staffing –  illegal immigrants will invariably be paid a lot less than ‘legal’ employees. Poor medication management points to poor training. Training costs.

Lack of medical and nursing care? Medical and nursing care costs.

Poor sanitary conditions? Cleaning up costs.

Lack of staff training? Training costs.

Do we see a theme here?

It is a very pertinent theme as we move towards an NHS which will increasingly draw on private enterprise.

This announcement and these figures are in advance of a new regulation system that comes into place on Friday. I’m fortunate to have a very good friend working in CQC as an inspector.  We go back to when we worked together as care assistants in the same residential home. Now, that makes me feel old but I raise it only to show how strange it is where our careers take us – anyway, I use her as a sounding board about my day to day frustrations and equally have a neat little insight into some of the behind-the-scenes changes in the various regulatory bodies that have become the CQC. It sounds like a mess, to be frank.

I lost any faith in the regulatory system a while back – not because there aren’t good people working there – indeed, taking my friend as an example, I would be hard pushed to think of anyone with a higher moral compass as a practitioner and she couldn’t be more focussed on providing good outcomes but the constant flux in the system (and yes, retraction of staffing levels) does have an impact both on quality and on staff morale.

At the ‘sharp’ end we have abusive systems in residential homes which are able to rattle along without sufficient oversight and regulation because there aren’t the people to provide the level of supervision needed.

I don’t want to colour the past in roses unnecessarily. I know there were problems, certainly with the physical structures of homes but with private companies, the motivation to ‘get better’ and ‘improve’ is not sufficient to force their hands. It only occurs when the delivery is so very poor that they are actually losing money.

There was an interesting quote from Cynthia Bower, the Chief Executive of the CQC in the Guardian where she says .

“This is where we’ve been focusing our attention over the past year as we get the sector ready for a new registration system that will be even tougher when care is not up to scratch.

My ‘mole’ in the CQC would claim that this is a part of the problem – the focus on changing systems has taken people away from front line inspections and where I’d agree with her is that the desk-based inspection systems do not provide any protection to those the system is meant to protect.

I know the system is due to change but in my old fuddy-duddy way, I would say there is absolutely no replacement for spot inspections regularly, day and night, weekday and weekend, from inspectors.

A ‘good’ report one year is no more valid than a CRB check one day after it has been completed. Bad things can happen the day after an inspection takes place.

Yesterday I was talking to a family member about a problem that she raised regarding a residential home where her mother is currently placed. This is a ‘good’ residential home.

It isn’t an issue that could be termed to be ‘abusive’ but it shouts ‘poor staff training’ to me. One member of staff saying one thing can make a ‘good’ residential home ‘poor’.

I know it’s not fashionable and I can’t see it happening – not in the current climate – not ever, but when the staff were employed directly by the local authority, at least training, pay and conditions and supervision could be better enforced.

Of course, we can never roll back the privatisation of the care sector but it’s amazing how few lessons have been learnt from the difficulties faced. I suspect it’s because it is an aspect of people’s lives that no-one really wants to think about unless they are directly faced with it.

I suspect it is part of an ingrained fear of growing old and possibly internalised ageism which sees ‘the economically redundant’ elderly as being somehow peripheral to mainstream society and their needs, wishes, wants, desires and aspirations – even if those aspirations are about living out ones’ life with the necessary care given in a dignified and sensitive manner.

Older adults will never have the same voice as young families in drawing the attention of the exchequer.

Why aren’t we shouting about these residential homes that deliver so poorly? Why isn’t every single closure on the front page of the national newspapers? Why does no-one care about the ways we treat older adults in this society? How is this able to happen?

Money, guilt and fear, I suspect.

This is why I wanted to work with older adults initially and it remains the same ten years after qualifying. There is so much more work to be done. It can feel like swimming against a rising tide but if we don’t shout out and shout frequently, all will be lost for our futures.


Slightly dull post here but I needed more space than Twitter would allow! I’m in the process of trying to update my links and blogs on the sidebar.

If your blog has disappeared and you are still updating it and want people to visit – let me know, I’ll ‘unhide’ it.

If your blog has never appeared, it might be that I don’t know about it or have been caught up in a rush of ‘things to do’ and may have missed it so let me know in the comments.

If you know any other good sites/links that could help people (or just me!) then also add them here and I’ll try and update the ‘other links’ page as well.

I do try to check the blogs and sites I list and tend to list the ones I like to visit but if there’s something I’ve learnt over the last few years, it’s how quickly sites grow and shrink, come and go and there are thousands more than when I started out

Usually oversights are simply just to lack of awareness or lack of time on my part..

Thanks in advance for the help!

Funding Continuing Care

It was interesting to hear Stephen Dorrell, the chairman of the House of Commons Health Committee raise the issue of ‘continuing care’ on Radio 4 this morning which were picked up on the BBC website.

Continuing Care is health-funded care which can be provided in a hospital setting, nursing home setting or in the community but it tends to involve jumping through many hoops and having very high dependency needs in order to ‘qualify’ for the ‘free’ care. It is a thorny subject as a lot of money can be at stake.

Basically, he explains that we, as a nation, have been failing a group of people whose care has shifted from ‘health care’ and NHS funding which is free at the point of delivery to all, to social care which is means-tested. The barrier to accessing ‘continuing care’ funding is set very high. Higher than it might have been in the past and it is this moving of the barrier that he is referring to.

This is a development which has not been fast in coming. In a way, it is surprising it has slipped under the notice of the general public who do not have wider understanding of the details unless they are personally involved.

It is easy to see this as an injustice, especially as care costs, which are means tested can be exorbitant and lead to the ‘selling of the family home’ type protests and distress that make for an anxious government.

The systems to make a claim for continuing care are very complex and wrought in obfuscation.

However, the comparison that Dorrell makes to the ‘old geriatic hospitals’ where care used to be delivered free is a little disingenuous. I don’t think anyone would want to see a return to those types of systems, indeed, it is impossible because currently even acute wards are closing, let alone long-stay wards.

The political motivation has, for decades been – quite rightly, in my opinion – moving towards a ‘care at home’ agenda. Partially because it would be in someone’s best interests and partially because it is cheaper.

The difficulty is that the funding that was free in hospital did not follow this client group home. At home they became subject to the vagaries of the so-called ‘postcode lottery’ funding systems.

It is an issue that absolutely needs to be resolved with much more clarity.

The difficulty is that with budgets being so preciously protected at the moment, it can only lead to an increase or tightening in the qualifying criteria in the future. That is why legislative clarification would be so welcome.

It will cost though – and it will cost a lot. If the money isn’t to come from means-testing, it will have to be taken elsewhere. Personally, I would be happy to pay higher taxes to live in a society that is able to care for people with dignity but I might not be in the majority there – anyway, with impending rounds of job cuts, it may be that there are fewer tax payers as a whole to contribute!

Part of the complication of the ‘continuing care’ criteria are the differences between the way the health budgets and social care budgets are sourced and granted. Local authorities face a freeze or reduction in their incomes. They would be delighted to move care costs to the NHS if they could because regardless of means-testing, they still accrue costs by delivering services. The NHS through central funding is being squeezed in so many directions that picking up more care costs could potentially be crippling.

That doesn’t mean it won’t or shouldn’t happen – it is just that more routes for money coming in will have to be established first. Whether this issue is included in the comprehensive care funding review is to be seen,  but it really does need to be.

It’s very easy for politicians to say that this shouldn’t be happening. A solution which involves a method of actually paying for the funding needs to be tightly connected and it’s a question of deciding who pays and if/how that can ever be equitable.

To Section – as a verb

Is ‘to section’ a verb we should be using? My understanding and instruction was always that we should try, if at all possible, not to refer to ‘sectioning’ someone.

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It seems a bit flippant. It seems to imply a decision made. I know these are values I am attributing to the words  but I can’t escape the discomfort I feel. Then, on the other hand, it is a word that describes a process in a way that is understood.

I know that is not a rational response to reject a word out of hand but I feel quite strongly about the process and having seen regularly, the distress it causes at close quarters, trivialisation is the last thing that should ever come to mind.

This occurred to me yesterday following a discussion with a nearest relative when I was explaining about the assessment I was going to be undertaking.

Just for the record, none of the pieces of conversation below quite matched the way the ‘real’ conversation went yesterday, but they are parts of conversations I’ve had with a variety of people over the past couple of years.

It’s one of the  tasks that I have as an AMHP (Approved Mental Health Professional) – and on a human level, it can be difficult. I am obliged as a part of my duties in setting up Mental Health Act Assessments to consult the relevant nearest relative in the case of an application for admission under Section 2 of the Mental Health Act and to consult and  ensure that they do not object in case of an assessment under Section 3 of the Mental Health Act.

There’s that ‘section’ word again.

Depending a little on the situation and whether it might be a person’s first assessment under the Mental Health Act and how close the family member actually is, you can judge how to pace the conversation.

‘I’m going to be carrying out a Mental Health Act Assessment of your mother’ Notice the difference between ‘mental health assessment'(which could be any type of more generic assessment carried out)  and ‘mental health ACT assessment’ (which is very specifically an assessment carried out in order to make a decision about compulsory detention in hospital). That’s the key difference and often it needs to be clarified.

That may be enough

‘Oh, is she going to be sectioned?’ may be a response if this has happened before.

‘Well,’ I might say ‘it’s an assessment so we don’t always know the result in advance’

Except some times it is a lot clearer than others.

That would depend on the circumstances and the lead up to the assessment.

We don’t consider Mental Health Act Assessments until all other possibilities have been expended but sometimes it might be someone we don’t know well or something might come up as a part of an assessment that we hadn’t known about in advance or it might just be a wholly inappropriate referral where some of the information given by a panicky care coordinator or family member isn’t quite what we see when we turn up on the doorstep.

Sometimes the prospect of being forcibly admitted to hospital is enough to ‘encourage’ someone who might otherwise be reluctant to engage with services.

If it is a first assessment or someone who hasn’t had any knowledge of the jargon and the way we things might work, I’ll explain in more depth the workings of the Mental Health Act and the bases by which we assess and what the implications are and may be. It depends on level of distress and what some of the precipitating factors might have been and how closely that person was involved – if it’s been possible to have some of these ‘lead-in’ conversations beforehand or not.

So this may have been discussed in great detail before this point arrives – but sometimes it would be someone who had been unknown to our services and with whom we had not had previous contact.

‘So you mean you’re going to section my mother?’

I try to reassure and often will tell the family member not to be frightened of the word itself. ‘Sectioning’. Being admitted to a psychiatric hospital for detention or rather admission, assessment and/or treatment under the Mental Health Act. It is scary. The thought of not being able to leave may be frightening but the stigma attached to ‘being sectioned’ is also frightening.

There are a lot of perceptions of what psychiatric hospitals may be like – and some may be exactly as they are perceived to be but most of the wards I admit to, I know the staff and I know the quality of the nursing care that will be administered. It’s easy to reassure someone of this but it’s hard to break through the preconceptions – understandably.

We also know the stories, we know the general perceptions of what ‘being sectioned’ might mean and the labels that might be attached.

I explain that the word holds all sorts of connotations but sometimes it is about legalities and above all it would be to ensure that we can provide the best care possible for the individual in question.

I explain that we conduct an assessment and that we do this in as humane and thoughtful a way as possible, always respecting the person and not making the situation any more distressing than it need be.

But sometimes it does need to be distressing. Sometimes the thought of ‘sectioning’ brings some of those images – as exist in general media perceptions – of someone being dragged off into the night to a hospital.

And you know, sometimes things do happen that way, I can’t deny it. Well, I don’t work at night as a rule (only if something from the day has dragged on) and there are  few times when I’ve personally been involved when the police have had to actually put hands upon someone during the process. It can happen though.

Usually the police are very sensitive. We have some excellent, sensitive and extremely professional police in our borough who are, for the most part, a joy to work with.

Duty of care. It comes back to that. It would be wonderful if everything we did could be done with consent but the nature of the job is that it is not.

‘So you’re going to section XXX?’

Not necessarily, I might respond – we are going to conduct a Mental Health Act Assessment and make a decision as to whether she needs to be admitted to hospital or not.

It sometimes feels like fighting a losing battle.

‘This is the social worker. She sections people’ One of my colleagues introduced me to one of the nursing students.

‘Well, I organise Mental Health Act Assessments where they are needed and make the applications for compulsory admissions’ I try, but that’s seen as me being a bit pedantic. I’m rowing against a tide

‘Yeah, that’s what I meant, she sections people’.

When I was a student, one of my practice teachers was a (as then) ASW. It seemed a faintly mythical task to me – and more than a little scary.

It’s less mythical now of course, as I’m carrying out the same role myself, in a slightly different incarnation. But it’s still scary. There’s still a thought that this assessment, this moment is something that will have a profound impact on the course of this individuals’ life.

‘When I was sectioned.. ‘

And the shame and distress that will cause to everyone involved.

It’s easy to reassure that it is nothing to be ashamed about and that we are ultimately concerned with our duty of care towards the patient and to ensure that the best possible treatment can be administered.

Or sometimes it isn’t as easy to provide that reassurance.

That word again – sectioned.

I see why we were told to try not to use it. It has so much weight to it. So many assumptions and fears attached to it.

But we also need to say it as it is sometimes.

‘Does that mean my mother might be sectioned?’

‘Well, people do refer to it as that sometimes, yes, but it is an assessment’.

And afterwards, when I report back

‘did you section her?’

‘She was admitted under Section 2 of the Mental Health Act’

‘So you sectioned her?’

‘Yes’. Sometimes it is just best to be clear.

You would explain the reasons, the rights and responsibilities of those involved and of the nearest relative. I don’t always get it right.  I try to put as much empathy into these conversations as possible.

But sometimes, often, the grief and distress, it cuts like a knife.

Risk, Capacity and Ethics

I know it gets a bit boring saying it but these last few weeks have been  busy. Ironically, bearing in mind what I have said about caseloads, the ramp-up in the disproportionate time available versus things to do ratio has been related to just one of my cases.

For obvious reasons, at this point, I can’t disclose too  many details but it will certainly be one of the ‘classic’ case studies that just about hits on all areas of practice including a hefty chunk of ‘ethical practice’ and what that may or may not mean.

This is a situation where I have worked from the basis of an assumption of capacity in regards to decisions being made, of course, in line with the context of the Mental Capacity Act. My judgement is not necessarily in line with other professionals and observers but ultimately, I am the ‘decision-maker’.

So, capacity is established. Even that is not clear-cut as I believe the individual has fluctuating capacity – as is not uncommon but the periods of lucidity allow the assumption to be made at those points.

And one of those ‘unwise’ decisions is being made. An unwise decision, we are told according to the Mental Capacity Act is central to our essence and choice as human beings with capacity and the making of an ‘unwise decision’ does not mean that someone does not have capacity.

So this is the perfectly acceptable and legally sound basis for the decision-making that I have taken.

We are given various examples of ‘unwise’ decisions on all the training we attend about the Mental Capacity Act. Often there is an element of humour in the training, you know, a man who might decide to spend his fortune on fast cars at the age of eighty rather than leave his money to his children and this is not a matter of capacity just because it is  not a ‘sensible’ decision. We all as an essence of our humanity take risks and make decisions that others might find ‘not very sensible’ but that doesn’t mean that we lack capacity.

It is a very important tenet.

The difficulty comes when firstly, there is not a necessarily clear-cut consensus that yes, this person is making a capacitous but unwise decision and secondly when there are risks attached.

Risk assessment is by it’s nature a tricky line to step. That’s the problem – if we knew all the facts, it would be simple.

I have been picking up lots of nervousness about this particular case because I think there was an expectation that the capacity assessment would go the other way – but the Act is clear about starting from an assumption of capacity.

I have spent an inordinate amount of non-work time worrying about the implications of the decisions being made. I went into work early one day after one of the ‘major’ decisions have been taken because this situation had been dwelling on my mind and I wanted to talk to someone about it.

I found my manager (who is always in early!) and ground her ear down a little about it. She was very good and patient with me as I explained my difficulties in separating the logical part of my brain where I am absolutely confident my practice is sound and I have acted in the way that is both in the best interests and respectful of the wishes of the service user – from the emotional part of my brain where I just want to be able to help more than we, as a service can offer or deliver in its current form.

I chuckled as I asked her, kind of jokingly, if she’d back me up in front of the GSCC if things didn’t go as we hope they will. She, of course, told me to stop being silly and that had I done anything more restrictive or authoritarian than she would have been truly upset with me. But in a way, that’s the ‘easy’ route – that’s the ‘safe’ route. When we talk about risk management and risk aversion, I can see the benefits and as a professional who does wield power to make decisions about peoples’ lives – that power unnerves me. I can see how easy it is to err on the side of caution.

A part of it is that I feel that although I can be clear that personally, I am taking the path which I am strong about, I feel that the service as a whole is not providing exactly what this person wants and needs and should have – because the needs are quite specialised and specific.

This should be exactly where ‘individual budgets’ can come into their own but the processes don’t always allow for people who are outside the ‘norm’. This is very far from a straightforward – ‘give a man a budget and let him plan’ that neatly fits the agenda of the individual budget. As I have discovered – although it isn’t really discovery as I knew this all along – it is hard to do anything quickly when you are wading through a swathe of largely unnecessary forms. It is hard to present some truly innovative systems and proposals when the system only permits choice to a certain degree.

As a practice assessor/teacher in the workplace, my last student often asked me about ‘ethical dilemmas’ as it was one of their competencies. I jokingly said that ethical dilemmas were a key part of the job as anything involving control had to be and when we cease seeing our power and influence as a part of that ‘ethics’ dichotomy, we take for granted the decisions we make and the power we have – we become dangerous practitioners.

We had a module on ‘ethics’ as a part of my Masters in Social Work but I also have a BA in Philosophy. I used to laugh about it and often do still. You know, the jokes about unemployed philosophy graduates and all that. To be honest, often they are fair.

But more than ever I am glad of the firm grounding I when I studied Philosophy as an undergraduate. Ethics – studied in far greater depth over the years of the initial degree, which seemed such a inately impractical course has bloomed into life.

Logic with it’s quasi-mathematical formulae has led me and directed my thinking in ways that I might not have been equipped to do otherwise.

I wonder, if, in retrospect, the first degree in Philosophy has aided my self-reflection and my skills as a social worker.

I remember when I applied for the Masters and the preference was for social sciences and I worried that people who had studied Social Policy would be better considered.

Now, I think Philosophy was the best grounding I could possibly have had. After all, doesn’t applied philosophy just about cover everything we do?

Day of the Ed

Having satisfied myself that I can’t separate my work from my politics, I have a somewhat indulgent post about the current events of the day. I’ve been following the Labour Leadership contest with intermittent interest.

Since the election the interregnum between Gordon Brown’s resignation and the assumption to the role of leader by  Ed Miliband has given the coalition time to ride out their ‘honeymoon’ period. At the time, I thought it might have been better (although I don’t think the Labour Party constitution would allow it) for another leader to be crowned as soon as possible. In retrospect, I can see the benefit of having had the hustings and debate about the leadership and more importantly, the time for the Coalition to ride out the initial positive freshness and have a strong leader in place for the upcoming spending review and into the future.

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I am no wise political pundit – I was always expecting a Miliband victory – just not necessary that particular Miliband..There was the curious factor in having two brothers fight the election against each other and in a competition between two Eds and two Milibands, I suppose it satisfies a certain neatness to have the candidate who is both an Ed and a Miliband win. Away from the flippancy,  I expect an intellectual rigour and broad understanding of policy. The noises made seem to be fairly positive and, as the election proved, the electorate needed change and if I had had a vote, I would have voted for him.

I don’t really need to explain my views about Balls – I have elsewhere and I won’t ever be able to shake off my distaste for him. I find him below contempt.

I respect Diane Abbott as a politician and have for a long time. She is a welcome face of diversity among the candidates – not just as a black woman but because of her background politically. She is a strong conviction politician. I hope she has a place in the future of Labour and that her voice remains strong although I don’t really have much doubt that it will – it’s just a matter of  how closely she is held to the centre of the power axis.

Burnham was a bit bland in my view and I didn’t really know where to place him but I’m not a long-standing Labour activist. My only ‘contact’ with him was a Secretary of State for Health and to be honest, he didn’t have time to make a deep mark. I have no doubt he’ll pop up again.

So back to  the Milibands. David, possibly lost out by being more closely associated with the previous government and the backing of Blair possibly didn’t help him in the wake of the publication of  Blair’s memoirs but ultimately, the race was just so close that any number of things could have affected the result one way or the other.

Ed placed himself to the left of David. He spoke more about grassroots and not losing sight of the Labour movement from which the party grew. David, as the more senior politician was more closely linked to the previous government and her policies – some of which, especially the military action in Iraq and Afghanistan and deeply unpopular. Ed is a little less tainted by association.

The whispers have already started about the place the union and affiliate membership had in the electoral college system that Labour uses to elect a leader. I expect they will continue for a long time. As a union member, I don’t see why the positions of the unions shouldn’t have value. Although there’s a massive difference between union member and union activist (which I’m not really – although I’m beginning to feel maybe I should be.. ). Lots of the target centre voters are union members as well – they aren’t the sole domain of the blue collar classes. I have a feeling unions may become ever more important over the next few years as well as the cuts bite and it’s worth remembering that union members are people with votes too and shouldn’t necessarily be discounted so readily by the press.

From here, I wish all the candidates well, especially the new leader of the Labour Party. Personally, I hope he’s able to restore some of my faith in the Labour Party.

On a more fraternal note, I wonder if it’s the first time that the winning leadership candidate told his closest rival that he loved him on stage.

Of Pride and Social Work

I have attended a number of meetings and training events recently that have been either borough-wide across social workers in many different teams or across different boroughs. These events have put me into contact with a lot of other social workers I wouldn’t otherwise have met  – in my office there are three others, one of whom is my manager.

At one of the events, I was the least experienced by about a decade (and I’ve been qualified for 10 years myself). All the other participants had been working in the field or in management for 20/30 years, some were recently retired or about to. They bemoaned the state of social work in general and how difficult things had become, how paperwork was overwhelming and face to face contact was not given the priority that the job deserves. When it was my chance to ‘introduce’ myself, I expressed surprise at some of the negativity because I’m fortunate to be in a position where I enjoy my job and perhaps despite some of the endless reorganisations and reconfigurations, the positives far outweigh the negatives. It is very easy to revert to the ‘wasn’t like that in MY day’ type rhetoric.

Another training course and a different group of people. Again, we were talking about social work and being a social worker in quite general terms by means of an introduction. The facilitator said that she felt it was so sad that no-one was proud of being a social worker anymore and that people didn’t tell others their job for fear of a poor response.

Participants nodded sagely and sadly.

I was confused. I have never not told someone I’m a social worker and am immensely proud of my job and my profession. Is that really so unusual? I didn’t think it was, especially. Maybe it’s the friends I mix with..

Processing these thoughts, I figured if we are so negative ourselves and show no sense of pride, is it any wonder the contempt that we are able to be held in more widely?

Yes, there is a media agenda and the government won’t get much political capital from pushing money or praise into social work but surely self-pride, respect and strength is what emanates outwards?

Personally, I think there is an overemphasis on ‘status’ and being ‘considered professional’ which reeks of self-indulgence and lack of confidence. It is almost like the profession is trying to look for reassurances from the ‘general public’, the ‘press’, other ‘professions’, in order to put ourselves on a par.

But often respect is as respect does. Yes, we have had to deal with some rather bizarre chopping and changing to regulation/training/function over the last decade or so – but sometimes we, as a profession, don’t always help ourselves.

We can look jealously at the esteem that other professions may be held in but that doesn’t mean we must expect automatically that the professional title we hold will be enough to garner that respect.

Professional independence doesn’t always have to be granted, sometimes it needs to be claimed.

We are in a precarious position at the moment. Local government is shrinking. Anyone who thinks social care or social work is exempt from the forthcoming cuts is living in an illusionary world.

The Guardian is reporting that Suffolk County Council are about to outsource virtually all their jobs and services

A few neighbouring boroughs in London have been looking at sourcing joint services between them which is an obvious way to reduce staffing costs.

A good social worker is and needs to be an advocate in a broad sense – for the people that the service is intended to serve.

A good social worker is a confident social worker.

Is being proud such a rarity in the UK that the matter was brought up again and again to me in various ways and means? Maybe.

I sometimes have waves of negativity. I have no doubt it is evident in my writing. I get angry at some politician or journalist who might show an extreme lack of knowledge in the sector or the environment. When I get into one of those fixes, I find the best thing is for me to recall why I wanted to be a social worker and what I love, not just about being a social worker but about my job in particular.

I wanted to fight societal injustice and still do. Social services are entrenched in social policy and social policy adapts quickly. We have to be able to think on our feet and think independently. Perhaps some of that independent thought has been ‘managed’ out of some of us by an encroachment of Performance Indicators and constant outcomes measurements.

Of course these need to be done because there has to be some measure of efficiency. Most people can probably think of a few in any office who might be less inclined to hard work than others. The ends cannot however, justify the means.

A good social worker is compassionate, competent and confident. Compassion without competence or confidence will not be enough. Competence without compassion is not enough. There is a need to actually care about individuals and the results of interventions. That doesn’t mean we have to like the people we work with but we have to offer an equitable service regardless of personal feelings and opinions.

Compassion and competence without confidence may result in being led by potentially poor management.

How are these skills developed? Not just through university courses but by good examples and good supervision in practice. A confident and competent manager will, as often as not,  have confident and competent staff.

So to anyone thinking about the profession who might be put up by the malaise of negativity that sometimes engulfs us, don’t be.

There is a lot of work to be done still. There are a lot of inequitable systems that need to be fought and they can be fought from within, indeed, they need to be.

The Disgrace of Individual Budgets

I have a few words for Paul Burstow, the Minister responsible for Care Services, who is appalled, according to Community Care, about the low take up and roll out of personal budgets in Adult Services – the take up is so far only 13%.

He said to his party’s conference

“It’s disgraceful. We need to be far more critical of public services. Why are they not willing to let go of control?” He was speaking at a Liberal Democrat conference fringe session on social care and the government’s Big Society agenda.

Excuse me for a moment while I scream with frustration.



What does he think that the lack of roll-out is to do with a nefarious political plot to hold on to the control aspect?

No, it’s not. It’s all to do with poorly adapted and poorly administrated systems and piloted exclusively in teams and departments that were ‘easy’.

Where are those 13%? I can bet they are with adults with physical disabilities and adults with learning disabilities where a lot more resources and efforts had been pumped into direct payments so they had a sound base to start on.

That 13% is also likely to include older adults who have capacity and families to help advocate for them.

We have some quite rightly wonderful accessible easy read documentation for the forms with beautiful pictures that show who effective support planning can be in the learning disabilities field – but where is the real research for people who may lack capacity to make decisions due to dementia – for whom the same type of documentation is not relevant because in general, those who are support planning will have much less time and much less money to ‘be creative’.

Where the systems have not picked up is with those who do not have the families and friends who are able to invest a lot of time into creating personalised packages – of the people who do not have the capacity to manage and organise their own care – for whom the system of individual budgets will not change anything too dramatically.

I wish Mr Burstow would meet and talk with people who actually DO the job to understand the difficulties, rather than meeting and talking to people who manage people who do the job or people who write the policies or people who audit accounts.

I want to give up control. Believe me I do. It might mean some respite in the constant stream of care management duties that spring up incessently. Sometimes though, it isn’t all about retaining control but maintaining quality as well. Sure, if a capacitious decision is made, all is well and good and the right remains, as it should, with the end user, but where there is a decision that needs to be made on behalf of another person, the choices are already limited.

Why should someone have a potentially poorer service through a provider agency because they are not able to manage a bank account and do not have anyone who can assist them – sure, theoretically the local authority can hold the account but who makes the decisions about PAs and flexibility?

There is little doubt that high quality regular care provided by a small group of people or person is the favoured option for those that have successful care packages. People whose direct payments have been most successful have worked because of the people they have employed directly as often as not. However this is not a service which is offered through this system to people who lack the capacity to act as employers and who either don’t have families or don’t have people who can do this on their behalf – they still remain with agency providers which most people agree offer a poorer service.

This is my gripe and my main upset with this system. It is inherently discriminating and providing a poorer service to people who don’t understand the systems. If social workers had caseloads of 10, we might be able to do this on someone’s behalf but it is not possible with the workloads that are carried in older adults services.

So the people who ‘can’ get a gold star service and the people who ‘can’t’ get exactly the same as they always got.

That is both demoralising and unfair. It makes me cynical of the whole system and those who advocate it because perhaps if this could have been thought through at the time, we wouldn’t be lagging so far behind of targets.

Sure, I’ve been to the training, I know about the trust funds that can be created to manage care but how many people in older adults’ services are going to have packages that pay enough to establish and operate a trust fund as well as paying for it’s maintenance. The answer is not very many.

The way the  roll out has been managed, stinks. For people it works for, it works very well – but there are many people whose needs and wishes have not been able to be accounted for in the way the forms have been written and the way the processes work. That might be unique to the local authority I work in – it must work well somewhere.

But these lavish statements of Mr Burstow, they grate incessently and I say that as someone who would love this system to work but who is ground into dust by the ways it has been implemented.

Balls and Hypocrisy

Just a quick post today. I was minding my own business reading the Evening Standard on my tube journey home yesterday when I came across the following headline


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I had to double-take and hold down a rue snigger. This is ED BALLS! The man who put an agony aunt from The Sun on the Social Work Taskforce! He is criticising Brown for pandering to the popular press?


I know social workers aren’t his target audience but Ed Balls really thinks he can gain favour by criticising Brown over this when he displayed the worst examples of actively pursuing the ‘hang ‘em’ brigade of the right-wing press in the aftermath of the inquiry into the death of Peter Connolly. He was the first to appear in the popular press telling them exactly what they wanted to hear and handing Sharon Shoesmith and the socialworkers involved, in Haringey,  to the howling press and public. All for the sake of some popularity.


I don’t know what planet Ed Balls is on but he is certainly in no place to criticise Brown for pandering to the press when he engaged in far worse during his unfortunate tenure as a minister.

Capped Caseloads

I was interested to see that Community Care are running an article about a survey that they ran which says that 9/10 social workers want caseload numbers to be capped.

I completed that survey and I’m in the 1/10 minority.

Most of my reasons are covered in the article. My point is that a ‘case’ is not necessarily a fair recognition of how much or how little work might be involved. One ‘case’ could be anything from some high intensity almost Assertive Outreach type working which involve both multiple visits a week and lots of peripheral organisation and meetings that might involve one ‘case’ taking the majority of a professionals’ time.

On the other hand, another ‘case’ might be one that is pretty much dormant, where everything is stable and the worker just hasn’t had the time to get around to closing because other, more pressing situations arise.

A blunt cap on caseloads doesn’t allow for any subtlety in the vastly different ways that cases are managed and the different work that is involved.

My very first social work job was in an adult community care team. When I left, I remember having to close 49 cases. Yes, that is appalling as a number on paper and I was consistently overworked – but – at least 20 of them did not need to be open and it was a matter of just not having got round to closing them.

Before I went in hospital earlier this year, I had a purge of all those cases that could be closed and managed to close five that I probably should have closed months previously.

Numbers aren’t necessarily the key. The other problem with a caseload cap is that there is an incentive for a worker maybe not to close a particular case if they don’t want to be allocated another one!

The problem is that  raw numbers are too haphazard a tool to measure workload.

I am in favour of weighted caseload management theoretically  but the systems to ‘weight’ the caseloads are not always able to take into account the various nuances of the job. It is something to ‘be aware of though’. A weighted caseload management system would find some way to balance the heavier pieces of work and the more ‘straightforward’ cases.

The problem is that anyone who has worked in the field for five minutes would know that an apparently ‘simple’ case can become complex very very quickly. We are talking about people!

One of the other issues about numbers is that there is an impression of ‘fairness’ across the team – you can know if you have the same number of cases as Joe and if that’s ‘fair’ or not.

I’ve always been slightly suspicious of this in the sense that having fewer cases doesn’t equate to having less work. Caseload management systems that try to equate ‘complexity’ can fail because although sometimes it’s very obvious something will be both complex and intense, sometimes these things just appear randomly in the nature that is human life.

So the answer?

The key to workload management has to be through good supervision and a dialogue between the manager and employee and a respect to know what the limits of an acceptable workload are and it will be different for different settings and for different individuals.