Commissioning

Yesterday, I caught up with a friend of mine whom I hadn’t seen for a few months. She works in commissioning. She didn’t work in commissioning when we first met but her career trajectory has taken a few odd side steps and there she is.

We talked about commissioning for a while. She doesn’t work in a part of commissioning that affects the services that would be delivered by my part of the service so I felt fairly safe moving into rant mode as I spoke to her.

I wondered, to her, why the process of commissioning is so far removed from the frontline service delivery.

But there are service user consultations, she added. Yes, I replied but they are narrow in scope and where are the voices of those who do not ‘self-select’ themselves on ‘panels’. Where are the voices of those who may not have the capacity to make some of the decisions related to their care needs? Where are the voices of the carers who don’t actually have the ability to leave their homes because of the lack of appropriate respite – particularly older carers? Where are the voices of the voiceless?

She had a good comeback of course and spoke to me about the reams of additional advocacy support she is involved with but it made my heart sink.

You see, all advocacy apart from statutory IMCAs (Independent Mental Capacity Advocates) and IMHAs (Independent Mental Health Advocates) have been withdrawn from the services that I work in. The voluntary sector agencies that might have helped have either been axed or cut back sufficiently that they won’t ‘work with’ people who enter our services.

But back to the commissioners. I wonder why I didn’t know the name of any of the people involved in commissioning services for our local authority in the user group I work with. Why don’t they come to our team and meet with us and talk to us, I suggested to my friend, while, of course, absolving her personally – I know she is both good at her job and dedicated to providing good quality services.

Surely we, who are involved in scoping out support plans, making suggestions about which care agencies might be better than others, we who receive the day to day complaints when services aren’t available or aren’t working, would be useful people for commissioners to engage with? But I don’t even know the names of the people who work in commissioning the services we are asked to use.

They make block contracts on the basis of cost which deliver poorly. Yet when renewal time came around, exactly the same contracts were dished out. Perhaps we should meet and discuss our respective jobs a little more often.

I feel angry towards the unnamed commissioners in our service. I feel angry because they drop services on us which are basically unsuitable but cheap. They say they ‘consult’ but as I have learnt over my time in the job, ‘consult’ does not mean discuss, it means tell.

I wonder how many of these faceless ‘commissioners’ would be happy to stand alongside me in a hospital as I tell a family they will have to travel miles each way to visit their parent in a residential home because we have nothing available locally. Or stand next to me as I apologise, in my role as a corporate ‘entity’ because the provision of respite which was promised is wholly unsuitable because its all we have to offer.  Or listen to the conversations I have to take about carers rushed off their feet because they are limited to these ‘15 minute’ pop-in visits to desperately lonely people or listen to the discussions about why we no longer do a hot meals on wheels service and deliver only microwaveable meals. Occasionally, I’ve been known to tap out a grumbly email to ‘commissioning’ about particular services – and why I think they work or what I think is lacking – simply because I am not sure what other action to take and I want to ‘do something’. I’ve never really had anything other than perfunctory responses. They seem to exist in a parallel universe of contracts and submissions and plans.

Who was consulted before these commissioning decisions were made? I’m sure people were. Or were they? What backgrounds to ‘commissioners’ have in human services – I honestly don’t know. I don’t know if they have ever had any professional expertise in the areas that they commission for or have just moved up through various administrative ranks without any frontline experience.

I know ‘back office’ is important. I know there are some people that need to commission services. I understand that. I just wish sometimes I knew who they were and the ways that they made their decisions. I wish sometimes they would show their collective faces in our offices to understand better the implications of the decisions they make.

I’m very far from an expert in organisational systems but surely it can only help when different parts of a ‘group’ come to know each other face to face through discussion and understanding rather than the continual barriers that are put up between us by people who feel it necessary to stay in their safe silos.

I don’t want to mistrust commissioners. I just want to know who they are. More importantly, I want to know they understand the effect of their decisions on the people I see every day.

Fear and Loathing in the Public Sector – Or Why I despise Oliver Letwin

Oliver Letwin, United Kingdom Conservative Par...

Image via Wikipedia

Yesterday I read this article about Oliver Letwin, who, according to the Guardian article

..warned that it was only through “some real discipline and some fear” of job losses that excellence would be achieved in the public sector.

Letwin added that some of those running schools and hospitals would not survive the process and that it was an “inevitable and intended” consequence of government policy.

A little background about Oliver Letwin. I’m always a little wary of using Wikipedia as a source but a few choice verifiable ‘quotes’  jump out.

He is the ‘architect of modern Conservative party policy’.

He would rather ‘beg than send his children to an inner city school’

Oh and earlier this year he said did not ‘want more families from Sheffield taking cheap foreign holidays’.

So do we have a picture of the man? The Eton-educated man who would not know the real effects of true fear in the workplace? That encompassing, sleep depriving fear of not knowing if you can afford your next mortgage payment or if your job will be there next week, next month or next year.

Does fear drive excellence?

Let me tell Mr Letwin exactly what it means in the working environment that I am based in.

I work in a Community Mental Health Team – our team has been decimated – actually to use that word literally, it is far worse than decimation – over the past two years. No, I don’t restrict the blame to the current government but include changes under the previous government in my criticism.

We have piles of unallocated ‘virtual’ files while we are pushed to the limits by increasing expectations regarding recording and inputting data which is supposed to ‘prove’ our efficiency.

We have had wards closed at the local hospital such that people who need emergency hospital admissions to psychiatric hospitals are placed away from their communities or on ‘inappropriate’ wards. I have police unable to provide assistance because their services have been cut.

Fear drives efficiency, he says? In our service we have been told there will be job cuts including possibilities of compulsory redundancies. Yes, I’m fearful.

The ‘consultation’ about what will actually be proposed for our jobs will probably be announced soon but we’ve known it has been coming for months. We’ve heard rumours. We’ve heard gossip. We’ve heard absolutely zero from our managers though. Nice. Way to generate lots of fear. All boxes ticked.

So what has this fear done for our efficiency? We are beyond demoralised. We have more people leaving and taking jobs elsewhere and  people are  taking longer periods of sick leave.

I know that Letwin wasn’t referring to the ‘front line’ staff in the public sector – oh no, he meant the managers because he is of a class and a mindset that probably finds it hard to hold a conversation on a human level with anyone who earns under £100,000 per year.

The distinction between ‘frontline’ and ‘backroom’ is a false one though as it is impossible that can operate without the other.

Hospital wards are closing. Cuts are being pushed through. We feel your ‘pressure’ Letwin. We feel your fear. But I could not possibly despise  you any more than I do for your ignorance and self-serving words that for me, epitomise what the Conservative Party and their ideology-driven cuts want to do to this country.

I would like to ask Letwin if he is happy to condone a country of Castlebecks. Well, you see, coming from someone who would ‘rather beg than send his child to an inner city school’ – he would never be in a position to actually know or understand the real concerns of people who are dependent on public services because he can always choose the private course for himself and his family.

I know he wants to ‘make a name for himself’. He likes to garner attention and oh, how clever he is to want to drive ‘fear’ into the public sector but that, to me, sounds close to cruelty.

Efficiency? I think we can do with  fewer MPs who feel the need to make claims for repairs to their tennis courts and to have their Agas serviced.

What kind of society have we become when we feel it is appropriate for a Government ‘Policy Minister’ to drive a disdain and almost bullying approach to a public sector that provides services he will never need?

Oh and the speech he made these remarks in?

It took place

at the London headquarters of KPMG, one of the biggest recipients of government cash, which won the first contract for NHS commissioning following the decision to scrap primary care trusts and further open the health service to private companies.

Nice work, Letwin. Roll on, executive consultancy. You are all in each others’ pockets.

Meanwhile I have work tomorrow.

You enjoy your private tennis court today.

Goodbye Southern Cross, Hello Open Public Services

So Southern Cross – the largest private care home provider in the UK will be closed.

What of the 31,000 residents who live in their properties? Well, the government has given us its assurance that they will be ok so that’s alright then.

Or not.

Goodbye, Hello

m kasahara @ flickr

On the day that the Open Public Services White Paper was published  (which can be found here – pdf) – which couched in the comfort of positive words like ‘choice’ , we would do well to heed the warnings of the way in which social care was sold off in chunks, from public to private and reflect on whether it is better to allow care homes to ‘fail’ in order to prove that the strongest will rise to the ‘top’.

The problem is that Southern Cross WAS the strongest. It did rise. It also speculated on property and ownership transferred away from the core business base of providing care and homes for those who needed both.

But on a more pressing issue, what will happen to those who live in Southern Cross homes and work for Southern Cross homes.

As the Independent says

Analysis by the GMB union revealed the names of 80 landlords who own 615 of the homes, many of which are subsidiaries of larger companies registered overseas. This makes it much harder to obtain financial information about the companies as rules governing accountability and transparency, especially in “tax havens” such as Jersey, Cayman Islands and British Virgin Islands are significantly more lax.

In addition, the GMB was unable to trace more than 120 landlords, which mean thousands of people are living in care homes where the identities of the owners and directors are unknown.

In the absence of full company accounts and other relevant information, such as the names of directors, it is “nigh on impossible” to assess whether they are suitable to run care homes funded in large part by public money, according to Andrew Craven, GMB statistician and researcher

At least the ‘Department of Health’ spokesman says

“Whatever the outcome, no one will find themselves homeless or without care. We will not let that happen. Today’s announcement does not change the position of residents. The Care Quality Commission will continue to monitor the services provided… We have been in constant contact over the course of discussions and remain ready to talk to all parties.”

That’s reassuring. Or not. Would that spokesman or anyone in the Department of Health want that level of uncertainty lying over their head or the heads of one of their parents? The residents of the homes will not know who their landlords are or whether they are fit to run care homes at all. Of course no-one will find themselves homeless – it will be the local authorities, the elected local authorities who will have to spend and fret themselves out of this one – nothing to do with the Department of Health’s reassurances – unless the Department of Health is going to compensate those local authorities for the time and cost they spend to ensure the welfare of residents of Southern Cross homes that may close.

As for the CQC, I think we have established that it is unfit for purpose and unable to regulate a care industry that has grown too large and too costly to be regulated efficiently. How about an idea? The Department of Health invests very heavily directly in the CQC so that they can provide at least twice-yearly, unannounced inspections together with a host of lay visitors attached to every single residential and nursing home?

No, the Department of Health is weedling out of this crisis as it will weedle out of the cost of ensuring that the residents of Southern Cross Care Homes are not made homeless.

Now, I want to link some of these issues to the Public Service White Paper that was published yesterday and particularly one or two sentences I picked out.

Firstly

In the context of rolling out more extensive ‘choice’ in other areas of government, the paper says

‘We will ensure that individual service providers are licensed or registered by the relevant regulator for each sector (e.g. the Care Quality Commission) so that those choosing services can known that providers are reliable, without stifling cost”

Does that not lead to a tiny little shiver down ones spine? The CQC is being held up as a reason to trust in this extension of ‘choice’.  Has noone mentioned the cost of good quality regulation, either.  It’s worth reading this post at The Small Places for more consideration of the way the CQC regulates social care services. The CQC has failed to regulate and the care sector is failing to deliver on personalisation so far. The care sector has had time to learn as well. We had direct payments for many years and before that the ILF (Independent Living Fund) which allowed payments to be made directly to adults with disabilities to choose care. The system should be sophisticated enough by now to deliver good quality, equitable services but it has taken many years even to reach this point. There’s a long long way to go.

Secondly

“The wider public sector has much to learn from local authority successes in commissioning, for example, in adult social care”.

See, look at us, government, we’re a success! Success. This is the end-result of success. Adult care commissioning is not a success. It has not extended choice unless of course (and I think I’ve found the key) success is based on the principle of privatisation and provision of contracts to the those who deliver at the lowest cost regardless of quality. That is the adult social care ‘success’ that the government is lauding in the Open Public Services White Paper.

We are dazzled by words such as ‘choice’ and ‘open government’  but they have no meaning outside ‘lowest cost’ and ‘discharge of responsibility’.

Think of Southern Cross. Think of Adult Social Care. It’s coming to our homes, our hospitals, our high schools and our highways.

So much for my week of positivity!

Making Adult Social Care Better 1

I think I’m fairly good at griping and raising ‘problems’. For the next week, I want to try and take a positive approach and look at solutions as well as problems.

A few conversations I’ve had over the past week have focused on what is wrong with adult social work and mental health social work at the moment but more importantly what can be done to make things better.

My frustration is that for all the discussions that take place in the sector, so few seem to focus on those of us who have worked and are working at the so-called ‘front-line’. A home carer knows about the ways that contracts have been managed and awarded at the lowest cost and they will be able to tell you with far more insight than any contracting manager about the effects of 15 minute ‘spot’ visits and the lack of dignity present in the care for older people. They would also be able to give you an amalgam of ideas which branch from consideration, knowledge and experience of a wide range of service users.

Are employed home care workers ever invited to discussion forums and debates about the future of care? No. But you know, maybe the feedback would be the most valuable.

On a more personal level it feels as if the conversations about service design and delivery take place around and above us – with us being the people at the front line of support. Yes, there are discussions  with service users and carers but how much effort is made to seek out opinions that do not fit in the model that the consultants want them to express? How many of the people who attend these meetings, discussions and debates become self-selecting.

If you create a service user group, for example, in a particular borough, it seems to me obvious that you are most likely to engage will be those whose voices are already heard through different means.

I like to set myself up as some kind of advocate in terms of having an understanding of the needs of people who don’t often have their voices heard in these kinds of meetings and debates because the discussions I have are mostly with people who are at their lowest ebbs on the scale of health and need.

For me, it is crucially important that these people are not left behind by commissioners and service design but my experience and understanding of the sector suggests that they are.

I don’t want to keep harking back to the roll out of personal budgets on the back of the model of direct payments but I will. The voices of those without support and without advocates are understandably quieter and the way that the services have been designed focuses quite rightly on choice but what is not present is a way for an equitable service to be delivered to those who aren’t for some reason able to express choice.

So things that can make things better

– Use of advocates in a more formalised manner throughout the system. Volunteer advocates have a role but I see more mileage in professional advocacy with extensive investment in non-directed advocacy as that is potentially where the greatest need lies. If I weren’t so tied to my job in terms of needing a salary to pay the bills, I would, at a flash, try to establish some kind of enterprise to focus specifically on support planning and advocacy for adults with dementias. I hope there is a role for independent social work in this area in the future – in the meantime, if anyone wants to jump on my idea and run with it, I am happily ‘open sourcing’ it.

– involving front line practitioners in conversations, debates and discussions with the local authorities relinquishing some of the reins of power in respect to conversation. Recognise our professional vigour and competence. We see people and have discussions with people that will never attend forums collectively. We can signpost and support commissioners and contracting officers but we are never asked and never given the time to think more creatively outside our little boxes of control. We have ideas and a happier, more connected workforce is an engaged and interested one.

– speak to home care workers too – those with agencies and where in-house services still exist, with them. They will have good ideas about the ways that their services are failing.

– home visits to facilitate discussions – why have all meetings in a central hall when it can be limiting regarding those who have greater physical and mental health needs.

Technology can facilitate greater conversation and communication with two-way flows but face to face discussion is still very important as technology and keyboards can alienate some people – perhaps exactly those people whom it is most important to connect with.

-Practitioners have to be more engaged with developments in the sector and unfortunately I don’t see BASW or the embryonic College of Social Work being particularly engaged with social workers. Why have social workers become so disengaged from professional organisations and unions? Is it to do with a fear of employers? I think some more group action could really build the strength of social work but it is hard to shrug off the feeling that we are a disengaged and disenfranchised profession that like to feel sorry for our collective selves and wallow in our diminished status. I think if we took a stronger political stance and stood up to our employers and their political agendas and displayed more independence of thought, we would be able to demand more respect.

I have decided that while I can moan and groan with the best of ‘em, coming together with ideas for improvement is by far the best way of making our voices heard.

Initial thoughts on the Dilnot Report on Funding of Care and Support

Scheduling and exhaustion meant I didn’t have time to look at the Dilnot proposals in detail yesterday so this morning I have fired up my browser and am going to make a few initial comments on the baseline main recommendations and hopefully over the next few days can look at some of the details.

The Dilnot Report on Funding of Care and Support runs at 82 pages.  It attempts to forge a solution for the currently antiquated and inequitable system of care funding that is currently in place. Much talk has been made of the current threshold of £23,250 of assets, at which people currently become responsible for paying for their own care services but little made of the current discounting of homes in certain circumstances and the ability to raise a charge on a property to postpone payment of costs for care services. Nevertheless, this threshold was deemed as being too low. People who own houses like to keep houses for children. People don’t like those who ‘haven’t worked as hard’ or ‘saved as much’ getting something for free.

The system is broken though, don’t get me wrong, I just think the focus of the discussion has been too much around middle class fears of actually paying for something they believe should be free. Now, I’ve got that off my chest, back to the report.

The main recommendations are

– to cap lifetime costs of care between £25,000 and £100,000 – with a suggested threshold (which is used throughout the report for ease) of £35,000

– means-tested assistance will be extended to those who have between £23,250 and £100,000 of assets.

– Those who ‘enter adulthood’ with support needs will not be means-tested and care will be provided free.

-Universal disability benefits will continue but may be some differences in names regarding Attendance Allowance. (erm.. DLA?).

– There will be a cap on so-called ‘hotel costs’ in residential care between £7,000-£10,000

-There should be a national, portable eligibility framework which is more transparent.

– A government awareness campaign about planning ahead and preparing for potential age-related disabilities. And their costs.

– There should be a new information and advice strategy to help people through the confusing forest of knowledge.

– Better carers support and information.

– More health and social care integration

Of course, these recommendation run alongside the Law Commission’s report for changes in adult social care law. Together they could create a much better and clearer system than we currently have.

The ‘lifetime cap’ allows for insurance policies to be generated and probably very profitable ones too for the insurance companies. Most people do not need high level social care provision but the fear generated by the media is enough to drive right minded people into the arms (those who can afford it and who have substantial assets) into the arms of the insurance companies. I’m not sure how comfortable I am with the lifetime cap on care costs. It means the more wealth someone has, the more they are protected. I understand the logic behind it in that noone chooses ill-health and disability but the more than government spends on those who do have substantial assets, the less there is for those who cannot afford it and the higher the criteria to access support rises.

I just have a few queries which may be answered in the details. If Mrs Smith has a house worth £300,000 and she lives alone with no other substantial assets – say, for example, she has savings of £10,000 – is her house sold to release the asset worth up to the cap of £35,000 – assuming she doesn’t have an insurance policy? If she chooses to live in a care home which is private, but then the money runs out, will the local authority still move her? Will she ‘top up’ the local authority fees, paying above the ‘cap’ to do so? What is she lacks capacity and has no family?  I suspect all these answers are in the report but they will be questions I will be looking for.  The system of deferred payment is mentioned and I’ll hunt around for clarification.

The cap though, seems to be there to protect middle class votes.

I do, however wholly support the increase in the level of means-testing. I think it is entirely right to continue to means test up to £100,000 and I’d even go further than that. I don’t have a problem with mixed funding, I am just not entirely comfortable with the capping.

Again, the clarity of the coverage of those who ‘enter adulthood’ with care needs is entirely right. There is a necessary distinction between working age adults with care needs and older adults with care needs but quite rightly it is wrong to have a distinction fixed at a specific age. Indeed, Dilnot proposes that those who develop long term care needs before the age of 40 should continue to have a zero cap and costs should be met fully by the state. Above the age of 40 there will be some kind of tapering of the cap up to retirement age where the full proposed £35,000 cap would be reached.

Regarding the accessibility of universal disability benefits, Dilnot clarifies that he does not propose any reform that would lead to anyone losing their disability benefits and that attendance allowance will continue. I do wonder though how this ties in with the government plans to remove 20% of DLA claimants.

There are some recommendations though to change Attendance Allowance (AA). Firstly to change the name to something more understandable and an appreciation that many who are eligible for it do not claim it. That absolutely reflects my experience.  People who reach the cap when the government takes over payment will not continue to receive Attendance Allowance (or whatever it will be called) because the government is fully paying for their care needs – which makes sense to me.  The Personal Expenses Allowance (PEA) is proposed to continue – this is the payment that is made to people whose costs are met by the government in residential care and is currently about £23 pw – there is a suggestion that it should increase but not a recommendation.

The cap on hotel costs is excellent news in my view because I saw this as a potential ‘get out’ clause for residential homes. I do want to know how some of the private homes will adapt to these new systems though and what the cap will mean for overall quality of care provision.

The idea of clearer, portable assessments is a good one and long overdue. Eligibility criteria interpretation can differ wildly and there needs to be more transparency.   The minimum threshold would be applied at the ‘substantial’ level of care so I wonder how this portability will work for those who live in areas that meet lower levels at present.  It seems that there is some kind of recommendation to do away with FACS over the longer term.

Can’t be soon enough – a new assessment framework will be developed ‘with experts’. Please please please can front-line practitioners be involved in these developments – not just people who professionally develop policies and have never needed to use assessments in their lives. This is why we end up with unusable systems. There is also a way of building self-assessments into these new models. That’s the idea anyway.

The last recommendations about building awareness and improving quality of information seem to be sound all round. Nothing to argue about there.

I am interested in the recommendations as they relate to carers. As far as I am concerned, I want more than just an assessment for carers, I want the provision of more services. Supporting carers very well both financially and with practical and flexible support is probably the one aspect which can potentially save the government more money in the longer term than anything else – but more than that, it is an issue of ethics and morality. I know that doesn’t often come into government services but it’s something I feel very strongly about.

There is more commentary about the details of Dilnot in Community Care, the Guardian has extensive coverage (including an article I wrote before the details were known).

I also recommend Arbitrary Constant for links and discussion about Dilnot.

Waiting for Dilnot

The Dilnot Commission on Care Funding and Support is due to report back to the government on Monday 4th July.

At Arbitrary Constant there is some useful background reading about the Green and White Papers which were published by the previous government regarding changes to the funding of adult social care.  It will indeed, by interesting to compare and contrast with the proposals set out on Monday.

The scare stories about the Dilnot report  started emerging from the press over the weekend with the Observer reporting on a £35,000 cap on payments towards care while the The Times (£) write about a cap of up to 30% of the value of a property.

The very thought about paying for care at these levels seems to strike fear and anger in the  heart of the property-owning middle classes and perish the thought that they might actually need to pay towards the cost of their care. Although it’s important to remember that social care costs can be potentially incurred at any point in someone’s life. It isn’t necessarily about ‘saving up’ till old age or insurance schemes at the age of 60. What if you need the services at the age of 55 or 25?

The King’s Fund has a post which underlines the major issues and potential obstacles to implementation.

And the Guardian yesterday had a good summary piece which seems to have some of the potential details and difficulties highlighted

Meanwhile Community Care reports that there is expected to be a hostile public reaction to Dilnot. The article says

That was the warning today from housing and care provider Anchor, who found that 44% of Britons believed the state should fund all their care costs in a survey of over 2,000 people.

Which is the crux. No-one wants to pay for what they think they should be getting free. The payments into the ‘system’ and into ‘national insurance’ should cover care costs. The thing is, they don’t and they can’t.

Cost have escalated. It isn’t just about care home fees, home care packages and support plans delivered through personal budgets are increasing as people with higher care needs can remain at home for longer.

The sometimes seemingly arbitrary divide between health care needs (free) and social care needs (means-tested) can generate understandable anger as systems like the continuing healthcare assessments can be incredibly complicated and seemingly counter to common sense understandings of what ‘health’ care actually is.

There seems to be a proposal to separate out ‘hotel costs’ of the care home from ‘social care’ costs which will, I expect, lead to all sorts of interesting accounting mechanisms to ensure that the highest fees can be garnered beyond whatever system is implemented.

But I want to be hopeful.  Dilnot is unlikely to be popular in ‘Daily Mail’ land, there are murmurings in ‘Guardian’ land too. Maybe we just need all parties to actually work together for the good of the whole at this point rather than worry about the cost in votes that any change in a system might incur.

Personal Budgets, Personalisation, Thoughts and Hopes

Yesterday Think Local Act Personal (TLAP) published the results of a National Personal Budget Survey.

The headline ‘results’ are of course overwhelmingly positive. Personal Budgets work. Direct Payments Are Good. Everyone is happy.
Questionnaire

jrambow@flickr

Is any of this a surprise though? We know that people who can and are able to manage (or have family members to help them to manage) personal budgets delivered through direct payments (where money is paid directly to users) prefer them to less flexible local authority provided care packages – particularly when the scope of local authority care packages is limited to agencies with block contract arrangements.

In Control – which publishes the survey – highlights the following ‘implications’ from the findings. The bold is a direct quote and the italics are mine.

Other implications that can be drawn from the survey results include:

  • Personal budgets work better for older people than you might expect and direct payments work just as well for older people as everyone else.

Who said we were not expecting personal budgets to work for older people? Does this make an ageist assumption and lump together all ‘older people’. Of COURSE they work as well for people who are 65 as they do for people who are 64 but what about people without capacity or who don’t have family or friends involved? What about a more subtle distinction between 65 year olds and 85 year olds rather than a blanket ‘old people’ response.

  • The processes used for delivering personal budgets are more difficult than they need to be and that impacts badly on carers and on personal budget recipients.

Did this seriously need a survey over three months to discover? You could have asked me three years ago and I wouldn’t have charged consultancy fees.

  • More work needs to be done to make direct payments more accessible generally but especially to older people.

This could have been written 6 years ago. We KNEW this from the roll-out of direct payments initially so why was NO WORK WHATSOEVER done around trying to work with more difficult to reach groups when personal budgets were being ‘piloted’. I really can say ‘I told you so’ as I begged our Personal Budgets roll-out team to allow us to pilot or be involved in the initial processes and they said our user group was ‘too complicated’. Heh.

  • There is a need to simplify and clarify the rules and regulations surrounding personal budgets.

So those are the ‘implications’ and forgive me my cynicism. I love the idea of personalisation. I want it to work. I want to work in more creative ways or outsource my work if necessary to other third sector organisations but this is not ‘different’. This is not ‘new’. I fail to see the value of reports and surveys that tell us exactly what we already know again, and again and again instead of actively trying to work with people who actually understand and know what is happening ‘at the sharp end’ to try and work out ways to improve outcomes for those who are not receiving direct payments currently.

So back to the report – which used a Personal Budget Outcomes Evaluation Tool (POET)

in total, 1,114 personal budget holders  completed the POET survey, including 832 returns from the 10 local authority demonstrator sites and returns from at least 76 other local authorities. 417 of these personal budget holders also wrote in a comment about their experience of personal budgets.
In total, 950 carers completed the POET survey,including 782 returns from carers in the 10 local authority demonstrator sites and returns from at least 66 other local authorities. 434 of these carers also wrote in a comment about the impact of personal budgets on their own lives

And

Almost half of people responding to the survey were aged 65 years or more (43%); the social care needs of working age adults (aged 16-64 years) were largely split between learning disabilities (17%), mental health needs (8%) and physical disabilities (25%).

I don’t want to play too many games with statistics but it would be interesting to know what proportion of people who meet the FACS criteria in total are over 65 and whether 43% is a proportionate figure in relation to total recipients of social care services. I think as well, to class ‘older adults’ as ‘over 65s’ is a little disingenuous although I know it is done because that is the basis on which statistics are given but it shows some of the ways that systems restrict and inhibit knowledge. It would be far more interesting to know the differences of take up of personal budgets between 65 year olds as opposed to 85 year olds for example.

And to some of the headline figures, that can catch the press attention – most people who receive personal budgets find there is a ‘positive effect’.

Looking through some of the figures, it seems that older people were much more likely to be receiving council managed budgets – you know, that ‘easy’ way of just switching around a bit of paperwork and making it look like there is now more ‘choice’ when in fact, the services and delivery is almost exactly as it was before the ‘change’.

As for the outcomes the report says

In terms of social care need groups, older adults tend to report less positive outcomes than other social care need groups in six out
of the 14 outcome domains

I find the report to be honest, a bit of a whitewash in itself. It is only accentuating the positives and like all discourse related to personalisation and personal budgets, seems to be going over all the same ground again and again.

People like choice, people like flexibility. Yes, and rabbits like to eat carrots. It doesn’t need a survey to tell me that. What action and money and research needs to be concentrated on is the HOW.

HOW is there going to be an improvement in service delivery to those who are marginalised in this process.

HOW are we going to wriggle out of the sham that is council-managed budgets while allowing those who need to have others to manage their budget and support their care to have the same access to quality care and personal assistants that those who are able to choose and decide have.

I’m rapidly coming round to the view that personal budget support planning needs to be moved out of the hands of local authorities who currently have no interest in the process except for meeting the government targets. Where is the innovation within local government for change? Sure there are people, and I hope to be able to count myself among them, who want to do a better job and provide a better service but the constraints of the type of job I am doing means that I can’t devote the time necessary to truly inclusive and supportive care planning so Mr G whose support plan I am writing up (he doesn’t want to be involved in the process as he ‘doesn’t like forms’ and can generally only tolerate conversations with people for between 5-10 mins maximum and that’s only if he’s known you for at least a year) does get a rushed service because I have to carry out Best Interests Assessments, do Mental Health Act Assessments,  complete reviews and CPAs, liaise with other professionals, arrange discharges from hospital for other people. Yes, it’s a little bit of wallowing in self-pity and I wholly accept that. We are all busy but local authorities have no idea if they want a quality support plan without changing the ways of working in any other respect. Where is the time to devote to Mr G’s creative support plan? Oh, well, we’ll just do a regular care plan and a managed budget. Should it be that way? How has the march towards personalisation helped people like Mr G? Mr G wouldn’t complete a survey about a personal budget even if he did get a letter. Letters worry him and he doesn’t have a phone. I don’t want the Mr G’s that I work with to be forgotten in the rush towards direct payments.

When I first attended training we were told that any additional time we might be spending in our day to day work on these awful process-driven systems would be made up by the amount of time we would save by people completing their own support plans and assessments without any assistance. That may work for some people and I hope it does but for most of the people in the team in which I work it is unfeasible due to the amount of people I work with who have high support needs and who don’t have the capacity to make decisions about their own care needs.

The survey angered me, in a way that is probably irrational. Partly because it seemed to have taught us nothing at all. And partly because again, I see no new thoughts and ideas about developing systems that will be truly inclusive.

HOW can social care improve for everyone. That’s everyone. Even those who don’t want direct payments. Even those who don’t have advocates. Even those who are self-funding their own care packages as the criteria for receiving government support rise higher.

Those are the questions I want Think Local Act Personal to answer.

I have my own ideas. I think there will be a movement to roles for professional ‘support plan advisors’ who aren’t necessarily based in the local authority – perhaps individual social work consultancies but there has to be a separation between planning and delivery and the cost of these services shouldn’t need to be met out of the personal budget itself.

First and above all, there has to be a consistency and a transparency in the way resources are allocated and if necessary a weighting towards people who need assistance to access the same kinds of services who have been excluded from the process and the benefits in the past.

A survey of the skills-base of professionals who do implement support plans needs to be undertaken to establish what is needed and what is important to have.

Maybe it is a professional type qualification or maybe not. There is not much discussion about what the role of the social worker should be in the process. Should we be the ones support planning? I think there’s a argument that a social worker is well-placed to look at building plans together in conjunction with a user and family member if necessary and setting up things like trust funds or managed local authority budgets but only if the social worker is removed from the local authority talons.  Maybe some kind of team of people with different kinds of experience and expertise working together with some background and training in non-directive advocacy for people who do lack the capacity to organise their own support plans. Perhaps the social worker or support worker in these new roles could have longer term relationships with the users and carers and wouldn’t feel so pressured by management if freed from the local authority reins.

But who is going to suggest and discuss the new ideas? Where do they go? Who will collate them?

While I see lots of discussions around me about personalisation, I see little that says anything other than it HAS to work because it is best for ‘people’.

I genuinely believe that is has potential to deliver a much better system but and this is a big but, there has to be more creativity and different kind of research that looks at new models and methods of delivery and consults people – yes, like me – who while being critical really really do want things to work better.

My criticism isn’t because I want to bury my head in the sand and ‘retain the reins of control’. I really don’t. I want to relinquish control but I want more than anything an equitable system that doesn’t fob off ‘more difficult’ service users with a second class service.