A Vision for Adult Care – a few brief thoughts


I’ve only just had a chance to read the ‘Vision for Adult Care’ published yesterday and wanted to offer a view very initial thoughts although I haven’t any doubt that it will be referred to continually for many years to come.

Having read it my initial response was a little underwhelmed. I don’t know what I was expecting. Perhaps that was just it really, we knew exactly what to expect. There wasn’t anything in there that should surprise anyone at all.

We know that there needs and will be a genuine desire to push the personalisation agenda and move towards personal budgets where service users and carers have greater control over the budgets that they are assessed to need with services rather than directly provided and commissioned services being chosen ‘on their behalf’.

I have always attempted to care plan with rather than for people. That has been the policy for about 20 years arguably since the 1990 NHS and Community Care Act. What stymied the ‘choice’ element back then was the realisation that services have costs attached and ‘block contracts’ are cheaper and provide more services are cheaper costs to the councils. My understanding is that block contracted care with little choice in the provider was never the goal of the reform to legislation 20 years ago. That was supposed to, and did, open up the ‘social care’ market. It has just led us down this prescriptive path because the prescriptive path was cheaper than the choice and user-led path.

That should be the lesson for the government of the day – but enough with my cynicism.

I can wholly embrace the desire to move everyone to personal budgets and moreover, I absolutely welcome and appreciate the acknowledgement that having a personal budget is not the same as having a direct payment.

The language of social care seems almost designed in some ways to alienate and obfuscate so I apologise in my use of jargon.

Managed personal budgets seem to be a way that some local authorities have ‘dodged the issue’ of blocks to direct payments or when people have been reluctant/unwilling to move to direct payments. The government seems to have made, at least an attempt to understand this.

As the document says

We want people to have the freedomm to choose the services that are right for them from a vibrant plural market. That is why this vision challenges councils to provide personal budgets, preferably as direct payments to everyone eligible within social care within the next two years’

That ‘preferably’ offers the councils some get out within the target of ‘two years’ but it will be interesting to see what outcome measures (because there will be new outcome measures) are going to be taken up in my council, at least and what kinds of pressures and supports will be rolled out for that broader ‘direct payments’ issue.

I wonder how many people accept and understand that these ‘direct payments’ and ‘personal budgets’ are all means-tested and can all be charged. I mention that because sometimes in the press there doesn’t seem a complete appreciation of that. I say that as someone who has recently assisted to set up a direct payment personal budget to someone who is paying full cost. He is paying as much as he is getting back. Sounds nonsensical? Not really, because this way he is able to ‘buy’ into the support package and information that is given in the same way it is to those who don’t pay for their own support. Apparently, according to the government though, we don’t provide the same levels of support for full cost users, that is also rolled out as a goal for the future. I wholeheartedly welcome that. Access to support, information and care planning should and will be a universal service. I’ve always believed it is inherently unfair that people who are charged full-cost have sometimes been denied that support – indeed, I have personally provided it and argued successfully with my managers that I should wherever it has been possible but I am aware that too often the local authority has washed it’s hands of anything that it does not have a direct responsibility for – mostly due to cost rather than callousness. But back to the ‘vision’..

The paper sets out a number of principles

Prevention

‘empowered people and strong communities will work together to maintain independence’

Wonderful. No-one can deny statements like that. The vision specifically explains (quite rightly) that early intervention promotes better outcomes (and lower costs) in the longer term. This is what we have been saying for years – as the eligibility criteria have increasingly tightened. Therein lies the so-called rub. The way the ‘vision’ ducks this is by emphasising community support and action alongside paid care services. The ‘Big Society approach to social care’. Gulp. I honestly still find it difficult to understand ‘big society’. Does it mean more people doing voluntary and community work? I am sceptical even though I don’t want to be. My concern is that it means a greater pressure on family and friends as carers.  The vision mentions the ‘scheme’ in Japan where families ‘swap’ care responsibilities in different areas of the country. I worry that too great a reliance on informal and ‘free’ support will lead to un inequitable access to equivalent services for people that don’t have large support networks or live in supportive communities. Time Banks are also suggested as a way of providing support which is good, I like the idea but too great a reliance on hours given willingly may not be the best safety net.

I absolutely agree that commissioning needs to be closer to the ground. I see some of the craziest commissioning decisions being made and can’t believe anyone in those service areas have any clue about what  the local community needs or wants.

The vision does state clearly that ‘Carers are the first line of prevention’. Good. And it goes on to explain ‘Councils should recognise the value of offering a range of personalised support for carers to help prevent the escalation of needs that fall on statutory services’.

I have set up a lot of carers’ direct payments myself and have a few carers who manage them. In some ways, it is very easy to ‘sell’ direct payments to carers as there is a much greater degree of flexibility but there is actually very little money allocated to carers’ direct payments presently. I hope this ‘vision’ and appreciation of the longer term saving that carers are contributing that we will be able to offer them more money through direct payments themselves. Carers Allowance is some kind of evil joke that is, in my view, insulting. Carers Direct Payments potentially can ‘make up’ for it but the local authorities have to loosen the poor upper limits on the carers’ direct payments.

We are promised a forthcoming carers’ strategy. I await it will much interest.

Telecare and technology is also mentioned. We have been promoting this for a few years. It can be very successful but it cannot replace human contact.

Personalisation

I’ve mentioned this above and am very glad that the document acknowledges that ‘A personal budget alone does not in itself mean that services are automatically personalised’. In some ways, that has been my cry in what I thought was the dark. The document mentions the areas that have been slow to pick up in the roll out of direct payments, namely older adults, adults with mental health problems, adults with learning disabilities and adults who lack capacity.  Regarding one of the ideas for managing direct payments for people who lack capacity, one of the suggested ‘solutions’ is placing the control of the budget in the hands of ‘another suitable person’. Interesting. I wonder what this means – informal care and support, a trust fund type project, a professional. All have potential costs and as the criteria for eligibility tighten, the money itself will be less. Higher quality care and m0re choice with less money. Sounds perfect.

There aren’t really any solutions offered but at least acknowledging some of the difficulties is a start.

Interestingly, there is a line about increasing choice to people living in residential care which is a fantastic idea. I am very curious and excited to see how this might happen in practice.

Again, the examples offered in the Vision relate to people that have capacity, support and ideas.

There also seemed to be a suggestion that the IMCA (Indepedent Mental Capacity Advocate) role might be broadened. This is a joy to my cynical self. I  have worked extensively with our local IMCA service and I couldn’t praise them highly enough. I really really hope we can use them more but they will need to be paid.

Plurality and Partnership

The vision emphasises an idealised support ‘partnership’ between individuals, communities, voluntary sector, private sector, NHS and local councils. Probably in that order of preference.

We are told the aim is ‘a broad market of high quality service providers’. Absolutely fantastic. This is my vision for social care as well. I am just a little cynical about the high quality=low cost possibilities but I am willing to be proved wrong, indeed, nothing in the world would make me happier. I want to be able to advise and promote high quality care from many different providers. But that was what we were promised 20 years ago.  The vision promotes a move away from the ‘block contracts’, again, personally, I feel in general they have been negative and have limited choice but there has to be an acknowledgement that they grew out of a necessity to reduce costs.

Protection

Safeguarding concerns have often been raised about the roll out of direct payments and a potentially larger, unregulated workforce of Personal Assistants as well as issues regarding management of finances.

The vision seems to have a great deal of faith in CQC (Care Quality Commission) to inspect services where safeguarding concerns have been raised. Anyone else notice the slight problem here? That’s a bit like closing the door after the horse has bolted – I apologise for the cliche.

There is also the suggestion of a type of ‘neighbourhood watch’ scheme for people in communities to ‘report’ and ‘look out for’ people who might be being subject to abuse. Honestly, I hope this is happening anyway. Fine, it doesn’t do any harm but it doesn’t replace a strong safeguarding structure and culture. I noted there is a particular statement that

‘Local government should act as the champion of safeguarding within communities’ which suggests  that whatever the new ‘practices’ outside the local authorities will do, it won’t be safeguarding. There is a consideration to put this function on a statutory basis. Please, please, yes, yes. Vulnerable adults need the same protections as vulnerable children. This is long overdue and a real failing of the current safeguarding system that at times feels too toothless. It is very hard to get police involved sometimes where I can’t imagine there would be the same difficulties if we were talking about children rather than adults.

Productivity

The vision goes into greater detail about the financial package the local authorities and social care has been ‘gifted’. So be it. It is unprotected money and we all have doubts as to whether it will be enough but noone is getting any money at the moment. There is a focus on efficiency savings.

One of the elements that made me happiest actually is hidden towards the back of the document where it states that ‘The Department of Health will amend the ‘Payment by Results’ tariff from April 2012 so that the NHS pays for reablement and other post-discharge services for 30 days after a patient leaves hospital. From next April, Trusts will not be reimbursed for unnecessary readmissions to hospital’.

Hopefully, this will mean that discharge planning is more coherent and less rushed with the Trusts knowing there will be cost implications of readmission if they ‘get it wrong’. Good.

On the other hand, the vision wants councils to rip apart any remaining in-house services. I understand their point that this is potentially narrowing choice but often, certainly everywhere I have worked, it has been the best quality service when compared with private sector care services. This makes me sad. Goodbye, in-house support. I miss you before you have even gone.

People

And so we move to the social care workforce. Sigh. Yes, the government say ‘care workers, nurses, occupational therapists, physiotherapists and social workers, along with carers and the people who use the services’ and you get the impression they put the list in order to importance in their own minds’ eye.

The vision explains that

‘New and continuing professional roles will be developed for front-line social workers, occupational therapists, nurses and others’.

And then goes on to explain the problems there are with sickness and absence in the sector. I wonder if all the reconfigurations have been an issue about increased stress and uncertainty, never mind. I’m sure the government hadn’t considered that.

Interestingly there is mention of working with Munro’s review of children’s services in social work to allow social workers to have more ‘decision-making authority’. Huh? I thought the decision-making was to lie with the service users.

I am thrilled that there seems to be a linking of social work with community development. Seriously. I think this is absolutely the best area for adult social work to place itself and I am genuinely excited to think there could be a role for social workers in community-based growth. However, the skills sets may not quite be there and there will need to be some additional support given at first.

Generally, it’s a mixed bag that tells about lots of hope and plans as expected in a vision. There isn’t much suggestion or explanation yet but that will come with time. Some elements are clearer, some even foggier than they were before and my brief thoughts have been less brief than I imagined.

I find it very hard not to be cynical and I find it very hard to trust this government to be honest. There seems to be a worryingly high dependence on ‘free’ care provided by family and community and no explanation of where the support will come from when these community supports don’t exist.

But I do want the system to be better. I want everyone to receive a better service, not just those who are able to actively engage with the process of receiving a direct payment and I want the changes to work. I don’t care much for the government but I do care desperately for the sector.

A vision is nothing more than a promise until it delivers though. I want the central government, a government without  a mandate, to deliver on outcomes and promises as well as local government officers.

And with that, I sign off the longest post I have ever written for this blog – thanks for staying till the end (if you did). It terrifies me that the word count for one post I wrote in 40 mins is the same as the word count for the essay (currently taking a PQ module) that has taken me about 4 weeks to write… .. . . .

7 thoughts on “A Vision for Adult Care – a few brief thoughts

  1. Thank you for such an informative and detailed post on this important issue. I live overseas, but my husband and I have elderly parents in UK and are very concerned about adequate care funding for them. Your point about appropriate hospital discharge planning is apposite – my family struggled to have a proper hospital discharge planning process for my mother in 2009, and only achieved it by making a fuss and by utilising my own understanding of process as a social worker. The effects of cost shifting can be perverse incentives.

  2. Agree with everything you say! I did have a burst of hysteria though when you said “I really hope we can use them more but they will need to be paid”, My guess is, No chance, to the being paid bit. My guess is also that social workers will be reduced and replaced with lower paid workers.
    Personalisation is a brilliant idea/concept, it can work really well for some families, but it does depend on how its set up and organised supported. That costs. Oh dear.

  3. “Old wine in new bottles” – the vision – not your comments on it.
    I’m astonished that it has taken so long to do a cut and paste job.
    It’s tantamount to treason to challenge personal budgets, but I do despair of those cheerleaders who don’t recognise that implementation will be so much more difficult at a time when downward pressure on overall budgets is such a powerful force.

  4. Thanks for the comments – unsurprisingly, I agree. In fact, the more I’ve thought about it and discussed it at work, the more worried I am. I am sure the agenda about pushing direct payments is stemming from less than noble purposes.

  5. “Personalisation” in itself is not the problem. Its how its put into practice. I first heard about the idea in a slightly different form as a “bucketfull of money” from an Australian speaker at a conference 15 ? or so years ago. Its been used, is still being used in other countries but its a couple of years since I checked what was going on elsewhere.
    I think when it was “introduced” here, and I think that was mainly by “in control”, of course some people would have liked the idea thinking it was a money saver. In fact to begin with there was quite a lot of information coming out saying it was. It IS possible to save money, but only if its done badly!
    Councils seem to have developed some very convoluted procedures around personalisation which tie social workers even more than before, to hungry computers. It didnt need to be like that !

  6. I’m a carer for my profoundly disabled son (complex care needs etc.) and one of the people willing to speak out against Personalisation. It may be advertised as a means of giving disabled people more control but in fact, as implemented here, is simply an opportunity for Local Authorities to cut services and costs by forcing the actual work back onto unpaid carers. In reality it is likely to become academic anyway – the scale of cuts starting to hit us anyway will mean there will be little money left to be personalised. We’ve just had nurses withdrawn when my son is at home – but he still needs them when not with us. We have another meeting tomorrow with Health and Social Services where his whole care package is being ‘reviewed’. Personalisation is the nice fluffy handle on the big black axe that is just starting to slice off real services.

  7. I personally think its not “personalisation” people need to be fighting, but the cuts. If people cant join in in person, liase and support online. The students have shown us how and woken people up. There is no need for cuts, its the current governments ideological choice.

Comments are closed.