Selling the NHS – The Beginning

The National Health Service Norfolk and Norwic...

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Yesterday, while most of the media, fixated self-referentially on the Murdoch hearings and Cameron was flying back into the country,  Lansley began to dismantle the National Health Service.

As The Guardian reports

In the first wave, beginning in April, eight NHS areas – including musculoskeletal services for back pain, adult hearing services in the community, wheelchair services for children, and primary care psychological therapies for adults – will be open for “competition on quality not price”. If successful, the “any qualified provider” policy would from 2013 see non-NHS bodies allowed to deliver more complicated clinical services in maternity and “home chemotherapy”.

So we are led to believe that being open for ‘competition on quality not price’ will act to pat us on the head, reassure us, and direct us back to the ‘big media story’.

It worries me and it worries me for a number of reasons. Lansley’s words are couched in the words of ‘choice’ but I wonder exactly whose ‘choice’ it will be to make these commissioning decisions for which, no doubt, large amounts of money will change hands and profit-making publicly listed and private companies will be able to partake.

I admit to a bias having been exposed and having experience in the adult care sector which was subject to a similar rollout of competition which was supposed to increase choice and quality.

I’ve written many times about the end result and how it is one that has inherently favoured larger providers and companies that have been able to deliver on economies of scale rather than the poetic vision of small scale providers delivering local services. Those small scale providers were quickly priced out of the market and I fear this will happen again.

But wait, I hear, ‘quality not price’ Lansley says.. to which I reply, ‘nonsense’.

Why? Because there will probably be minimum standards of ‘quality’ that a service has to reach and beyond those, it will be a price competition. That’s what is supposed to happen in care – but who checks the standards? who will check the standards? How can we have confidence in a well-resourced and well-delivered service when regulators are so weak.

I do not want any private company to make a profit on my potential need for services for my back pain, my hearing or a child’s wheelchair.

Of course, making the publicly delivered service is clearly both too expensive and veering against the government doctrine of handing the healthcare to private companies.

I am sure the first few providers will intersperse local voluntary organisations with large multinational corporations in their delivery methods. Again, I point to the adult social care sector. We started along the path with the NHS and Community Care Act (1990) having a lot of local providers together with a few Southern Crosses and Care UKs. The local providers were eventually priced out.

Of course in the case of podiatry and hearing services as well as primary care psychological therapies, we can see these as almost discreet services. The ones that will potentially be easy to deliver and it will always be possible to find wonderfully successful outcomes for people choosing Boots rather than the local NHS for their podiatry appointments because it is more convenient. And I’m sure it seems to pave the way for Individual Health Budgets where people  are given the money to ‘spend’ on the services that they need. Choice you see. Choice is what it’s all about.

I turn back and look at what has happened in social care. Choice has been extended in wonderful ways to those with the loudest voices but in some ways those with the highest needs have been left behind. That is my main concern about the introduction of private into public.

For some people, the people in the comfortable middle classes of Chipping Norton, this is fantastic news – they can access their IAPT (or equivalent) by a local provider when they are feeling a bit down. They can have their feet checked in a local branch of Boots instead of having to travel into Oxford. All’s well.

Those will be the areas where both competition and choice are the highest.

My concern is that people who experience the degradation of poverty will have quieter voices and less choice because there may be higher multiples of health difficulties and choice is determined through power. I can’t help but think of people who are restricted in their choice by issues of capacity. Will they be given advocates to assist with the process or will they just be ignored? Will the choice by made by GPs who are courted by these private companies, just as they are currently courted by drugs companies?

How equitable will the ‘new’ system be?

If we are extending choice, we have to extend safeguards and checks.

If we are extending choice, we have to extend quality.

It hasn’t happened in social care – there is no reason to believe or trust that it will happen in healthcare.

It does make me wonder – Are we all in this together? Really? With the impact analysis projects that are carried out to ensure equality, I know there are provisions to look at ability and disability, gender etc but are social class and income level also considered?

And think – Lansley considers putting ‘quality’ in as a concession – he was happy to go ahead with the Bill and with a pure ‘cost’ factor. This is his so-called concession but it is no concession at all if we don’t have a definition of what ‘quality’ is. After all, the CQC – too look at the Health Care regulator – defines ‘quality’ on the basis of paper documents and paper inspections given to them by provider services.

If that doesn’t wave any red flags, I don’t know what will.

This is a government of interests rather than representatives. The shame is that the last government was too and likely all the future ones will be as long as we allow our heads to be turned more quickly by celebrity gossip than the tragedies unfolding in our adult care services.

Waiting for Dilnot

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

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

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

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

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

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

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

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

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

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

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

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

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

Aftermath

It’s been a year since the ‘Baby P’ story broke about Peter Connolly and his tragic death following a litany of appalling abuse by his carers. As he was on the child protection register and known to Haringey Social Services and had contact with primary and secondary health care services, the fallout concentrated on what went wrong with ‘the system’ that is supposed to protect children and how the support could have got things so badly wrong. This, combined with the whipping up of a media frenzy which put social workers in the line of fire, is reflected on in a number of news sources today which look at the impact of that case on the profession today.

The BBC reports on a Local Government Association findings six out of 10 councils in England have reported problems retaining staff – a 50% rise on the year before.

While the six out of ten part doesn’t surprise me, the 50% year on year rise is very significant. Social Work as a profession has felt the pressure of being highlighted as the responsible agency and the government has happily allowed individuals to be hung out to dry and has just responded with wonderful new initiatives for shoring up graduate recruitment and making wild and vague gestures that seem to wish to pander to the tabloid crowd like the appointment of an agony aunt to the Social Work Task Force.

The Guardian takes a more thorough approach looking at some of the causes of the initial difficulties in the first place. Ray Jones, I think, hits on some significant points during his look through the pattern and history of legislation which has affected Childrens Services over the last couple of decades.

I was at school in 1989 so the implications of the Children Act of that year would have floated above my head as I concentrated other matters, I remember the implications of the 2004 legislation and the split of adult and children services in local authorities. I remain to be convinced about the wisdom of that decision however there is no going back. Children’s social services joined with Education and Adults, in our local area anyway, joined with Housing in one of those awkward convenience marriages in which there is little love lost. Jones explains the problems that these liaisons created

At a stroke, the top management competence in child protection and care services was largely lost, with 80% of councils appointing former teachers and education managers as children’s directors. So, whereas the 1989 act led to greater specialisation and competence in the care and protection of children, the 2004 act has undermined the experience and expertise that has been developed. As a result, in too many areas child protection and care services are now in chaos.

Jones sees possibilities and makes his own suggestions for change. Personally, I see it as evidence of a lack of knowledge and understanding of social care on a broader scale in the government both local and national. There is little will to change a social care system to make a significant positive difference as firstly it will be costly and secondly in this ‘blame culture’ era where the poor are targeted by those in government as scapegoats for various policies over the decades, I can’t see a way out without it being fought for.

Patrick Butler, also in the Guardian, pulls together some of the positive aspects of the tumultuous year in social care and the movements towards change and improvement in part due to the spotlight that has been placed on the systems in child protection but he asks the crucial question of why it took one child dying in  one London borough to draw attention to facts that could have been picked up way earlier. As he says

The emails uncovered in the Shoesmith judicial review reveal arse-covering on a grand scale. They suggest an establishment anxious to defend policy at all costs and deflect blame, not one particularly keen to learn – let alone admit it had taken its eye off the ball. The other part of the answer is that no one was really kicking up a fuss.

Anyone who has spent more than a little time in the public sector can probably recognise the self-preservation instinct. I have two stories of two different managers though and for me, it was the difference between staying in a position and leaving it.

In my first post-qualifying job, I got on quite well. It was a pleasant team with helpful colleagues and a good and varied workload – it was hard work though. I got on well with my manager and did what I was told. I saw colleagues though, being targeted by her and I’d verge on the word ‘bullying’. That was a part of the culture of the workplace. I escaped it – I was the most junior member of staff in a large team. I was also an agency member of staff and I did what I was told but I saw some of the more experienced staff suffer – people that I had an enormous amount of respect for. I was worried. I went to a meeting once with one of the more senior managers to try and thrash out a case I was working on. He asked me and my immediate manager to do various tasks and the moment he was out the door, my manager turned to me and asked me to do all the tasks she had been asked to do. Some of which were enormously inappropriate for me – with my level of seniority (i.e. none) and experience (very little).

I left within months.

When I went back to social work a few years later, I took a job another team – again as an agency worker. A couple of weeks in, I made an error. It related purely to agreeing a cost which was far higher than should have been allowed by our service so it wasn’t something that led to significant harm or risk just more cost to the local authority. I realised my error (which had been genuine) and spoke to my manager. She immediately called her manager and took responsibility for it explaining that it was her fault and nothing to do with me as she had not told me what to do.

And 6 years later, I am still in the same authority.

There needs to be support in place and rather than adjustments at the most senior levels – which might well be needed, there also needs to be a much more robust supervision structure from the outset. I know there are attempts to shore this up through the relatively recent supports for newly qualified workers – and quite right they are too – but it is not just a year out of qualifying that additional support is required. This is a profession which constantly teaches the importance of reflection, power and discrimination and yet we see in our own services that the power imbalances can be enormous and discrimination and victimisation can occur.

Hopefully the focus on social work will lead to positive outcomes but it is clear the government cannot be trusted to take the lead on it. I’ve been heartened by the more obvious role that BASW is taking in campaigning and fighting for the profession but it also comes down to each and every social worker remembering that there is a wider picture than the individual and the purpose of social work is much wider than the day to day. We could be a good position to advocate on general social issues but sometimes the work levels are so high that there is no time left to speak up.

My hope is that the last year has created a stronger impetus to create a movement for change in social work that has a wider remit than just social workers  but also shifts across into wider social justice.

Dear Deirdre

Dear Deirdre

I suppose you are making an effort with your survey on the Sun website asking readers to tell you all that is wrong with social work.

Personally though, I find it insulting that you were given a place on the Social Work Taskforce that is to report on changes and improvements to be made to Social Work. Although apparently more front line workers are being included, unfortunately, Deirdre remains.  And no, justifying her position because of a Sun petition is not a defence, it is even more of an insult. Let’s put this simply – I say this for the following reasons:-

The Sun organised a campaign which included false reporting of social work – victimised individual social workers and questioned the mental health of a social worker. Now, they are claiming ‘victory’ in successfully causing the dismissal of a social worker and social work managers. Fine with the managers, but honestly if I live and work in a country where red top journalism and over-hyped dishonest media campaigns can lead to dismissal rather than incompetence in the workplace then it isn’t doing very much for morale – don’t you think?

What experience do you have of social work? Seriously. What knowledge beyond what your colleagues report? Where has there been any will to engage –  I see you pulled out of the Community Care Live event? Can’t take the heat, eh, Deirdre?

Fine, if the taskforce wants a media representative – there are many worthy journalists from Community Care or The Guardian who have consistently shown a knowledge and appreciation of the wider issues within social work but AN AGONY AUNT FROM THE SUN??? Who on earth is going to take Social Work seriously if they think that newspaper agony columns offer some kind of expertise in social work?

I don’t want to be trialled and judged by media – I want to do my job well and effectively and be supported by professional organisations and relevant government departments – not held up to some kind of media trial that you seem to be creating by surveys.

If the task force was REALLY interested in views it would have made the meetings for social workers actually more accessible rather than bunching them in with a few days notice and filling up within hours. I desperately wanted to attend one of the feed back days but my only possibility in London was about a week after I found out that they existed because the other date filled up within a day. Hardly feasible for the front-line workers who, you know, have work to do..

Well, I’ve made my views clear but lets try and get to Deirdre’s ‘survey’ and give her some of the opinions she so  obviously wants from Sun readers.

For the record, Deirdre, your first question on that survey, you know where you get one answer and have to say if you have ever had contact with a social worker or you are a social worker.. you know, sweets, those two things aren’t mutually exclusive.

I am a social worker. My foster child has a social worker, myself and my partner have a supervising social worker, my father who is, himself, elderly (sorry Dad, I know you are reading this!) has a social worker. So what on earth made you think that no social worker can possibly actually USE the services of social workers for your oh-so-helpful survey.

Bleh.  Oh well, I guess it makes a change not to see the pressing issues of infidelities or what to do if you’ve impregnated your next door neighbour’s daughter on your problem page (although I suspect that’s only in the online edition).

image gene hunt at Flickr

Go and fill it out though, guys, and let her know exactly what we think.

Oh and Deirdre, if you do ever find your way here, I’d love to hear your defence.

Wow, I sometimes have grumps but don’t often have a full-on rant. Sometimes it feels quite good.

Working the Media

Community Care are running a campaign ‘Stand up Now for Social Work’ which aims to highlight both the good and the bad in reporting of social work. It’s a fascinating campaign and a positive one and also, as we can see by recent news stories, one that is desperately needed.

Indeed, the magazine which is a mainstay for UK social workers, has set up a blog specifically to cover the campaign and media issues as they relate to social work called The Monitor.

image ernst moeksis @ flickr

A couple of posts there have caught my eye specifically over the past couple of days. Firstly a piece about social workers not being so wary of journalists and the importance cross-pollination of positive news stories relating to social work and social care as well as a need for a more realistic knowledge of social work by some sections of the media.

Perhaps it is easy to put the barriers up when you see some of the coverage that exists and some of the generalised hatred that seems to exist for the social work profession as a whole. I wonder if it is something that is relatively unique to Britain and the red-tops/Daily Mail style of reporting that seems to find anything connected to government somehow evil and controlling and fails to appreciate some of the actual day to day work that happens.

I have no wish to be ‘appreciated’ to be honest. Of course, on an individual level it is rather nice but as a profession it is wholly unrealistic.

As for speaking to journalists, apart from contractual restrictions, it is as much as matter of time!

Another post from the blog titled ‘Ten reasons why Social Workers must speak to the media’ provides exactly that.

Rather than re-listing all the points, I’d recommend reading the post as it provides some pertinent posts that almost made me want to go out and collar a journalist or two.

Until I considered that the new forms of the media are allowing us.. and me.. to have a distinct voice without the need for a conduit. I won’t have the readership of the Times or Telegraph but I do have the ownership.

Community Care reports that Behan, the ‘government’s social care chief’ (really? I’d never heard of him.. I didn’t know the government had one!) has called for

directors and social workers to stand up for themselves and stop “playing victims” in the face of public criticism.

and he goes on to say

“How much have you been doing to get stories into the Guardian and Community Care on adult care?” he asked delegates yesterday at the Association of Directors of Adult’s Social Services spring seminar .

But I humbly suggest  he’s got things wrong. We don’t really need to target The Guardian and Community Care because those news sources are naturally sympathetic. We should be focussing on the Mail, the Sun and television news and drama as well.

Not least, now we are living in an age where anyone can publish a blog, record a podcast and build an audience, albeit a small, niche audience. It might not change the world today, but it’s the way we are moving and social work needs to embrace more fully the possibilities of web-publishing, social networking and moving away from a mainstream media if the mainstream media shows little interest.

The stories are there – we just need to promote them and through it a greater understanding what what ‘social work’ actually is and does.

Miscellany

Something of a hotch-potch of a post today – I hope I can be forgiven a little stream of consciousness relating to some thoughts and stories that have caught my attention.

Simeon Brody at Mad World points out a rather narrow-minded article in the New York Times which questions the value of programmes that aim to reduce stigma relating to mental illness.

The Guardian publish an interview with the head of the Social Work Taskforce, Moira Gibb. A couple of points that jumped out at me were that the entire conversation focussed solely on children and families social work – I wonder if there is a general perception that no other kind of social work exists – if anything that is my fear relating to the task force.

As the questions are asked about standards of child protection and the focus remains on vacancy rates within children and families teams, the work that takes place within the adults’ services and the needs of vulnerable adults will be forgotten.

Another interesting point from the interview I thought, when Gibb, the Chief Executive of Camden Council was asked

‘Could the Baby P case have happened in her highly successful borough of Camden?’

Well, there’s a journalist that might have done a bit better research and asked her directly about Rhys Biggs.

I think I’m in rather a contrary mood at the moment, if it doesn’t tell.

I have many thoughts at the moment about seeing social services from the other side, as a new foster carer – it’s amazing how it flavours your experiences and although I am loathe to say it, three weeks into our very first placement, I’m yet to speak to or see the social worker who has apparently been allocated to work with us.

I say that with the full knowledge of the pressures, workload and harrassment that is involved in working in this field.  I am, have and do try to be as sympathetic as it is possible to be. It’s a fascinating place to be from the outside. I’ve had a lot of general thoughts about the experience of fostering but have made a general decision not to write about it here however in the context of being a ‘client’ of social work and social services, it is an eye-opener. I try and get on with things as I can but it’s hard to even be overly sympathetic when calls aren’t returned, emailed aren’t answered and the only time any kind of movement seems to happen is by direct and bolshy telephone calls to managers.

It does, however, provide me with a lot of further sensitivity of how it feels to deal with social services ‘from the other side’.

And today, the Chancellor of the Exchequer announces his budget . Among much reporting of financial doom and gloom, Carers UK are holding a protest march in London and Edinburgh to draw attention to the poor financial support for carers – and quite rightly too, in my opinion.

Age Concern are drawing attention to the needs of older people and urging the Chancellor not to forget them and Action for Children are calling for the young not to be forgotten!

Finally, MIND announced their shortlists for Journalist of the Year and Champion of the Year – certainly some interesting names there!

Hopefully back to something a little more coherent tomorrow!

What is needed?

Ray Jones, Professor of Social Work at Kingston University, has written a piece in the Guardian’s Joe Public blog analysing what he feels is needed within Social Work.

He is far more knowledgeable and eloquent than I and I have to say, I found myself nodding away as I read the piece.

Rather than quote blocks of text and just intermittently writing ‘yes’ or ‘I agree’ or ‘good point’, I’ll let you go over there, read and decide!

Much more helpful than the ‘grass roots’ demonstration organised on Facebook that call for the sacking of ‘everyone who had anything to do with ‘Baby P” that took place in Central London yesterday.

I heard one of the organisers speaking on the radio and she seemed to want ‘action’. She wants a public enquiry.  She wants everyone sacked – without pay. She wants more action on sentencing (too lax) and child protection (too incompetent).

News has become a mawkish interest in the more gruesome details of the abuse that took place. The Facebook group in question has a diagram with the injuries that were inflicted on this child. Is that really necessary, I have to ask myself.

Nothing can take away the tragedy of the death of a child – yes, things weren’t done that should have been done, yes, lessons do need to be learnt. There were failings in a system. Will this ‘never happen again’? Unlikely.

People (including the MP of a neighbouring constituency) demonstrating on the streets to change child protection procedures and calling for the sacking of ‘everyone’ including front line workers.  I’m staggered.

And you know, for another reason, I’m REALLY glad I don’t work in Haringey.  Good luck to them in finding and keeping a decent workforce.

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