Individual Fudge-its.

I have tried to embrace the personalisation agenda. Really, client-choice is wonderful. I welcomed Direct Payments and saw a few through to the finish although always keen to emphasise the difficulties as they arose. Basically, the idea of giving the users of services the power and control to purchase services directly is a good one. Money and finance is such a crucial key in the dynamic and it is an almost Victorian and very ‘modern’ adage for the providers of social care to be spreading cash and services like charities rather than according to rights and needs. I always emphasise that any service provided is an absolute right – nothing to be grateful or thankful for. We have a duty to provide for those who need.

That is where the  mindset needs to be changed however, I think the move towards spreading out individual budgets has been wholly focussed on a model that works extremely well with younger physically and learning disabled adults who are able to advocate well for themselves or have active families and networks around them to provide the support and guidance – either formally or informally.

Where the system seems to struggle is firstly that (wrongly in my very humble opinion) choices and more importantly, money is less forthcoming with over 65s. The budgets are tighter and there just isn’t so much money around. There are also less ‘support’ hours available from social workers – in the sense that allocations in over 65s services are MUCH higher than in the other more specialist teams. Whereas someone who has a learning disability may have been known to a particular social worker for many years and have had time to build up relationships with a team and a family, an older adult will likely have much less time to have any form of ‘relationship building’ going on.

Self-assessment questionnaires are all well and good  but from my own experience, I’ve had a couple of people completely freeze up when presented with them (even in the context of me explaining that I would be happy to help) or laughed at (What?? Another Form?? All the questions ask about physical disabilities?? It’s just like a DLA/AA form (accompanied by a disheartened sigh ).

Any time I have raised concerns at meetings or training, I have been shouted down by the trainer as being opposed to client choice and just being an old stick-in-the-mud ‘care manager’ style of social worker who wants to retain all the control myself. I find that offensive for a start as these trainers have no idea what challenges exist and in their minds we have hours to spend constructing care plans for every person that we come across.

The truth is that it is a fudge of the highest degree. There is no more choice than there was for the people who don’t have networks of support. They are still constricted to the same care agencies that charge the lowest amount and pay their staff the minimum wages. Sure, they can employ people directly but there is no safety net or extensive support to recruit that was once promised. Being an employer is not for everyone – especially if it is someone who might be suffering from a cognitive impairment without a family member to actively choose and advocate. There is more flexibility, for sure, but it is found through such a convoluted method to have been painful to reach. The ideas are good but unless the commissioners and project managers listen to those who have experience, there will be no different outcomes for the most vulnerable service users.

That is my concern and has always been my concern. It has been emphasised that no more money will be made available. It is hard to provide a better service without more money coming in and noone seems to be prepared to accept that. Between one party saying they will ‘try and keep people out of residential homes’ and the other talking about insurance plans to ensure that more people go into homes there is a hotch-potch and neither of the main parties seem to have engaged with the personalisation agenda very much through their arguments about funding, fear of the middle classes who feel resentful about having to pay for services for their parents with their own inheritances and the thought of an actual cost being attached to the provision of quality care.

Self-directed support sounds wonderful and it honestly is wonderful for some people. What seems to have been lost is not that I particularly want to choose the services that other people get – I like the idea of choice and flexibility – but really the idea that some people need a lot of support to plan and develop personalised care and support plans and there has been no account whatsoever taken of the time factors in a team that this means.

We are running pilots at present in our borough and I feel almost resentful at the lack of listening that has been done. There is an assumption that is actually ironic when you think about it that the roll-out of individual budgets is about empowering people and not assuming ‘we know best’ however the manner of the implementation is the same through mental health, learning disabilities, physical disabilities and older adult services.

Some people are actively ignoring the growing pace of the agenda – I’ve tried to embrace it so as to be in a better position to add my voice to those who are shaping the policies. I am trying to be positive and think that some elements are really good – it has just increased my paperwork a thousand-fold.  I know complaining about paperwork is old hat  but the extra man hours haven’t been factored in.

We have an option to ask some local advocacy services to help with self-assessment questionnaires and support planning however, in our service where we do have the opportunity to build up relationships with users and carers over a period, I should see it as some kind of triumph that everyone I work with has preferred me, a face that they know and (hopefully!) trust to assist as opposed to someone else new coming in to do these pieces of work. At least they know I’ll be accountable over the longer period.

And so while trying to be positive, I have a certain amount of annoyance with the implementation. Yes, it’s a good idea. Yes, it sounds wonderful on paper. No, noone has actually listened much to ALL the practitioners who work with different user groups and noone seems to have taken note of the barriers that existed to direct payments as a starting point.

I think it is another means to privatise and decentralise services and to give ‘responsibility’ to the service user as a way of diluting responsibilities of the provider. I hope I am wrong and just a little too cynical for my own good.

I still try to be hopeful for the future though. I still intend to make my voice heard by making positive suggestions as opposed to merely grumbling and griping in the corner.

That’s the ‘right’ thing I do, I’m sure of it. I have no doubt whatsoever that this will be something of a theme for me over the coming months.

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ADASS concerns over Free Home Care

Over the weekend, a few news reports emerged regarding a statement from ADASS (Association of Directors of Adult Social Services) which raised questions about the government’s speedily announced plans for ‘free personal care at home’ and particularly about some of the sums involved.

According to the ADASS survey the true cost of the policy could be a minimum of £1 billion, with the overall cost to local authorities rising to more than twice the £250 million originally calculated by Central Government.
Calling for an urgent meeting with the Department of Health to help clarify these issues, ADASS President Jenny Owen said: “Government assumes that personal care needs can be met through an average package of 6.54 hours of care per week at £15.75 per hour amounting to £103 per week.

“However our research shows that local authorities have estimated a much more expensive average care package for a user with high needs. Information we have received from 61 authorities shows that the average cost of care is about £200 per week.

“Also, the number of existing self-funders in any given area is often unknown, as is the number qualifying as eligible under the Fair Access to Care eligibility criteria.”

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My first reaction to the statement is that if the government truly believe that most ‘critical’ care needs are met through packages of care of 6.54 hours per week, they have some very dodgy figures that they are going on – in my very humble and perhaps limited personal experience.

‘Free’ also sounds so good. Perfect for building an election campaign on. Everyone likes ‘free’. Free however needs money and funding. Free is likely to create far more problems than it solves if all the money is channelled solely to those who are at the very edges of the ‘critical’ band of need.

I was discussing this with a colleague from a neighbouring borough last week at a forum we attended. She commented that she had always been able to manipulate the FACS (Fair Access to Care Services) criteria according to how she determined need as she assessed them and that it can be as flexible as one wants it to be. I can see her point to an extent in that it is fairly easy to interpret the bandings in different ways and something that might be ‘critical’ in the view of one person – could be ‘substantial’ or even ‘moderate’ in the eyes of another.  This will be of vital importance as if it is to be a method of determining whether care is free or not, it will become more tempting to assess upwards those that might completely refuse care if they have to pay for it (who are frequently not the people with the least amount of money, for the record).

I have no problem with ‘free’ but where I feel uncomfortable is that those who are fully able to pay are going to be the more vocal and assertive in demanding the rights to ‘free’ and those who have fewer means will be excluded from lower level services in order to fund the more critical needs of people who are more wealthy.

A critical need is a more immediate difficulty but a moderate need not attended to or managed can become a critical need fairly rapidly. I also fear a system as complex and controversial as the current continuing care system which is as inaccessible and confusing as it is possible to make any kind of system at present.

Continuing Care is currently ‘free’ as it is care provided by the NHS to those whose primary needs are health-based rather than social care-based which to all intents discriminates against older adults and particularly those with dementia (as it is seen as a social care need rather than a health need). The arguments can and do go on.

How the new proposed system will add more expectations of entitlement, we will just have to wait and see. The ‘free’ care will have to come from somewhere. It is likely to be minimal when it is provided. A  few 30 mins visit here and there isn’t enough to meet social care and health needs appropriately in the community.

I also wonder how it will tie in to the push towards Individual Budgets. Will the free care be provided through Individual Budgets? I think it’s going to have to be  – as, before long – all care will be provided through Individual Budgets,  This may increase the level of human hours needed to support and assist which is no problem as far as I’m concerned. I’d love to spend many more hours supporting people putting together individualised care packages however the time taken by the workforce and the costs of staffing have to be taken into account at some point.

Ideally, I’d love to drop the cynicism and embrace the policy with open arms. I am just so sceptical that the electioneering is taking the place of consultation and common sense and the government have just jumped on this issue without an understanding of the implications.

Social Care is an easy target for swift government promises. Helping Vulnerable People is A Good Thing. No thought of where the additional money will come from and rather about what will be lost from the preventative and early invention work to provide free care to those who are very well able to pay for it – can only lead to poor legislation.

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.

Is Care Management Social Work?

How much of social work exists in the Care Management model? It’s a question I’ve been toying with for a fair amount of time – especially as most of my work, post-qualification anyway, has been situated very much within the care management model. Although now, I have a slightly different role within Mental Health services, the domain of care management even within a multi-disciplinary team is seen very much as that of the social worker and the place of both is something I have been considering over the past few weeks.

One of the CPNs in the team I work in (bless her) constantly talks about ‘doing social worker’s jobs for them’ or ‘using social work’ language. She’s a great nurse with very high standards and we get on well, but she doesn’t think much of ‘social work’ in general (individuals notwithstanding!) and certainly not when she feels she is being asked to do this at the expense of therapeutic or clinical work.

My current role does give me more therapeutic leeway, although I am very much a product of the ‘care management system of social work’ as I trained when the NHS and Community Care Act (1990) was already very much entrenched in the systems. People spoke fondly and wistfully of ‘old style social work’ but beyond vague helping notions, it wasn’t something I could necessarily link immediately with the work I was being asked to do. After all, the idea of the new legislation was to be a provider and buyer of services that would give the end user a better quality and variety of care and would allow the care manager to manage on a strength-based model – that’s how it was sold to us when we were studying anyway…

When I was operating in an environment where I was primarily a care manager above and beyond all else, thought I felt that any individuality and professional competencies that I had worked to achieve were being sucked out of me almost before I’d started to work. All ideas of ‘buying services’ was throttled out of my by service level agreements and commissioners dictating which providers could meet the needs of the local authority in terms of pricing.

I was going into people’s houses, judging their needs against dry ‘Fair Access to Care‘ Standards – which were very tightly controlled by commissioning bodies.

stephmcg stephmcg @ flickr

I was then matching those needs against a local authority list of times (I did actually have a physical list) – so 30 mins was allowed for a shower in the morning, 45 mins if breakfast was to be prepared as well – all mechanical, all prescribed. Anything above and beyond that time allowance would have to be justified in triplicate.

Paperwork completed, a few phone calls made and the package was in place.

No real need for any professional competence derived from graduate level study. Not really. Of course, the profession likes to make you think there is, the academics like to make you think there is. But I am confident that any non-qualified community care assistant could do an equal job , if not better job – especially after a few years. When the need for critical appraisal and considerate reflection is lost on a day to day level, the elements that identify the profession seem to fade.

Supervision was a list of what you had done that week/fortnight/month in terms of targets – and what you still had to achieve.

Of course, communication is necessary. You have to talk to people to make them feel better – to help garner information successfully but it’s hardly something that demands a rigorous academic approach and discipline.

This frustrated and continues to frustrate me.

Of course there is more complicated work coming in and there would be some marginal therapeutic work around, in some situations – but it is almost the mechanism that frustrates than the work. The de-skilling seemed to be more or less complete.

It felt like I was bestowing the beneficence of local government funding and for all the academic discussion of strengths-building and relationship-building – you’d likely only see someone a couple of times – to assess and then to review unless there were particular difficulties.

I remember once trying to explain to a woman that I visited why I couldn’t explain what Pension Credits she might be entitled to (I can just about manage Attendance Allowance or Disability Living Allowance – any other benefits remain a blur in my mind) and then, why I didn’t have access to any cash to give her (the social worker who had helped her when she was a foster parent had given her money directly so what kind of a social worker was I if I couldn’t provide cash?).

There was a hope that Direct Payments would go some way to solving this – but direct payments, while extremely liberating for some younger disabled adults, have proved harder to ‘sell’ to older people and those in mental health services.

Namely, they are easier to sell to those who want to be sold to. When there is someone who needs more support in order to start having direct payments – the care manager isn’t, in my experience, given much leeway to have the time to explain, assist and support – well, certainly not in older person’s services where timescales are tight because of targets and turnaround is expected and pressured.

I can proudly say I was relatively successful in pushing direct payments out to older adults – more possibly than most in the team I worked in – because it was something I felt quite passionately about at the time. But even for me, operating in a target-driven system, it took time that I sometimes wasn’t allowed. All very well if the service-user is able to advocate for him or her self, contact the right people to assist with payroll and recruitment or has family around to help, but if they don’t – it’s a time issue for the care manager who is being pushed to targets, targets, targets.

Peter Beresford, writing in the Guardian, reviews a new book called The McDonalidization of Social Work by Donna Dustin. She writes (apparently because I haven’t read the book) of some of the effects of the care management that resulted from the 1990 NHS and Community Care Act.

The era of Personalisation is upon us which is apparently being welcomed as a move away from ‘care management’ and towards ‘individualised personal budgets’. The Care Manager is dead (so to speak) and long live the ‘traditional’ social worker. But I wonder how this accounts for social workers already burnt into the Care Management system who are too young to remember the glorious ‘old style social work’ era. What tools do they have to equip themselves with, years out of college but nested firmly in the bosom of the NHS and Community Care Act.

Social Work needs to reclaim some of the ground for itself in a target-orientated environment. If not, practitioners will become mechanic and complacent. Time needs to be given to workers to actively engage – but I can’t see the time ever being there as long as local authorities have tick-lists of ‘targets’ that need to be followed.

In my previous job we had a target to meet about adult protection investigations. If not enough people needed protection within a quarter, that was another target failed! There is nothing needs-led in the system of targets. It is completely service-led.

And I can’t be convinced by personalisation until I have seen concrete proof of its benefit to older people who are not able to speak or shout loudly about their needs. Within the pilot studies, I’d like to know how people with dementia are going to have their needs met or if personalisation is again, like direct payments, going to be a buzz word about individuals and choice – depending very much on who the individuals are and how much choice they are able to make without professional support.