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!

Statutory Duties and Consultations

Session of the Chamber of Local Authorities

Image via Wikipedia

A blogpost by Vern Pitt  on the Community Care website alerted me to a very quiet consultation that started this week.

According to the post

Quiet as a mouse the Department of Communities and Local Government announced a review of all statutory duties on local authorities today.

There are a good proportion of these duties which fall into the lap of both adults and children’s social services departments.  This is a part of the DCLG process of ‘decentralising’. The central government wants to remove some of these ‘duties’.

Yes, the website does say that essential duties will be protected but there is no indication of what the government thinking is that these essential duties will be. It worries and frightens me though. Not that I’m a fan of bureaucracy but I am greatly in favour of statutory rights and publicly provided rights of citizens who require support to receive it.

Perhaps I’m reading too much into it. Perhaps I have understood. Perhaps I’m just becoming paranoid in relation to the government agenda but it made me gasp audibly when I read through the all the duties of local government that are being put ‘on the table’. I know the document states that it is not a matter of removing these duties but the consultation puts a lot of ways we have been working and are working into the spotlight in an uncomfortable manner.

The framing of the context of this review seems rather sinister and follows the line of central government directives as being the ‘enemy of enterprise’ as the DCLG website states

Local authorities are most effective when they have freedom to innovate and respond to what local people want. We want to reduce radically the demands, burdens and restrictions placed on local authorities by central government.

Some of these demands, burdens and restrictions provide a safety net and a protection to those who aren’t able to engage as fully in the political process as Pickles might like us to.

Just have a look at the duties that are under consultation on the DCLG website. There are two relevant documents but the one I was more interested in was the ‘Review of Statutory Duties – other government departments’ document at the bottom of the page (it is an Excel document – hence my inability to link here).

It covers duties too numerous to list under the Department of Education in relation to Children’s Services and under the Department of Health in relation to Adult Social Care and Mental Health services – though a lot of the duties under Adult Social Care are being considered by a Law Commission which is reviewing Adult Social Care Law in general.

I can see some of these being removed from local authorities so that private companies can step into the gap. The government want to strip local authorities bare and have already taken many steps in that direction.

We need our voices to be heard in this consultation.

We need to protect public delivery of public services.

Another reason I’m going to be marching in London on March 26th.

Eligibility

I have been subject to a complaint which was raised to the local MP. This is not particularly unusual after a period of time working in social services. We are quite used to councillors’ letters and MPs’ letters.. once we even had a letter from the MEP!.

Still, these letters assigned with the portcullis of power still retain a special place in our ‘priority’ box for the day.

It was a mixed feeling when I saw the letter which had been left on my desk by my manager. In some ways, I was cheered as I had suggested to the service user that he should speak to his MP if he was not happy with the service provision or that he should make a formal complaint to the council. He had obviously taken himself off to the MP and raised his issues, which I felt was a great sign of his determination and self-advocacy skills.

My heart sank a little when I read the contents of the letter. He had raised a complaint about me, personally. Of course, that hadn’t been exactly my intent when I explained to him in detail about the scope of eligibility criteria and why he couldn’t receive the services that he felt he needed.

I discussed this with my manager as they have to respond to the director on my behalf – as that was who the letter was addressed to. I had, coincidently, an arranged appointment with the said service user later the same day so fortunately didn’t need to rearrange very much.

I decided not to raise the letter specifically with him but to address some of the content with him. However, he had received a copy himself and he passed it to me to read. I explained that I had seen it and we went through the details. He explained with a grin on his face, that perhaps some of the content might have been miscommunicated and that it was the service rather than the individual that had been the focus of his ire. I didn’t really have much doubt about that as we have a fairly stable relationship built up but it eased my ego somewhat. Not to say there’s anything wrong with people making complaints about me, it’s just the natural self-critical human response kicks in at times.

There were a few things I could action but the meat of the problem was that he felt he needed more services than the local authority had provided according to the criteria and his needs.

I explained this again. We looked at some voluntary services that he has accessed and some that simply don’t exist anymore or have been reduced to place him out of the scope of their bounds.

We’d  been through the Self-Assessment Questionnaire probably in more detail than I had been with anyone else I work with because he actively engaged with the process and had a fairly solid understanding of the linking of answers with money available but I couldn’t see any way to tweak the answers to give a higher band of need that wasn’t there. That isn’t to say that there wasn’t a need and that his life would not be enriched by more services. It would be. This is the sharper end of resource allocation.

The job isn’t all about helping people and making the world a better place. Sometimes it is about trying to defend resource allocation policies at the ‘sharp’ end to the individuals whose lives are changed by a policy decision taken very far away from them.

It made me ponder the role that we play and will increasingly play as these criteria are being tightened further. I read in Community Care yesterday that Birmingham Council is proposing that services will be restricted to critical needs only under the Fair Access to Care Services quoted on the Department of Health website. It’s worth considering them to understand the implications that this will have for expectations of care services in the future.

Critical

These are the most serious and extreme circumstances. There may be a risk to life and/or where even the basic essential tasks cannot be carried out. Personal care, domestic and family life are all at risk. This may be an immediate problem or one very likely to occur without urgent intervention. A number of these factors may exist together.

A case will fall into the critical band when one or more of the following occur:

· Life is, or will be threatened; and/or

· Significant health problems have developed or will develop; and/or

· There is, or will be, little or no choice and control over vital aspects of the immediate environment; and/or

· Serious abuse or neglect has occurred or will occur; and/or

· There is, or will be, an inability to carry out vital personal care or domestic routines; and/or

· Vital involvement in work, education, or learning cannot or will not be sustained; and/or

· Vital social support systems and relationships cannot or will not be sustained; and/or

· Vital family and other social roles and responsibilities cannot or will not be undertaken.

Of course, there is some degree of interpretation involved, as there always is – but for example, ‘substantial’, the next ‘grade’ down refers to abuse and neglect has occured or will occur but to reach the ‘critical’ threshold, it has to be ‘serious’. For me, that triggers a lot of alerts about the nature of the role of personal budgets and the types of support that can be provided.

Services will only be provided to those who have no other means of meeting these roles. I worry that this will lead to a greater burden being placed on family members to continue to provide support until they drop because as long as the functions are being carried out, they can’t be replaced by statutory services. There is no scope for helping someone to do things for themselves and there seems to be little scope for reducing dependency which might happen further down the list of ‘criteria’.

The personalisation ‘dream’ of life-enhancing care packages which allow for more flexible leisure interests to be pursued is even further away than it was a year ago.

This is my fear about the wonderful idea of ‘big society’ that the government promote.  It can ring very hollow for those on whom we rely and for those that do not have the networks, community and families to rally around them. From my angle, I see voluntary services pulling back due to fears of cuts rather than extending out to the people who may benefit but for whom the state will no longer reach out to.

I can see increasing letters of complaint as the perception of what adults might expect from statutory social care is increasingly separated from the reality of provision.

It isn’t helped by the rhetoric of transformative personal budgets which are far reaching. There will be no money to be exceptionally creative anymore. Yes, it is possible to choose carers – quite rightly, but there will only be provision for the very barest life or death needs to be met. None of this ‘going out shopping together’ – that takes too much time. None of this ‘going to the football match’ – that costs too much money.

And so, as I batted off one complaint, probably unsuccessfully, replying via my manager that the work and the package had been provided according to our borough’s eligibility criteria, I have no doubt there will be many more. Indeed, I hope that there are so the people who hold the political power see the effects of the cuts as they are happening. I might recommend MP’s surgeries to more people now.

The Next Steps

The new coalition government published some of the details about their plans for the next five (gulp) years yesterday. I had a brief glance at the issues as they relate to social care in particular.

[picapp align=”none” wrap=”false” link=”term=long+road&iid=286186″ src=”0282/35f40062-1076-4ea0-bc52-70cc19ec1abe.jpg?adImageId=12933483&imageId=286186″ width=”234″ height=”156″ /]

I feel distinctly underwhelmed, I have to say. I’m glad the Tories’ ‘insurance scheme’ has hit a road-block at least. It made no sense at all to me and didn’t really address a lot of the more widespread issues relating to social care funding. The Lib Dems  seems to have dragged them back to the idea of negotiations and discussions.

Negotiations and discussions and commissions. That’s a bit of a drag. Haven’t we been here before? A few times. I know realistically there wasn’t another way forward but it feels like there is constant ploughing over the same paths again and again with more consultation documents about the same things. I wonder if the government really are serious about saving money when they just repeat the same consultations endlessly. At least the document mentioned the Wanless Report (which, incidently, I have a lot of time for). I wonder what difference the consultation will bring from consultations raised over the last few years and it seems like just another chance to delay the decision making even more.

All the other policies presented, apart from the completely unsurprising trashing of the ‘Personal Care at Home Bill’ which to be honest, didn’t make a whole lot of sense to me anyway, are just progressions of the ways things were moving in social care anyway.

As the Secretary of State for Health confirms

Today’s coalition announcement sets out how the Government will push forward reform of social care. The Government will:

• establish an independent commission on the funding of long-term care, to report within a year;

Unsurprising – see above

• break down barriers between health and social care funding to incentivise preventative action;

More preventative action can’t really be argued against. Preventative work has been completely neglected in the face of cost-cutting in the short term and meeting performance indicators. I’ll be keeping a close eye on this one.

• extend the greater roll-out of personal budgets to both older and disabled people  and carers to give more control and purchasing power; and

This was always going to happen regardless of which government was in power.

• increase direct payments to carers and better community-based provision to improve access to respite care.

Nice words – actually there has been a massive increase in respite provisions over the past few years and increasing it can only be a good thing.

The government has also promised to increase and prioritise funding into dementia research which is very positive. I wonder how much funding will be spared the scythe of government cuts in general though.

Burstow has been appointed as the Care Services Minister. He has, I understand, a fairly positive background in speaking up on social care matters. It could have been a lot worse, I guess and we’ll see if he has the power to battle it out with the Chief Secretary to the Treasury in order to secure funds for the department and the sector.

So I remain a little ambivalent. It’s hard to argue against any of the provisions made but where the difference will be made is in the amount of money that can be argued away from the Treasury by the Department of Health in the coming months.

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The Future of Adult Social Work

I am running late for a training course that I haven’t finished the ‘pre-reading’ for yet – due to an unusually busy weekend (for all the good reasons which involve sunshine and basically being outside!).

But I thought it would be remiss not to mention the publication of the the ‘Future of Social Work in Adult Services’ document on Friday.

It’s a short document that clarifies some of the expectations and directions that will likely be taken in social work in the UK, drawing on the definition of Social Work given by the International Federation of Social Workers and then narrowing it down to not only a more UK centric focus but also an adult-centred perspective.

It is a fairly uncontroversial document that balances some of the future direction of the personalisation and transformation agendas – addressing some of the fears about the dilution of ‘social work’ and ‘social workers’ into unqualified posts where some of the expertise is reduced in order to reduce employment costs saying

Giving people control of their own resources and determining how their needs are met is transforming social services. Services are being personalised. Many people will want to organise all their supports and services themselves, based on good information. Others will want help from peers and user and carer led organisations. However, many will want social work to support them when they feel most vulnerable, to manage risks and benefits, and to build their self-esteem and aspirations so that they can take control or make difficult decisions.

This acknowledges the fear of some social workers about being pushed out of the role however I wonder how it tallies with the workload issues and the reassurances that certainly happened in my borough that some of the increased paperwork that is generated by self-directed support will be farmed to smaller advocacy services. It can’t work both ways – either the professional support is offered and time is allowed for it by management – or it is not offered and independent, voluntary sector advocacy services are employed (very well in most circumstances) and ‘social work’ tasks revolve around managing pieces of paper in an office. Not necessarily by a qualified professional.

The report also expands to explore other aspects of social work within specialist and multi-disciplinary teams. I admit to being concerned at a driving focus on community care legislation and directions but that doesn’t seem to be the case. It emphasises that

Social workers also have an important role in working with people whose rights may be undermined through abuse or neglect, or where the law requires some deprivation of liberty. Social workers can assess and manage risk and balance competing rights in order to protect those in need. Social workers make sure that legal action is taken only where necessary, for the shortest time and with the least restriction.

This distinct approach provides an important contribution to multi-disciplinary teams, to support better outcomes. It also complements the contribution of other professions. Social workers in multi-disciplinary teams bring a perspective of the whole person, rather than just their symptoms or circumstances. Seeing the individual in the context of their family, friends and community, and reflecting their hopes and fears for their own future is where social work can bring an important contribution to the work of the team.

The document needed to address social work as it stands within a legislative framework which often (although not exclusively) allows and demands that social workers play a role. For me, the key to my role as a social worker within a multi-disciplinary team is exactly to ensure that the ‘whole person’ is not lost in the background when the consideration of medical concerns are raised although to be fair, in my team, I would say we are very much pulling in the same direction and by no means would I say that the medics, nurses, OTs, psychologists think in any different way – however the training does shift the focus and I think it is a really important that a person who has not come through ‘medical training’ sits at the multi-disciplinary table.

The document also looks towards the future, setting out a few possible roles that will develop over time

Social Work and interpersonal support: With the development of information, advice and advocacy services, support planning and brokerage, there may be new roles for social workers alongside services led by people using services and their families. This may include services for people who fund their own social care.

Social work and safeguarding rights: Social work could have an important role in community development work and promoting social cohesion, for example where disabled, mentally ill or substance misusing people are victims of hate crime.

Social work with families: Social workers already help to break the cycle of families where generations of individuals are trapped in abusive relationships, crime, substance misuse, poor health, unemployment and other factors. Their role in this work could be strengthened to support the current priorities for local authorities to create safe, healthy and prosperous communities

All possibly interesting ways to go and perhaps each will form a post in its own right. All I will say at present from initial, swift reading of the document is that the its interesting (and very positive, in my mind) that social work with families moves into the broader context than simply being placed alongside ‘childrens’ services. Families are about more than that and without ways of working with and alongside adults, there can be no way of proactively protecting children. One of the reasons I always opposed separation and polarisation of ‘childrens’ training and ‘adults’ training – and ‘childrens’ services and ‘adults’ services.

I expect to read and reflect more on the document over the next week and/or months. In the meantime, it generally strikes me as a positive step. I just wonder why it took so long to come out!

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Direct Payments and Continuing Care

We are used to ‘Direct Payments’ in the social care sector. They were introduced in the Direct Payments (Community Care) Act 1997.

While without doubt they are incredibly beneficial and empowering to some service users as they allow the user to receive the money paid for care directly and for that care to then be bought independently – the concerns remain about access to direct payments not being entirely equitable.

The actual direct payments themselves though, where implemented, in my experience,  have had an incredibly positive effect on a large group of people who are able to choose how their own care needs will be met and in particular by employing their own care staff directly rather than relying on council provided care agencies and staff.

image otama at Flickr

There is also a significant government policy shift to broaden and develop the ideas inherent in the ‘direct payment’ system through the introduction of ‘individualised personal budgets’. There is even a proposal to pilot a system of ‘personal budgets for healthcare’ – something I had been a little more detached from without having read too many of the details.

I was interested then to read this story in the Independent.

A case brought by a paralysed former soldier and a woman suffering from a progressive muscular disease who wanted the NHS to provide a direct grant allowing them to live independently by employing their own care staff was dismissed after a judge found that legislation prevented any such payments.

Steven Harrison, 41, who broke his neck in a diving accident in 1998, and Valerie Garnham, 60, who has suffered her condition since birth, were told in October last year that the NHS primary care trusts funding their care at home would no longer be able to do so because of an edict from the Department of Health (DoH).

Steven Harrison and Valerie Garnham had been receiving ‘direct payments’ however their physical health and social care needs had increased to the degree that they now meet the criteria for receiving ‘Continuing Care’ – namely having their care funding from the NHS rather than the local authorities.

So once the band shifts from social care to health care, the entitlement or even the ability to receive direct payments shifts and the carers who have been working with the individuals closely, sometimes for years, have to be dismissed so that support can be funded directly from the NHS.

Mr Harrison, from Wakefield, West Yorkshire, and Mrs Garnham, from Holloway, north London, claimed their human rights were breached by the denial of direct payments and that the legislation governing the health service meant that such funding could already be given legally.

Mrs Garnham said: “I don’t look at myself as a useless cabbage that sits at home and gets withered and wizened. Is my life worth living if I’m going to stay in bed and wait for a local authority nurse to turn up? We were very proud that we actually employed five people.”

Islington Primary Care Trust in north London, which pays for Mrs Garnham’s care, is expected to pay up to three times the amount it paid her in the form of a direct grant to cover the cost of employing a nursing agency to do the same work.

But Mr Justice Silber, ruling in favour of the DoH, said there were no powers under the NHS Act 2006 for direct payments to patients. Lawyers for Mrs Garnham said they planned to appeal.

It makes no logical sense of course, but the law is the law even when it is an ass. I hope the appeal succeeds and imagine, from the perspective of a layman, there is more than a little merit to it. We seem to be moving towards systems of increased individual budgetary control and to steal the money away when a cohesive and individualised plan of care is in place already, seems like a step back many decades.

It seems like a ridiculous position to be maintained even if it needs some quick adjustments to primary legislation just to affect these particular cases.

We know that government policy is aiming to move in this direction in any case and it seems absurd to remove independence forcibly and as well as potentially less costly and better quality care for the individuals receiving it.