Law Commission Report on Adult Social Care – some thoughts

I’ve not had much time to look through the Law Commission Report into the proposed changed in Adult Social Care Law but to say it’s been long needed is an understatement. Adult Social Care Law is a hotch-potch and a mess. A couple of weeks ago, I was talking to a student who asked for some help with her law revision and she put it very succintly to me when she said it was much harder to understand community care legislation because it was ‘all over the place’ as compared to legislation related to work with children or in the mental health fields.

Hopefully, there is an upcoming reassessment and improvement in the way that community care legislation and legal duties are delivered through a single Act. That was the purpose of the Law Commission Report.

There are 12 parts to the report and I’ll briefly look at each section and make no apology for summarising the bits that I, personally, will find useful and interesting. The report in full and in summary can be found here. Among all the links, there is also an audio version available.

Part 1 – Introduction

Unsurprisingly, this explains the background to the report namely that adult social care legislation is currently spread across disparate Acts of Parliament and there are some pieces of legislation that remain ‘on the statute book’ but are not currently in use/useable (s47 of the National Assistance Act!)

Usefully, this section does introduce an initial brief definition of ‘Adult Social Care’ as being

the care and support provided by local social services
authorities pursuant to their responsibilities towards adults who need extra support. This includes older people, people with learning disabilities, physically disabled people, people with mental health problems, drug and alcohol misusers and carers.

The introduction continues to explain the timetable for the change process and some of the policy developments (most notably ‘personalisation’ and the move towards personal budgets in social care) that are taking place in the context of this review.

Part 2 – Defining Adult Social Care

While a brief definition was given in the introduction, this second section explains the need for a more robust definition of what or rather, who, comes into the definition of ‘adult social care’ in legislation.  This ‘definition’ will go beyond who receives services from social services departments and will include those who are not eligible for services so as well as duties regarding assessment and provision of services, there is likely to be a duty around providing more general information and advice.  This comes from splitting into two the principles of provision of social care – the universal (where the advice, information and support would come in) and needs identified following an assessment.

Part 3 – Structure of the Reform

This talks about the need for a consolidation of social care legislation. Currently, the suggestion is that there will be one single ‘Adult Social Care’ Bill which will cover both England and Wales (although this depends on how far Wales may diverge post-election).

As for the details of legislative powers and guidance, there are going to be three ‘levels’

– Primary Legislation

– Statutory Instruments

– Statutory Guidance

This seems to make sense and is particularly uncontroversial but I was particularly pleased that there will be a Code of Practice introduced (the Statutory Guidance). Those of us use to working with the Mental Health Act and the Mental Capacity Act will have a good understanding of how Codes of Practice link to primary legislation and I think they have been enormously helpful in explaining the legal issues to laypeople and practitioners.  It is actually specifically mentioned that the role of this Code of Practice will be similar to that in the MHA and MCA.

Part 4 – Statutory Principles

These ‘principles’ are familiar to those of us who work with Mental Health (and Children’s) legislation whereby there will be some underlying guiding principles and ideas to pull through the whole legislative framework.

There is an interesting discussion in this section about the way that the content of these principles had been considered when open to consultation. One of the principles (and the ‘main’ one) will be about a general aim to promote and contribute ‘to the well-being of the individual’ but the Act will also encompass some of the ways that this can be done by ensuring the individual in question is included in the process.

There is also a principle (unsurprisingly) about safeguarding adults from abuse and neglect and using a ‘least restrictive’ principle which will be familiar from the Mental Capacity Act. I am interested in how a ‘least restrictive’ principle will work in the context of people who do not lack capacity but I expect the issues will become clearer in the passage of time.

Part 5 – Assessments

Ah, the Assessment – that ‘core legal right’ at the heart of the Act and what will be the ‘gateway’ to services however they are delivered. Firstly the term ‘community care assessment’ was criticised as being old-fashioned. To be honest, we don’t use the term in any context except a legal one anymore anyway.

It is agreed that the threshold for accessing an assessment should be low and and that the assessment itself could be seen as a ‘service’ in its own right – the comparison is made with having a GP check up.

The local authority would be able to flag up voluntary sector services for people who did not meet the eligibility criteria and would be a source for advice and information as well as services.  The paper also talks about clarifying the position of people who refuse assessments so they might be able to access information and advice without having to have an ‘assessment’ of any kind.

The threshold for a fuller assessment will be met when a person may have needs that could be met by service provision so there will be a change of language in the law however there is a (quite right) determination that the threshold will remain low – because you might not know  if the need could be met until you have assessed!

There are a number of more specific guidelines mentioned about the way assessments should be conducted and who might conduct the assessments and how they would be undertaken. Generally, there are likely to be statutory instruments covering some of these issues and the details will follow, no doubt. There will be some scope for specialist assessments to be requested in certain circumstances where the user might have specific needs.

There was some mention of this being a reserved task for social workers but that was dismissed quite summarily (because there wouldn’t be enough social workers, I presume) and will be a matter for the statutory instruments!

There will also be further specific guidance about the scope and place for self-assessments in the process.

Part 6 – Eligibility

This is quite a complex one but basically, the recommendations include codifying what is, in effect, current practice – namely that the social care needs identified through an assessment are measured against eligibility criteria and if the individual meets those criteria as determined, the local authority arranges or provides services to meet those needs.

There would be in indication in the Code of Practice regarding the levels of eligible need and how the councils would interpret them.

The law is not going to specify where the line should be drawn by the local authorities regarding setting the ‘thresholds’.

Interesting discussion in the document about duties under s21 of the National Assistance Act. I won’t go into details because I don’t have time but it looks like the duties will be recommended to be retained.

Part 7 – Carers Assessments and Eligibility

Unsurprisingly, there will be a consolidation of duties under various carers’ legislation to provide a carers’ assessment. I’m shocked when I hear of the number of people who are not being offered carers’ assessments when they should always be as a matter of course. Hopefully, this will be an imagining of a long distant past.

The ‘cared-for’ person needs to have at least some social care needs for the carers assessment to be ‘triggered’ and not only ‘medical’ needs. This is a bit of a blind spot in my view but the document recognises this and feels that any changes made in regard to this have to be done as a matter of policy by the government.

The requirement to provide a carers assessment will though apply to any care provided and not be limited to those providing ‘substantial’ care as it is as at the moment.

It is proposed that rather than the carer needing to request an assessment, the local authority will have a duty to provide which is far better as I see it.

Part 8 Provision of Services

There is an discussion in this section about whether or not to define what ‘services’ actually are in the context of that which can be provided. It was felt by the commission that there should be some kind of list involved and that there was also a need to specify preferred outcomes of the provision of services. The list will take the form of categories of support in the context of those which will provide the desired outcomes.

The recommendation which explains it far better than I can annotate, explains

Community care services (however named) should be
defined in the statute as any of the following provided in accordance with the
well-being principle:
(1)  residential accommodation;
(2)  community and home-based services;
(3)  advice, social work, counselling and advocacy services; or
(4)  financial or any other assistance.

The statute should set out the following list of outcomes to which the wellbeing principle must be directed:

(1)  health and emotional well-being;
(2)  protection from harm;
(3)  education, training and recreation;
(4)  the contribution made to society; and
(5)  securing rights and entitlements

I actually really like the idea of including the outcomes. I think it adds significant clarity to the position and scope of provision of services overall.

It’s also interesting that social work services are seen as a discreet ‘service’ as opposed to advice, counselling and advocacy. I wonder if that is a shoe-in for a different type of social work with adults in the future. We can but hope.

Carers’ services will follow similar guidance as above.

A care/support plan must also be provided in written form for the user and carer (if necessary) that should include assessed needs, eligible needs and desired outcomes. I see in my future more paperwork but actually, if it is going to be an improvement, I’ll welcome it with open arms!

Direct payments will be retained in their current form and interestingly there is a proposal to introduce them to allow for payment for residential services.  I am not necessarily opposed to this however I do think there are some practical issues that are a concern. I’ll have to come back to this though in a post of its own!

None of the existing provisions for services that are being provided free of charge (for example those subject to s117 aftercare) will be affected by this and they will continue to operate in the current form.

Part 9 Adult Protection

There will be a specific role for the local authority to lead on safeguarding processes regarding adults at risk of being abused. In fact, the term ‘vulnerable adult’ will be replaced by the term ‘adult at risk’.  The document states:-

We, therefore, proposed that an adult at risk should be defined as a person aged 18 or over and who:
(1) is eligible for or receives any adult social care service (including carers’
services) provided or arranged by a local authority; or

(2) receives direct payments in lieu of adult social care services; or

(3) funds their own care and has social care needs; or

(4) otherwise has social care needs that are low, moderate, substantial or
critical; or

(5) falls within any other categories prescribed by the Secretary of State or
Welsh Ministers; and

(6) is at risk of significant harm, where harm is defined as ill treatment or the
impairment of health or development or unlawful conduct which
appropriates or adversely affects property, rights or interests (for
example theft and fraud).

Quite a broad definition but contrary to be beliefs of some, does not include everyone over 65!

Harm will be defined as

(1)  ill treatment (including sexual abuse, exploitation and forms of ill
treatment which are not physical);

(2)  the impairment of health (physical or mental) or development (physical,
intellectual, emotional, social or behavioural);

(3)  self-harm and neglect; or

(4)  unlawful conduct which adversely affects property, rights or interests
(for example, financial abuse).

but significant harm will be a judgement process.

Section 47 of the National Assistance Act will be repealed which is unsurprisingly and there will be another commission to look specifically at what it should be replaced by. This is, perhaps, where compulsory powers of entry will come in.

Adult Safeguarding Boards will be put on a statutory footing and there is some additional guidance on how they will operate.

The qualification that Guardianship can only be used for people with learning disabilities when there is abnormally aggressive or seriously irresponsible conduct’ will be removed which I think will allow for better protection for people with learning disabilities in the longer run.

The other sections of the report, I’ll cover very briefly

Part 10 Ordinary Residence and Portability

There is some clarification on the rules about residency in a particular authority and the principle of being able to take the assessment between different local authorities is, quite rightly, introduced.

Part 11 Overlap Issues

This part clarifies some of the areas where there are different pieces of legislation and particularly where there would be a crossover between health and social care issues but also with housing issues, forensic services and with childrens’ services.  There is some guidance about clarity regarding continuing care guidelines and how direct payments might work if they are extended into healthcare (which is likely).

It also recommends that adult social care teams can assess 16 and 17 year olds .

Part 12 Other issues

This includes a look at the right to advocacy which the report says should be retained as far as it already exists but not extended.

The local authorities will retain their registers of people who are blind and partially sighted and have discretionary powers to maintain other ‘registers’.

There will be a continued review about a proposed definition of ‘a disabled person’.

So that’s all! Well, it’s been interesting to read through. Generally it seems like a substantially positive review and I think it will improve the way that services are delivered and at least make it clearer. There are parts of the review I’d like to explore in more detail – particularly the safeguarding arrangements and some of the items in the overlap issues like continuing care but I’ll have to come back to them.

I’d be interested to hear other thoughts about the process!

Inspections and the CQC

Orchardville Care Home. Loving care is given t...

Image via Wikipedia

I was interested to see that Mark Easton in his BBC blog, touched on the issue of residential care and the confusion in the regulatory system.

He talks about a man, Dave, who needed to place his mother in a care home and looked to the CQC ratings and saw two stars (good) and his mother found herself in an awful care home.

She moved to a better place but the post goes on to say how

Ministers are pushing ahead with plans to replace regular national inspection with a “localism” model, relying on residents and their families alerting the authorities to problems.

Whoah. So now care home regulation is going the way of volunteers and ‘big society’. This is frightening stuff. I know the CQC has been being wound down, in effect, for years. There are fewer inspectors and they inspect less frequently.

Local authorities ‘quality assurance’ teams who may have picked up the slack are being disbanded in the face of enormous cuts in local authority funding from the central government. Our teams are being decimated (or if you want to take the term literally – more than decimated).

Easton has a telling – and chilling quote from the CQC

As the CQC explains: “We rely on people who use services and those who care for and treat them to tell us about the quality and safety of services. This feedback is a vital part of our dynamic system of regulation which places the views, experiences, health and wellbeing of people who use services at its centre.

Again. A little stunned and frankly horrified silence on my part when I read this. It felt as if I was being punched in the stomach and that the people who rely on a decent and human system of care homes are being kicked in the stomach by the government and the death of the regulatory system as well.

Feedback is very far from ‘dynamic’. I’ve tried to raise issues myself with the CQC about concerns in residential homes that I’ve visited and when you finally track down the officer responsible, you might get a sympathetic mumble but little has actually been done – oh, except in one instance where I managed to trigger a massive safeguarding alert which encompassed ALL the residents of said home.  Maybe a regular inspection could have highlighted these issues before a social worker who only happened to be visiting by chance raised the alert (when I spoke to the inspector, she admitted she had never actually physically visited that home).  Is this really the best way to proactively improve the quality of care homes? Is this what the ‘Excellence’ scheme is about? To encourage the CQC to be let off the hook as larger care homes tick more boxes.

This is a scandal. This is NOT as expectation that should be on residents and families who often feel incredibly vulnerable leaving their loved ones in a care home to pick up.

It isn’t easy to find the correct CQC number to make a complaint. Their website was actually redesigned to be far worse and far more user-unfriendly that I expect it was done by a work-experience student or the child of one of the higher tier managers who said ‘I know about computers.. I can do it’.

I really hope they didn’t spend public funds on that redesign.. information is much more difficult to find now – or perhaps that was the purpose (I’m saying that tongue-in-cheek – I’m don’t really believe in conspiracy theories – incompetence is usually the more obvious answer!).

Easton goes on to explain that

English councils are expected to improve their monitoring of care home standards just as they make cuts to adult social services, squeezing commissioning budgets and looking to find efficiencies in backroom quality assurance operations. The head of CQC, Dame Jo Williams, recently made the point herself: “The providers will be asking themselves: what can I do to cut corners?”

It is not just central government inspection of care homes which is being cut back. Ministers have also scrapped official assessments of how well local authorities commission care services. In future, councils’ responsibility to ensure good standards will be monitored by a new local consumer champion HealthWatch, which itself relies on local authority funding. The NHS Confederation has warned of “inherent conflicts of interest” with a council funded body scrutinising its paymasters.

So just when you thought things couldn’t get any worse.

This demonstrates that the ‘so-called’ Excellence scheme is a sham by a body that is not fit for purpose (namely the CQC).

We need to protect and provide support to vulnerable adults but no tools are being provided to support this and gradually the tools we had are being stripped away.

This is more difficult to stomach as Ofsted have a new inspection regime that demands that childrens’ homes are inspected twice a year and all inspections will be unannounced.

Why is the same system not introduced for vulnerable adults?

That is the question we should all be asking. Why does our society allow adults who are dependent on us to suffer so much in comparison and to be subject to second-rate, third-rate services and regulation of care homes?

We should be clamouring and demanding the same inspection mechanisms as given to children.

But people need to know about the changes in order to protest against them. Too many of these changes have happened stealthily and without much debate.

So slowly we are seeing the ‘big society’ that Cameron envisaged. It isn’t about community networking and organisation. It isn’t about volunteering and ‘making the community a better place’. It is about absolving the government of responsibilities.

Would we allow ‘friends and families’ to provide the base of inspections in childrens’ services or in hospitals? No. Why could and should we allow it in adult social care?

Personalisation in Mental Health and Older Adult Services

Personalisation is a very broad brush term to describe the so-called ‘transformation’ agenda in adult social care. In very general terms it refers to the process of moving from resource-led to needs-led systems of service provision (just as the NHS and Community Care Act 1990 was supposed to do) but this time… with individual budgets.

The idea is one is it difficult to find fault with. Users and carers would have more control in choosing the type of care which was provided through having ‘pots of money’ either virtual or actual payments  and deciding how best they could be used.

The change was led, ironically, by the soon to be extinct ILF (Independent Living Fund) which was the forerunner of the Direct Payment system whereby money was put directly into the hands of service users to choose and buy their own support and hire their own carers (with substantial support regarding admin and regulation if necessary). It was a new way of doing things and it generally worked very well.

Then with the ‘Putting People First’ white paper, the idea was to be rolled out to everyone receiving a package of care from the local authority. Wonderful. We would be living in a world where patronising social workers wouldn’t be dictating that ‘they knew best’ and imposing care packages based on large scale contracts negotiated down to reduce the costs and people would be able to choose the services they wanted and the carers they needed and liked. It would all end happily ever after.

I was a great campaigner for direct payments. I saw a lot of people do extremely well from them. I also think a lot more needed to be done though in increasing the take up and levelling the parity of service provision.

It appeared to me that those best able to advocate for themselves or who had active and involved families got the lions’ share of the services and were able to cherry pick whereas those who weren’t able to access the best systems either though lacking mental capacity, through lacking the desire or just being so knocked out by disability/age or lack of family got the scraps left behind by the system. The contracts that had been negotiated by commissioners who never themselves would actually use the services of minimum wage carers who were overworked by the care agencies determined to slash costs in order to win these prized contracts.

Soon though, the announcement came that everyone would get ‘personal budgets’ for social care. Wonderful. That would level the playing field, surely.

It was quite exciting. For a time. Until we realised that the people the local authority were ‘piloting’ the system with where exactly the people that they knew the system would work with – namely those who had successful direct payments packages.

Now, in my time, and the only time I’ve done properly authorised and supervised research as a practitioner, so happened to be related to direct payments. I spent a few months researching the lack of take up of direct payments by older adults and adults with mental health needs.

Now, my research was primarily literature-based. I did no direct interviews (ethics committees take time!). There was substantial sources of literature available, even at that point.

So what was learnt from the research that had taken place at that time and how was this used to improve the service provision when personal budgets were rolled out?

It wasn’t. So we find ourselves in the same place years later.

That’s a very long background to my point this morning but I think it’s important to emphasise the context through which I read the SCIE report ‘Keeping Personal Budgets Personal : Learning from the experiences of older people, people with mental health problems and their carers’.

I read this report last week and as is the case in all the best research, it backed up, with evidence my own feelings and ‘hunches’. I like research that does that.

The main learning from the report is that the key to the implementation of a successful personal budget is both information and involvement of a professional. People wanted support with completing self-assessment questionnaires in general so while our local authority employers promised us (don’t worry, we never believed them for a second) that time saved in leaving people to complete their own self-assessment questionnaires is time we could use in ‘creative support planning’ actually, the SAQ can be a daunting document.

In my experience, it is extremely poorly drafted (possibly because the focus groups were very narrow) and I am almost embarrassed to give it out. It focussed heavily on physical care needs and asked particularly strangely worded questions about capacity which shows the author of the forms have no understanding of the Mental Capacity Act and the idea of ‘decision-specific capacity’. It reminds me (and service users I’ve taken it to) of a DLA form. Jumping through hoops and ticking boxes to get money is not dignified.

The SCIE research also emphasises the importance of having a consistent person available to take a user through the process. Again, less necessary when there is a someone who is high functioning or who has highly involvement family/carers but the resource distribution of support doesn’t create an equity for those who need more. Professional time is increasingly stretched and the time spent rushing through a SAQ and package of support is not respecting the principle of self-directed support. As professionals with heavy caseloads though and targets which are tracked and time-limited, it is hard to balance this ethically.

Moving onto the Resource Allocation Systems (RAS) which is the way that the self-assessment ‘turns into’ a sum of money – either real or virtual for the user to ‘spend onservices’. I can’t express my anger about the RAS system strongly enough. It is heavily biased against older adults. It is even more heavily biased against people who have carer support.  I don;t know how widely this information is known  but if you have a family member providing support, you suffer massively when the finances are pumped out of the ‘RAS system’. The more help the family member provides, the less money comes out. I feel this is immoral and short-sighted. It places additional stress on unpaid carers and pays no heed to preventative care.    Yes, individual cases can be argued but that takes more time and effort.

The we move to the support planning stage. You have the ‘virtual budget’ in  hand so what amazingly creative package of care can you create. Again, the evidence in the report shows that it is often information that is shared by the professional in the first place that leads to the quality of support planning.  Users wanted continuity of staff throughout the whole process of assessing and support planning so our local authorities great idea of commissioning organisations to help might miss this point – although that idea and those commissions fell through when the organisations they had commissioned were so overwhelmed with referrals they were unable to take on any more users. Oh, and the user groups that were commissioned? Physical and learning disabilities charities. Nothing for mental health or older adults. Surprise. Even though those were the groups least likely to get the support and planning needed.

There is so much in this report and it is worth reading if you are involved in any way in implementing personalisation in adult social care in the UK.

The sadly predictable thing is that I could have told the councils these messages 5 years ago but noone would have listened – come to think of it, I DID tell the implementation team 5 years ago and many times in between. They are so vested in this new system of delivery of services being ‘better’ that they are blinded to the vast swathes of people who are again increasingly sidelined and excluded from the positive thrust of the personalisation agenda.

Sadly, it feels like the lessons will never be learnt because the wrong people are being asked. No-one wants or is able to invest real money in providing better services and more flexible and easier ways of managing the service provision in the less engaging client groups.

It’s unfortunate that the agenda has sprung into life at a time when cuts are at the front of our communal minds. It has become too easy to see personal budgets and cuts in the same sentence when they were never meant to be.

The truth is that the whole system is failing those who need the support, advocacy and choice the most. You know, those elderly people with dementia who have care staff on minimum wage coming for 30 mins in the morning to give them a shower. There are lots and lots of them around.

I want to ask how is the personalisation agenda helping THEM? How is it helping us to help them? We are closing day centres because people can ‘group together and commission day services jointly’  but sometimes the purpose of a day centre is the company that you surround yourself with, the support of peers and not about completing a specific task or learning a specific skill.

More able, more active older adults may well use their ‘day services’ budget to go to the local bridge club or swimming pool – but how about those with advancing dementia whose carers need the respite that day services bring as much as the company and hot meal are welcomed by users. Are the local swimming pools and adult education colleges going to be suitable for all?

The idea of personalisation was the it would be something that would be actively chosen and engaged with and there is no doubt, it works very well for those who are actively interested and engage with their care services.

My concern is that the process has, again, run away with itself and left behind, far behind, those who cannot make decisions for themselves about their own needs and who don’t have family to advocate for them. They are left with the same ‘old style’ service delivery model of the cheapest agencies providing poor quality care by rushed carers on minimum wage. The difference is now the day centres are closing and the government are telling us this system works better.

The sad thing is, if they had read and understood the research that was available at the time regarding the take up of direct payments by adults with mental health problems and older adults, they would have learnt all these lessons and maybe put better systems in place. The cynic in me says they only wanted to see success and the same groups of service users suffer yet again.

One of the things that saddens me the most on a personal level, is that I was always a great advocate of the direct payment system. I plugged away with it and got some incredible results with specific service users.  I was the little pet of the direct payments team, explaining again and again to my colleagues who wonderful it was to be able to reliquish control and allow and promote user choice.

I wanted and was sure the system of personal budgets would be even better. It would be more inclusive. It would fix the faults of the direct payments system because, look, we had research to back up why it  hadn’t worked so well with these particular service groups (older adults and people with mental health problems).

All the research was ignored. Mistakes were replicated and exacerbated. If anything it is even more exclusive and inequitable than the previous system and no-one seems interested in listening to any of the real concerns and criticisms.

A great opportunity has been missed. Hopefully someone somewhere will actually read the SCIE research paper and think about making real changes in the systems of delivery and implementation. It could all have been done in advance though and that’s the true tragedy of the personalisation agenda.

Good Practice Framework

My recovery is not as complete as I would have liked it to be at this point and while that means my gradual return to work is still in progress, it also means I have had a chance to explore more information sources than I might have had on my ‘full time’ work schedule.

I came across the Good Practice Framework on the SCIE (Social Care Institute of Excellence) website and have found some very interesting pieces of information there.

Basically, it is a collation of good practice (unsurprising, given the name!)  across adult social care and an explanation of how different projects and schemes have worked – in the hope that this good practice will be able to spread nationally.

I’d suggest anyone interested in social care in the UK have a look through some of the examples in a service area that interests them.

The quality of the write ups of some of the practice examples varies wildly. Some provide very little information apart from ‘we did this well because we consulted service users’ and others go into step by step details about how they implemented the actions – but it is a good source of ideas for things that can be changed sometimes with minimal cost attached.

Generally, it’s a good use of the website though – I think if more comments/discussion could be generated, it could be even more useful.

There are so many networking opportunities now for services and councils to share ideas, it’s a shame not to make use of them. I’m off to get some more ideas about how my ideal service would exist… at zero cost, of course!

Personal Budgets – Some thoughts

I attended some training on Personal Budgets a while ago. It was fairly comprehensive training that was surprisingly well-presented (it isn’t that I don’t always expect good training but sometimes it can be something of a curate’s egg.. ).

It leaves me in the position of being able to now set up pilot Personal Budgets, having a greater awareness of the process. I immediately, during the training, thought of two people whom I felt that this new system could benefit but first to the details.

Individual budgets or personal budgets as they are also known, are a key part of the programme of ‘Personalisation’ of adult care services. It is detailed in the ‘Putting People First’ paper but was first mooted in the 2005 Green Paper, Independence, Wellbeing and Choice. The idea is that the cost of the services will follow the individual and will involve different sets of choices about how that money is spent.

There is no doubt that the moves towards a more fine-tuned way of meeting needs opposed to making resource-led decisions about services that can be provided is a wholly positive outcome.

The idea is that you would start with a Self-Assessment Questionnaire which is completed either independently or with the support of either a care manager or an independent advocate (I am using ‘care manager’ broadly to mean an allocated employee of the local authority/health trust who would usually be setting up the care plan).

This questionnaire is then ‘validated’ by an employee who needs to ensure that the dreaded (in my view anyway) Fair Access to Care Services criteria are met and then a RAS (Resource Allocation System) defines an indicative  budget.

 

This budget is used to discuss a personal care plan with the service user and the idea is that the budget should not be a ‘cookie cutter’ type care plan but should indicate the person who needs the service within the financial constraints, of course. Care can be provided via a direct payment or the indicative budget can be used to purchase ‘in house’ services and a wide variety of mixtures in between. The people that I am considering taking through the process, as a part of the pilot stage, both really would benefit from more mainstream day time activities rather than going to the provided day centres (which are great, in their way, for people who enjoy them – and many do).

One person wishes to do some computer training and keep in touch with family all over the world as his daughter is on the verge of emigrating to Australia and he already has family there. One of the examples given to us during our training referred specifically of someone who wanted a computer and internet access to ‘keep up’’ with the times and I think there is a good case that this would provide this particular man with a much richer life if it were to be provided.

The other person is a woman whose husband is providing substantial care for her. She is subject to very low moods but has expressed an interest in pottery and she is very experienced and skilled in various art mediums. Although the day centres offer art activities, she wants to be challenged and we are looking at a lot of courses across London – however this has financial implications. I am hoping that we can use individual budgets in these contexts.

So we can see how wonderful they could be – however, my fear remains the quantity of paperwork they have generated around them. There is no question that the idea is positive and would provide better services but they are, at present, very far from simple and straightforward. My hope, in my ever-positive light, is that the pilot scheme will iron out and streamline the process – my fear is that in the system that is local government bureaucracy, paper is seen as a good thing and forms as positively exciting! Even in these days of ‘paperless’ offices.

Our trainer assured us that we wouldn’t find the process too draining on our time and days of increasingly caseloads as the people who were able to complete their self-assessments independently, would balance out those who needed a lot of support – however, I think she was gearing that comment towards those who work in general adult teams. My main worry about the new system is that it will be very difficult to plan the time to put together these budgets, although in the back of my head, I am remaining positive overall.

Like Direct Payments the focus seems to be on younger adults with disabilities, those who are able to advocate well for themselves and adults with learning disabilities. My thoughts on returning from the training was that little thought and time seems to have been spent on the consideration of people who may lack capacity in some areas to make judgements about some of the choices that are expected in this process.

I hope very much I am being overly cynical and am proved wrong. Today, David Brindle in the Guardian writes about RAS and its more helpful nature towards informal carers, whose contributions are recognised.   He makes some excellent points and it restores some of that positivity about the process.

I have some niggling doubts in my mind though – perhaps it is reminiscent of the introduction of the 1990 NHS and Community Care Act – when we were promised that ‘Care Management’ would be needs-led rather than resource-led, however, the fact is that those needs became more and more narrowly banded into large block contracts involving very little choice or flexibility.

Plus ca change..

The Way of Wirral

Wirral Council are planning to replace qualified social workers with unqualified equivalents. This is apparently in the face of the new ‘personalisation’ agenda where there will be a stronger focus on self-assessment and providing guidance and support through the new systems – none of which requires professional social work qualifications.

image DSNelson at Flickr

Community Care picks up on the story and digs deeper and finds out some more about the figures in question. The plan is, apparently, to replace 29 qualified posts with 26 unqualified posts.

The distinction between qualified and unqualified is a little disingenuous. Anyone who has worked in Care Management will know that something of this divide exists already – and I know when I took my first post-qualifying steps. I felt a little foolish and shamed that I, with my sparkly new DipSW felt I knew nothing in comparison with some of my colleagues who, although unqualified, had had many decades worth of experience in the field.  Especially (as was pointed out to me) as I was being paid more.

Community Care quotes some of the social workers in the affected council saying

One social worker said there was a “high amount of concern” among practitioners. “Initially, people were shocked and concerned about their personal jobs and they then started to think about the future of social work with adults.

“If we can be marginalised to this extent we have to wonder whether other councils will follow suit.”

The practitioner added: “Our view is that the majority of the work we do is complex. It couldn’t be done by someone without a social work qualification to the same standard.

So worrying times.

The model seemingly proposed by Wirral looks remarkably similar to a model used where I have worked. There is a single access point of contact and work is then either given to an unqualified worker if it is not ‘complex’ or passed on to a social worker if there are more complicated issues involved – usually personal care needs (rather than domestic care needs) or high level care, any adult protection investigations or any respite or residential care placements.

Actually setting up a care package and care management for basic needs is absolutely something that one does not have to have any higher level study in social work to achieve. There is no magic involved – it is fairly straightforward.

I am surprised at the level of disposability of workers in Wirral though – I don’t know much about Wirral except that it’s near Liverpool on the map – I don’t know the size of it but I don’t imagine it is that large that to lose 29 social workers won’t be insignificant.

The problems that we had when I was in the team that worked to a similar models were that sometimes things that seem very simple can actually be remarkably complex.

You can go into a situation where someone has just had a fall at home, for example, always been completely independent, but needs some help through the difficult recovery period – exactly what re-enablement programmes are set up for, in fact. The person, say, Mrs A, has never had any contact with Social Services before because she has never needed to. She’s filled in her self-assessment saying that she’s fine (because she doesn’t need any state help) – but is beginning to struggle so her nephew who visits monthly, makes a call.

Seems to be well suited to the new system. But on arriving and being a remarkably proud and dignified woman, she has held back on saying that really she’s virtually unable to move from her chair and hasn’t been able to have anything other than biscuits and water in a few weeks.

It happens. When social services start sticking their nose in, they uncover lots of unpaid bills because she hasn’t been able to get to the post office – which, in turn is a source of stress. Mrs A is still grieving for the loss of her husband just a year previously  who had managed all the finances. She’s lonely at home but she doesn’t want anyone to come in to see her – needs, perhaps, some active engagement.

Anyway, it’s a very quick example, but anyone with any experience in the area will know it isn’t always easy to separate simple from complex situations on the telephone.

Particularly with older people who might have very different perceptions of state help and be extremely reluctant to accept services  that either they are then expected to pay for with the meager pensions or not pay for and be taking ‘hand-outs’ from the state which although perfectly entitled to, is not something that their pride allows.

Anyway, back to Wirral. Maybe I’m being over-protective of the Social Work status. I can understand the concern of the workers in question. There will always be a need for qualified Social Workers in these settings because there will always be some work which is ring-fenced for us. Safeguarding Adults investigations, complex case-work, higher need packages. Personalisation is likely to lengthen rather than shorten that list.

And for care management? I’ve said before there isn’t a need for a qualified social worker necessarily. There are, though,  issues that need to be taken into consideration if it is just a matter of replacing qualified with unqualified in a wholesale manner.

Wirral council’s spokeswoman said, according to the Liverpool Daily Post

To achieve the ‘personalisation agenda’, as agreed by cabinet in March of this year, the access and assessment branch is being restructured. As a result, new posts within the branch will be established to ensure that going forward, social care staff have the right skills and experience to respond to the changes in the social care sector.

“A number of the new jobs in the branch will not require the postholder to have a social work qualification. This will mean that qualified social workers are deployed more effectively and can carry out more appropriate duties.”

I think the use of personalisation to justify this change is a smoke-screen. I’ve worked to the model of having more unqualified staff to do more work and it was nothing to do with personalisation agendas – it was to do with the cost of recruiting and retaining qualified staff.

The claim that self-assessment somehow reduces the need for qualified staff is completely baffling. Self-assessment for service users isn’t about replacing work done by staff – it is about empowerment of service users. Staff would still have to work on interpretation and implementation of care packages – and no, it doesn’t have to be someone who has a degree in social work doing that.

But it looks to me like a pure and simple cost cutting exercise by Wirral – dressed in personalisation packaging to ease some of the disquiet – rather than an alarm bell ringing as to future needs in the system.