Human Rights, Home Care, Personal Budgets and Cost Saving

I read on the BBC website among others that there is a report suggesting that care provided in the home by local authorities to older adults may be overlooking human rights issues.

Old man exmouth market


An inquiry into this  was initiated by the Equality and Human Rights Commission in November 2010 and will report in December 2011 but some interim findings have already been published.

I think the context in which the inquiry is taking place is crucial in times that Cameron trying to pretend that he invented the personalisation agenda and rebrand it as a version of ‘Big Society’.

The scope then of the Inquiry as to determine where the responsibility of the ‘public authority’ under the Human Rights Act actually lies and I’m going to quote directly from the EHRC (Equality and Human Rights Commission) as I think this is a crucially important point in the progress of personal budgets and home care provision (n.b. the underlining is my own).

The nature of social care is changing rapidly with a greater emphasis on personalised services and choice.  The majority of social care services are already delivered by private sector agencies, either via contract with local authorities or directly with individuals through a mix of public and private funding.

This complex web of transactions is combined with a narrow judicial interpretation of the meaning of ‘public authority’ under the Human Rights Act. This combination has created a confused picture concerning the duties and obligations of the various groups involved in respecting, protecting and promoting human rights.

Further, an increasing number of care transactions are likely to take place at the margins of, or even outside of, regulated care. There is the possibility that these transactions are beyond the present human rights obligations of the State.

We are also seeing the emergence of new on-line care marketing and brokerage services aimed at people purchasing social care with either ‘individual budgets’ or private funds. These marketing and brokering services are currently completely outside of the regulatory system with no means of monitoring the quality of the advice and services they offer. The Government wants to accelerate the pace of reform even further. While personalised care and support has many potential benefits, this is uncharted territory. There are concerns that human rights protection (and other issues) could fall between the gaps.

I’m going to come back, I’m afraid, to my perennial bugbear of people who lack capacity to make choices regarding care provisions and care delivery and wonder again how this group of people without family members, friends or advocates will be able to secure their own well-being in a world where responsibility of the state and the public authority is being discharged to private individuals. Will it become the responsibility of an advocacy service to determine that the support package and the provider of the support package are of a good quality? Or the carer/family member? Hardly the same as a protection under the Human Rights Act.

Food for thought and while I am extremely happy with the forward march of personal budgets and direct payments to those who are able and happy to manage their own budgets, the way that local authority managed budgets provide ‘more of the same’ regarding cheaply bought, block contracted social care remains floating fairly close to the edge regarding what is acceptable and what isn’t.

My fear is that the roll-out of personal budgets has not led to choice for all. It is a false choice and a false impression of the so-called ‘success’ of the roll-out. It has led to great benefits and more choice for some, yes, but I worry that this is actually at the expense of those without the louder voices to shout who have, again, been pushed to the bottom of the pile when quality services are being distributed.

So back to the reports findings so far.

Back to the BBC report

The Commission describes cases of people being left in bed for 17 hours, or more, between care visits and a failure to wash people regularly.

It received reports of people being left in filthy nightwear and bedding after a homecare visit, or without a wash or hair wash for several weeks.

Visits are sometimes so brief, the report says, that people have to choose between having a cooked meal or a wash.

The short visits also mean that staff have to rush tasks like washing and dressing, which frustrates elderly people and care staff

That doesn’t even bat an eyelid with me. This is what I have dealt with for the years I have been working in adult social care. Complaints and apologies about the time we can allocate for specific tasks due to budgets. Apologies on behalf of private agencies who have block contracts that cannot assure any kind of continuity of care.  That’s not even mentioning the  missed visits, the non-payment to staff of travel costs so they are cutting short visits in order to make it to the next ones. This is the reality of social care for older adults in the UK. Not the ‘season tickets to football matches’, not the ‘let me choose nice Mrs Walters’ daughter who I know from church to be my home carer’ kind of idyll that we are presented in the personalisation literature.

The reality for the people I work with and for is increasingly rushed visits and yes, choosing between a cooked meal (but only if it is a microwave meal because there is never ever time to cook a meal more complicated than tinned soup or beans on toast from ‘scratch’) and a shower.

The way to solve this problem and promote dignity is to increase and not reduce budgets for social care in the home. But budgets are being cut and cut hard.

Local authorities use block contacts with private care agencies to save money. The private care agencies generally pay staff at minimum wage. There are some fantastic carers and some fantastic agencies but they are penalised if they don’t offer their services at the very very lowest cost.

As for personal budgets? It is a wonderful reality for some but for most of the people I work with and for, it is a pipe-dream for people with a different kind of disability and with different kinds of support needs from the ones which are mostly promoted in our training programmes and in our policy documents.

If the government truly and genuinely means what it says about increasing and drawing out the personalisation agenda and increasing personal budgets delivered by direct payments there have to be ways clear and research undertaken to help us to create protective and interactive systems for people who are not at the forefront of the march because they don’t realise how much they are being penalised for not having a family member who is able to help with choosing and designing a care package and because they are not able to do this for themselves.

There has to be money spent on developing ways to allow those who at the moment are most at risk of vulnerability to be protected and cared for.

There are so many problems with a society that treats older adults or, in fact, anyone in the way that older people who are in need of care are treated currently. No-one wants to address it because no-one wants to pay. And it will cost.

No-one wants to lose their homes. No-one wants to lose their savings. No-one wants to pay higher taxes. No-one wants to lose weekly bin collections. No-one wants to pay insurance premiums.

The people who hold the reins of power will never be subjected to the humiliations which become a part of daily life for older adults who have need of support that is provided because they’ll be able to buy in their own ‘help’ privately.

Older people in need of assistance are less noisy than younger adults and less emotive than children in poverty and need. Ultimately we shouldn’t ration compassion and there’s no need for a choice to need to be made between one group or another

In the roll out of direct payments and then personalisation and personal budgets, it is the more able younger adults who have led the march and those who have been setting the policy and agenda seem to have completely forgotten the group of older people who don’t have involved family members and who  might not have the capacity to take decisions about care needs for themselves in the rush towards pushing the responsibility for support planning and choice of care routines. They  have forgotten amid the wonderful stories of attending football matches instead of day centres that some peoples’ reality is more about choosing a microwave meal or a shower.

Until those issues are addressed and the protection of the most potentially vulnerable groups of people is managed, the new system will not be equitable and it will not be fair. But perhaps that suits this government that wants shift responsibility from the state to the individual – which is fine to an extent but there are some people who really need that protection.

I look forward to the final report of the EHRC in December.

5 thoughts on “Human Rights, Home Care, Personal Budgets and Cost Saving

  1. Just checking the law –

    “Which” has a reasonable summary of how the law is currently interpreted – I believe incorrectly. I understand in England only Sunderland is implementing the law correctly. The problem is to do with somehow guidance – facs – has been allowed to override the law.

    The early 1970’s fetish, later institutionalised, around commissioning and providing, has caused real confusion.

    It is very simple.

    Clear statutory duty to carry out a full assessment of need. Then to think about the results of those assessments – for the individual and for the community – and then plan appropriate services and ensure they are delivered. Councils provide schools under statutory duties, there is no problem about planning health, care, support, hotel, estate, housing and personal services as required. Person centred planning, holistic assessment has a comprehensive set of questions.

    Providing services means asking what do we already have, and asking is it as effective as it might be? What might we change?

    The current way through facs of ignoring most of the issues is ridiculous. We need to bite the bullet as Sunderland has, and get on with the job.

    There are very interesting solutions possible, like local co-ops based around extra care schemes, delivering excellent solutions – instead of services – to their local communities.

  2. I was interested to see the front page of The Sunday Times yesterday was touting this new Cameronian idea of people being given ‘personal budgets’ to spend money on non-council services if they wanted to!

    It’ll never catch on.

    Is it me or….?

  3. I hope some of these criticisms become part of a process for improvement. I think there are great opportunities but I worry that the ‘personalisation’ agenda is leaving behind a group of people who would be much better served by it because they policy makers are chasing after the ‘easy’ processes – namely people who know what they want – at the expense of possibly very innovative thinking around co-ops, community based projects etc.

  4. Just catching up on your blog CB, I’m really looking forward to the EHRC report as well. One of the issues I hope they take up is that at the level of law, private home care agencies may not be considered to be ‘public authorities’ in the meaning of the Human Rights Act, meaning it is hard to make them accountable for human rights violations that are not unlawful in other ways (ie. a crime, or breach of duty of care etc). Having said that, I’m increasingly of the view that the HRA is a pretty blunt instrument for holding care providers to account – I’ve heard of barely any instances where people have been able to do this.

    I worked for a home care agency that was rated ‘good’ and I have to say the issues raised by EHRC were pretty endemic for us. I don’t want to justify it at all, but I would say the problems ensuring continuity of care and visits on time are very deeply structural. They relate to a desire to reduce overheads by having fewer staff working longer shifts (ie. instead of having, say, 10 staff getting everyone up between 7 and 9, you have 5 staff doing it between 7 and 11). Continuity of care is a perennial issue with an industry with such high staff turnover, but more than that, it’s a problem that ties into a) travelling and b) enabling people some kind of choice over who provides their care. You try to minimise travel time by putting everyone in the same area in one carer’s shift. You only need one person to refuse to receive care from that carer and either you have carers crossing town midway through the shift, or you have to change everybody’s care. What tends to happen is those who shout loudest (read: those with assertive families) get what they want, and those who don’t complain (read: those without families, and usually those who are timid or without capacity) end up with a hodge-podge of carers, arriving late, and often they end up with carers other service users have rejected.

    I am pretty cynical about personalisation, but one thing I would say is that when a service user with a ‘proper’ (as opposed to virtual) IB rang up to complain, the agency were quicker to sort things out than people on a block contract who were stuck with us anyway. However, this seems to me to be a sure fire route of ensuring the assertive few get a better service, at the cost of those who are unable, or unwilling, to complain.

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