Looking back and looking forward

I haven’t posted much here over the last year and most of my posts have been about looking back rather than looking forward. 2013 was an important year for me in a lot of ways. By moving out of a social work job, I’ve developed new layers of understanding about what social work is and what it means to me, and to us all to have strong and value-based social work practice in society. Also, despite having worked in an NHS team for years, by moving out, I’ve learnt a lot more about this messy, wonderful healthcare system that we have in this country. It’s something to be thankful for as a concept but we can’t shy away from being critical at the details where necessary. Criticism can come from people who have broader political agendas but sometimes it comes from people who have been damaged by poor care and treatment and sometimes it comes from people who want to be ‘critical friends’ and we shouldn’t confuse the motives for criticism. Sometimes those who love us the most can be the harshest critics – not because we want to destroy but because we want to improve – for ourselves, our families and for those who have the quieter voices and aren’t able to raise them. Sometimes.

I worked in the same geographical area for ten years – the same local authority, the NHS Trust which covered the same area. As my focus became broader and I saw, up close, how things operate in other local authorities and in other NHS Trusts, I have come to realise how narrowly I focused on extrapolating the general from the particular. My main theme of 2013 has been one of learning and really, that’s an incredible opportunity. To me, there is no greater privilege and opportunity than to learn.

For 2014 I have a further opportunity to learn and to use the learning I have gained to good effect. I want to focus and share some of my thoughts on the year ahead how I got to where I am now.

Power

Everyone working in health and social care has power. Everyone. Because we see and work with people who have vulnerabilities at the stages of their lives when they need to use the services which are provided. A dentist can see the most confident politician shifting into a blubbering mass of fear at the sight of their drill. A care worker on minimum wage, not being paid for travel time, can have the measure of someone’s entire day, week, month in their hands with rough handling, a harsh word, or worse. Sometimes when we feel we are ‘on the frontline’ we forget about the power we have. I’m definitely guilty of that. I think back to my previous job and how we used to grumble and moan about ‘managers’ never listening to us – while forgetting the immensity of the powers over people’s lives that we held in our hands.  We can fall into the trap (and I’ve done it myself so this isn’t me intending to preach) of thinking we are powerless in organisations when we have enormous power in our own hands.

Now I’m in a position where the power I have is more explicit. I’ve never been entirely comfortable with the thought of having power. I laugh it off sometimes, because honestly, sometimes it scares me. When I stop to acknowledge it, I have to deal with it. I have to use it well and I have to use it to improve services and advocate better for people who use them. This year, I’ve found myself in rooms with ‘important’ people and often thought “what on earth am I doing here?”, “why would anyone be interested in what I have to say” and no one else (to my face, anyway) seems to be thinking it. So I’ve had to grapple with my own change in ‘status’ although the more I think, the more I see the power I had before but never acknowledged as fully. If I don’t feel comfortable with it, that’s my problem and if I don’t realise it, I’m not using it to its best. So this year has been a year for me to get to grips with it. I still need to work on my self-confidence and not running out of meetings, into the bathroom to look in the mirror and wonder if I’m still the same person that they all seem to see and treat with respect, and listen to with interest. I know I need to work on that but I’m coming round to it.

Constructive Criticism

This year I started a creative writing class which runs weekly. I don’t really see myself as a budding novelist. I’ve had that dream sometimes but I think if it was going to happen it would happen by now. We are a disparate group of people who have different jobs and move in different circles and are different generations. Each week, we write one (or more) pieces and then bring them back to the class where we critique each others’ work. It’s taught me an interesting and useful lesson about constructive criticism. Sometimes when you write sometimes, particularly if it has an autobiographical tilt to it, then you can be very sensitive to criticism. One of the first weeks, someone in my creative writing class wrote a story about the death of her son. I was asked to provide constructive criticism. It was very hard. It wasn’t the most beautifully written piece but the rawness and  heart in it together with the honesty was something I will never forget. It reminded me of some of the ways we react to criticism and how we can be constructive in our criticism of services without tearing them down or destroying the people who you are criticising. Being a social worker, I’m used to press criticism. My view was always that we should worry less about what right wing commentariat and government ministers say and get our own act together to develop more professional self-confidence and that will batten back some of the foul and most unfair criticism. People will never love social workers as long as social workers whine about not being respected or mutter about press conspiracies against them. People don’t know and understand what we do and often see the ‘iron fist’ of state functions as the ‘velvet glove’ of tirelessly working alongside people to get to grips with systems isn’t as interesting a story.

Now we see more entrenched criticisms of other professions in the health and social care sectors – GPs, A&E, mental health services, nurses. I hope they learn from us as social workers. We can and should never, ever defend poor practice for a start. It shows no credit to anyone. We should accept there are people out there who share our professional background who might not be committed to the same values that 90+% of us share. If we defend them BECAUSE they are social workers, doctors, nurses – we do everyone a disservice. We have to prove and show how the good works and not allow the bad to define it. But that means we have to condemn the bad too, alongside the press. We have to learn the skills of constructive criticism of organisations that we love. We have to teach the public about the role we have so it doesn’t become defined by a press with an agenda – especially as we move into the election period. We have more channels now to share what we do and how we do it – we can take advantage of that.

Change management

I’m probably not the one to harp on about ‘change management’ as I’ve never had to manage anyone else – but the coming year is going to be a significant one for me in terms of changes and mostly managing my own changes.  These changes will come through work and out of work. I’m about to move house and leave an area I’ve been living in for many many years. Both these things terrify me. Although I can come across (to people who know me) as quite laid back – I’m actually terrified of uncertainty. I will deal with it. I always have and will continue to because we can’t and wouldn’t want to construct lives in tiers of certainty I guess. Keeps me on my toes. How I deal with change will very much define my year though. I am not the only one – again, this is common in the sector I work in. We might not all be moving house, but we all have to deal with endless reconfigurations, rewriting of roles, adjustments of responsibilities. I joke that I have got good at it but that doesn’t make the underlying anxieties disappear.

Then I think it’s a microcosm of life. We all have to deal with unexpected changes and being asked to deal with things we never realised we had it in ourselves to do – a weird analogy with death. I remember when my dad was very unwell and near to death. His health went up and down like a yo-yo and there were many times when we thought he was close to death and then, he managed to continue on, despite all the odds. I often had thoughts about wondering how on earth I could imagine a world where he was dead. I tried to imagine it in my head sometimes and found it too difficult. He had always been there. I knew, obviously, he wouldn’t always be, but I couldn’t understand how I would continue to manage in a world where I couldn’t pop round to my dad’s or where he wouldn’t be on the end of the phone when I needed to talk to him. Of course, he died. And I went on. It’s a kind of ‘change management’ isn’t it? I didn’t know how I would do it, but I have, and I do continue in the world where I can’t pop round and where I have photos to replace the reality. So it is with other kinds of changes – sometimes we can’t imagine it beforehand but we deal with things because we don’t have any choice and we deal with it well, because we have to – we are human and resilient. In some ways, my experiences of bereavement as much as reconfigurations at work – prepare me to change. I don’t know what it’ll be like, but I’ll deal with it because I have to.

Hope

This possibly isn’t apparent to too many people, even those who know me quite well but I’ve probably lost a lot of my hope this year for various reasons. I have become more cynical and developed a more pervasive and lingering sense of despair about where services that I love and have been a part of over many years have gone or are going. I have to force myself to believe more now and I worry that I have lost hope. This is an area I am going to actively rather than passively focus on for the next year. I need hope and I miss hope. Yes, the financial situation has been dire and local authorities, NHS Trusts, voluntary sector organisations and central government are all strapped for cash and this is having a real impact on people but there are genuinely decent people doing fantastic work in all these sectors. Money is important and I can’t forgive some of the funding and political decisions made but on a micro level, we can all improve lives and experiences for individuals and that’s what I need to focus on more. Sometimes I forget.

2014 is going to be an interesting year, for sure, and my wish is that we all have a chance to realise how we can make a difference and recapture hope –even on a small level  – but preferably on a much larger one – and what we can each do with the power we  have to make these sectors whom people rely on, much better for 2014 and many years beyond.

Happy New Year

CQC and Southern Cross – a retrospective

I’ve bemoaned both the changes in the CQC and the financial troubles of Southern Cross over the last few years since I started writing this blog.

For today, a bit of a ‘lazy post’ – I thought I’d collate all the posts that I’d made on those two subjects. It provides a little bit of context and stops me repeating myself.

Southern Cross

Trouble at Southern Cross (2/7/2008)

Active Care – Another Tale of Southern Cross? (16/8/2008  – READ THE COMMENTS!

Alton Centre, Active Care and Southern Cross – An Update (5/9/2008)

Southern Cross and Hillingdon (19/12//2008)

Frozen Reading (12/2/2009)

8 deaths – 10 days (26/2/2009) – oh the irony when I comment that Southern Cross own a lot of real estate.

The concerns and worries about the financial management of Southern Cross go back a long way. This is not ‘new’ news. The ‘new’ news is that the company is now close to the brink of collapse. There is almost an inevitability in this as those who sought to make a quick buck in the care sector realise that sometimes the figures don’t add up. Property doesn’t always pay. But making money on the back of what was a public monopoly (provision of care services) can lead to some rich pickings until some of that money needs to be spent. Corners are cut. Staff costs are cut. Older people are warehoused in increasingly larger residential and nursing homes while the roll-out of the so-called personalisation agenda rings very very hollow at the moment for those who are the most dependent and those who need long term care. Where this the personalisation within residential and nursing care services? Where are the small group homes with support for older adults with dementia? They don’t exist because they wouldn’t make a profit.

That is what those involved with personalisation need to address. Not how people who have capacity and ability to manage personal budgets or have families to help them will manage but how will personal budgets (health and social care) and personalisation help and create better systems for older adults in dementia nursing care. Give me an answer to these questions and I’ll have more faith.

CQC – Care Quality Commission

From the first day the CQC came into ‘being’

DoLs, IMHAs and the CQC (1/4/2009)  – these were all introduced on the same day. Do look at the quote from Barbara Young, the first Chair of the CQC. VERY telling.

Britain’s Homecare Scandal (10/4/2009) – another Panorama investigation.

Inspections (3/12/2009)

Can Gerry Robinson Fix Dementia Care Homes? (8/12/2009) – another TV programme.

Linford Park Nursing Home (3/8/2010)

Closing Care Homes (30/9/2010)

Lessons from the Care Sector (26/10/2010)

Trouble at the CQC (3/11/2010)

Johann Hari’s Manifesto for Change in Care Homes (26/1/2011) – one of which was ‘proper inspections’.

Scrutiny, CQC and ADASS (15/2/2011)

Excellence Ratings for Care Homes (1/3/2011)

Inspections and the CQC (11/3/2011)

Whistleblowing (7/4/2011)

Which Care? What Care? (19/4/2011)

Care Home Crises (16/5/2011)

So is this surprising? I wish it were.  I want to emphasise though that it is the management of the CQC that I feel is badly serving those who need support and care rather than the individual inspectors who I know have as many criticisms of the system as the rest of us do. How did this, or the last government allow regulation so toothless just as they are ratcheting up the OFSTED inspections? Does it say anything about how we, as a society, want to value or hide away adults with disabilities?  I suspect it does.

The State of Healthcare and Adult Social Care in England – a brief glance and thoughts

Yesterday the CQC published their report ‘The State of Healthcare and Adult Social Care in England’.

I have to try and put my criticisms of the CQC and their increasingly lax regulatory process to one side, although I couldn’t help a snigger when they claimed in their statement on the front page of the report to ‘Act swiftly to eliminate poor quality care’. Not exactly my experience when they rely on members of the public to actually alert them to poor quality care rather than carry out their own random and regular ‘on the ground’ inspections but it is the only report we have and there are some useful pointers in it.

The CQC inspection remit is very broad and obviously the quality of their inspections vary.  This report relates specifically to the 2009/10 year.

The report covers four distinct areas – safe care, choice and control, person-centred services and standards of care. All the areas are very broad in their scope.

In summarising the report, I’ll look at it in those same areas and highlight some of the issues that arise.  I will also focus on the areas in which I have a particular interest – namely adult social care and mental  health but there are lots of pointers and lessons for healthcare outside this remit – I just don’t have time to comment on them all!

Safe Care

This covers physical safety such as safety from infection risks as well as safety from neglect and abuse.

The first ‘headline figure’ that the CQC lauds is that 80% of care homes met ‘safe working practice standards’. It does make you wonder about the other 20% though and add this to the fact that this is a self-reporting standard.  Those care homes which met the ‘medication’ standard were 72% for older adults compared to 79% for adults under 65. I wonder what the variation would tell us about the different ways of management and attitudes towards older adults.

In the ‘maintaining dignity and care’ standard which includes responses by local authorities to safeguarding alerts, there was a growth in ‘better’ outcomes as there was an increase in local authorities performing ‘well’ as opposed to adequately (from 89 to 113). There were still 3 LAs performing poorly though on this fundamental duty. Unfortunately they aren’t named.

Safeguarding alerts increased over a third to 103,030 nationally across all client groups but the largest part of these referrals came in relation to older adults. No surprise there. No surprise at the increase either if you’ve been working in adult social care. We’ve noticed a real tightening up of the procedures and ways that we report and investigation abuse allegations.  There was though a significant increase in the reports relating to adults with mental  health problems (up 34% – same as older adults).

CMHTs

There was a fairly low response rate for users of Community Mental Health Team services (17,000 patients in all).  Only a third were asked about physical health needs over the last year. I suppose I have a slightly different attitude as in an older adult’s CMHT we have a lot more interplay between physical and mental health so it’s something that might be more obvious for us to discuss.

Surprisingly only 56% of users had an out of hours telephone number to use.

MHA detentions

There was a large increase in detentions under the Mental Health Act over the last year and the CQC report that only 21% of wards visited met the Royal College of Psychiatrists recommended 85% occupancy rate.  29% were over-occupied and 7% had a 125% occupancy rate.  I’m not surprised by this. My own experience is that wards are closing at a fairly rapid rate and have been over the last couple of years. They cost a lot of money. This will get far worse and it is worth holding Trusts to account over this. I hope the CQC does this.

Choice and Control

This banner is about increased knowledge for users about options available to them as well as greater use of personal budgets to choose care needs and use of advocacy services as well to promote choice.

The number of residential care home places fell but the numbers of nursing home places rose nationally and particularly there has been a growth in provision of places for people with dementia. This is patchy at best across the country with the highest proportion of additional beds in the North East and the lowest in the South West.

I was concerned that the base figures of people on personal budgets was the indicator of how ‘good’ a council was at providing choice. My experience of implementing personal budgets is that all too often it seems like an empty ‘paper exercise’ in upping the councils’ figures for surveys such as this rather than a real and concerted change in mentality towards providing choice to those who require additional professional support to seize more ‘creative’ outcomes.

According to the report, which remember is dated 2009/10, only 3 councils are proposing to increase their eligibility criteria for services this coming year from substantial to critical and one was planning on reducing the eligibility criteria from substantial to moderate. I find that really hard to believe but figures are figures.

In relation to mental health service users, 48% of users said they definitely understood what was in their care plan. That’s a fairly shoddy figure!  And 53% felt that their views had definitely been taken into account when putting together care plans. Perhaps we can see some of the potential difficulties for self-directed support in mental  health arena when these figures are already so low but it is important to note that the low response rate of users is possibily another variant.

Regarding medication and information about medication 29% of respondents said they were not told about the side effects of medications that they were on.

Regarding inpatients both those detained under the Mental Health Act and those ‘voluntary’ patients, the CQC identified that the hospitals had been increasingly focused on security and ‘rules’ and that, more worryingly, more ‘voluntary’ patients were being held on locked wards and potentially were being deprived of their liberty.  The report mentions that they were held neither under the Mental Health Act nor the Deprivation of Liberty Safeguards but the use of the Deprivation of Liberty Safeguards in psychiatric hospitals is generally not done. It may and should lead to a greater number of patients detained under the Mental Health Act for their own protection. I wonder if there will be any affect on numbers from this report.

Person-centred Services

A couple of interesting trends to pick up in this section which will no doubt, be a sign for the future. Firstly that less people as a whole accessed community care services – a fall by 4.7% from the previous year (that’s 83,930 fewer people). The report suggests that in the face of research showing an ageing population, it could be due to increasingly stringent application of criteria for assistance. Add this to the fact that people who benefited from help from grant-funded organisations (often those people who fall short of meeting the council ‘criteria’) also fell, there is a potential for a large unrecorded unmet need to be ‘falling through the gaps’ in service provision between the statutory and the third sectors.

Generally though there was satisfaction with the way that assessments were picked up and the involvement that people had in planning services.

The provision of telecare has grown over the last year, again, unsurprisingly – and I expect it will grow for many years to come and technology and care overlap in  more creative ways.

Demand for the provision of ‘extra-care’ sheltered housing – which is sheltered housing with additional care services attached – was growing, sometimes beyond the provision of some local authorities. I see this as a potentially massive growth area and am often frustrated by a lack of provisioning particularly for those with mental health as well as physical  health needs. If I were to be able to approach our commissioners with any one piece of information it would be that.

Worryingly only a quarter of councils demonstrated a strength in supporting people with complex needs and only seven displayed a strength in specialist services.

Regarding services for carers, there has been a large increase in carers taking up direct payments. This reflects my own personal experience as I have done a lot more carers direct payments this year and this amount grows every year however,  the report worrying raises issues regarding money which was provided to improve the outcome for carers and was not ring-fenced and wonders aloud where this money might have gone. Sign of the times with the elimination of ring-fenced funding.

Standards of Care and Support

It’s interesting that the CQC explain how they judge that a care service is of a good quality or not. Their ‘evidence base’ is interviews of providers and users of services, information given to the CQC by the service, surveys given to staff, users and professionals (I have only once ever received such a survey),  a key inspection (how often? Announced? I know a lot of services that haven’t been inspected for over a year), and information held about the history of a service.

My scepticism shines through because some services can ‘game’ the systems by having all the information required by the CQC written up perfectly but how they perform on simple human care levels differs enormously. I strongly believe that frequently (at least twice-yearly) unannounced thorough inspections are the way to truly judge quality.

Unsurprisingly the highest quantity of top level ‘excellent’ services were provided by the voluntary sector and the local authority. Private providers lagged behind. A sign of the times, perhaps as the government pushes the purchaser/provider split into the health service. Look to the care sector and be warned.  Today it’s the care homes for your parents and grandparents. Tomorrow it will be your hospital services for you and your children. Perhaps then, we as a society, will care more.

Smaller care homes were more likely to be judged highly than larger care homes.  Care homes for younger adults were more likely to be judged highly than care homes for older adults. No surprises here. But anger, a lot of anger. It’s about money, of course and there is less money available for the provision of care for older adults on a per capita basis. So larger homes and poorer quality care is the message given to providers.

The problem as well is the way that ‘good’ and ‘excellent’ are defined by the CQC as well though. I know poor ‘good’ homes and great ‘adequate’ homes. That was always the failing of the ‘star’ system but worse, to have no system at all and out of date ‘stars’ still on the website to give  a wholly inaccurate view of what the level of care is like at any given home. The CQC should be ashamed of the way they have destroyed robust and transparent  regulation and the previous government should be ashamed of how they allowed this to happen.

Finally and perhaps one of the most telling figures to take from the entire report is the one in the final sentence of the last page.

Only 16% of councils demonstrated low absence and vacancy rates and high recruitment and retention rates, which confirmed staffing issues continued to be an issue for 2009/10.

We can only imagine what the effect will be on these figures for 2010/11.

Or 2011/12.

The use of these reports is that it brings to life the importance work that is done in local authorities and the effect that good quality support and provision has on peoples’ lives. Yes, of course service provision is essential and too frequently, commissioners are detached to an infinite level so they have little idea about what is needed ‘on the ground’ but often to, it is the human contact, the ‘being listened to’ and having views acknowledged that also makes a difference and that is dependent on quality staffing, quality training and having the time to spend with people.

My own experience in a pushed, under-staffed team is that I am spending less time instead of more time with people as I chase from emergency to emergency and the outcomes for those people who would otherwise had more intensive face to face contact is falling. This leads to sharper deteriorations, more likely readmissions or admissions to hospital that could have been prevented and eventually higher costs.

But with councils and NHS Trusts looking towards the immediate cost cutting of the next year and not at the longer term costs in 5, 10 years, this is the way we will go.

We shouldn’t be satisfied with delivering lower quality care. We aren’t. We need to speak up and speak loud and build links actively with user groups and carer groups and other professional groups to ensure that the government never forgot whom exactly they are betraying and to remind them over and over again that we aren’t going away.

Excellence Ratings for Care Homes

Yesterday, the government announced the unveiling of a new ‘gold standard’ or excellence rating for care homes. This is supposed to address some of the poor care that is delivered through local authority funded care.

I have my doubts. Not that I’m one to be necessarily cynical. But this time I am.

There are a number of reasons for my cynicism.

I believe the problem of poor care standards in residential and nursing care could be much more easily resolved than by a further level of ‘tick boxes’. All it needs, in  my massively oversimplified world, is more spot checks and random inspections – weekend and week day – day and night.

If a care home is doing its job and providing good care with adequate staffing, there should be no problem in well-informed inspectors and lay visitors popping in at any point and being able to speak to any resident or family member.

But this is too simple for the government.

The gold standard of excellence that they are introducing will be funded by the care homes and thus by possibly increased fees as these costs will filter down of course.

They will provide a new set of ‘tick boxes’ for homes to complete.

The Independent explains what the new system will involve

What will be rated?

* What may be included in the new excellence ratings

* Ratio of staff to residents

* Turnover of staff

* Activity programmes for residents and evidence that they are taking place

* All staff to be registered with the new Health and Care Workers Professions Council

* Minimum qualifications for staff

* Spot inspections and independent feedback from residents and their families.

Firstly, it’s important to note that these are issues that ‘may’ be included. Secondly, I thought that some of these issues were already a part of the inspection programme.  And if they aren’t they should be checked for ALL care homes – not just the ones that pay more to be part of the excellence scheme.

Basically, this ‘new’ system is a way of the government trying to add another layer of cost to what the CQC (Care Quality Commission – who are SUPPOSED to be regulating care homes)  should always have been doing.

The CQC claim that the new system will be owned by the CQC but administered ‘under licence’. Why under licence? Because it allows private companies to get their teeth in and allows more money to flow in. The CQC has proved that it is spineless, toothless and unfit for purpose.

The press release goes on to say

Chief executive Cynthia Bower said: “CQC’s role is to identify and react to signs that people may be at risk of receiving poor care. This means we can say we don’t see signs of risk at a provider, but this is not the same as saying a provider is offering ‘excellent’ care.

I say she’s plain wrong. The CQC does not identify poor care. They may react but they don’t identify. It is like pulling teeth from a dog to actually report poor care to them and the thought that they might actually, you know, physically walk into a care home and check the standards is living in a fantasy land where a community and country actually pay attention to the quality of care in residential homes. It should be a role of the CQC to define and award ‘excellence’ in care as a part of the current registration regime but under this new system, this role will be tendered out, at a price, of course – because, after all, what isn’t for sale in this country now – to private providers to ‘check’ and do the job the CQC should always have been doing –  but only for those who pay for it.

I don’t understand why the ‘star’ system was abolished (as it was last year) only to introduce another system at a higher cost. Why not judge ALL homes on this excellence standard rather than attach a higher cost to those homes that wish to ‘register’.

It all seems like a complete smokescreen to hide the toothlessness of the CQC (Care Quality Commission) and a way to garner more money from the independent and private care providers to pay for an inspection system that is not fit for purpose anymore.

Does no-one else see this? I’m amazed the government have the gall to get away with announcing this as if it is something new.

If they or anyone REALLY wanted to improve the quality of ALL people in residential care, they would fatten the CQC up with more inspectors and give the inspectors more leeway to inspect.

One of the worries of mine was also mentioned in the Independent namely that

At Christmas, the Care Quality Commission (CQC) carried out spot inspections of 234 health and social-care institutions, including nursing homes, which revealed significant lapses in standards in more than a third of cases. Ten reviews resulted in the highest form of censure, which could to lead to the commission withdrawing licences to operate.

After one review, a nursing home in Luton – run by Southern Cross, Britain’s largest care-home provider – was closed immediately because conditions were so bad. The commission found that 26 other institutions were not meeting required standards in all areas and ordered improvements.

So surely more and better spot checks are the way to unearth poor practice rather than another hoop to jump through at cost.

Why don’t the CQC just adjust some of their own criteria to include those elements raised in this so-called ‘excellence’ standard? Why does it need to be a separate and discreet system? Possibly because this way the government can raise money from it and farm out the inspections to private companies rather than relying on the toothless and frankly incompetent CQC to do.

Yes, I’m angry. I am angry because a real attempt should and could have been made to improve the quality of all residential care services nationally and it was fudged and obsfuscated. We are to be fooled by this ‘gold standard’ which is another way of saying ‘if you want our money for placements, you must pay’.

I see this system as being biased towards the large care providers. The Southern Cross/Care UK/Bupa providers at the expense of some of the small operations.

Some of the best service delivery I’ve seen has been in smaller one-man operations. I remember the care home I visited where the owner’s mother was a resident, her husband was the handyman and it felt like an extended family where the owner lived next door and spent most of the day sitting in the lounge chatting to the residents.

Would she be able to pay for an ‘excellence’ rating? Who knows – but the excellence and level of care was unmistakeable.

Should we be jumping in the air and celebrating a new excellence system? Maybe that’s what the government smokescreen wants us to do.

For me, the death of an effective regulatory system makes me sick to my stomach and makes me despair for the future care for older people in this country.

Changes in the NHS – initial thoughts

NHS logo

Image via Wikipedia

I’ll write more about the government proposals to reform the NHS after the Health and SOCIAL CARE Bill is published tomorrow. Oh yes, did anyone pick up that slight subtlety there that it is supposedly covering social care as well as health.. sneakily hidden in.. er.. the title of the bill. You wouldn’t have thought it.

But I shouldn’t be too cynical. That’s just the way that social care has and will roll.

The BBC have a great ‘simple guide’ to the reforms and what they may mean.

Most of my reservations are about the introduction of GP-led commissioning – so I’ll focus on that today.

I know it’s presented as being about more choice and more efficient services – but, as I’ve said before, when the Tories introduced the so-called needs-led agenda of the NHS and Community Care Act in 1990, the talk was about improving efficiency, cutting costs and providing more choice – hmm, those words seem familiar.

What were we left with?

Centrally commissioned services that led to ‘bidding wars’ and reverse auctions so that the company that could provide the service at the lowest cost would ‘win’ the contract. No choice – perhaps less choice as the cheapest options had to be sought regardless of quality.

Why does no-one look to the lessons that should have been learnt from the care sector? I know, there are some wonderful services out there and I don’t want to be dismissive but I feel strongly about the introduction of ‘the market’ to the care sector and I feel equally strongly about the potential failure of ‘the market’ in the health sector.

The US is hardly a glowing example of an efficient and cost-effective health care system after all.

I am not sure I buy into this ‘choice above all’ agenda. Choice is always going to be limited by cost. On a personal level, I live in one of the most deprived areas of the country. I don’t ‘know my GP by his name’. I don’t even necessarily trust the practice.  My current GP practice was ‘taken over’ by the PCT (Primary Care Trust)  for a while because of poor management and a few… financial shenanigans that led to all the doctors in the practice being dismissed. That’s a pretty big deal.

I wonder how a similar scenario would ‘play out’ in the ‘new world’ – where there is no PCT to ‘take over’. But Lansley and Cameron probably haven’t considered those kinds of scenarios. I just hope they remember that we don’t all have local village practices that we’ve been with for years and where everyone knows us and smiles at us in the street.

There are some of us living in very poor areas where some of the chronic health problems that are linked to poverty will very obviously and quite rightly take priority.

So would I get the same treatment for a more minor ailment and a lower priority ‘condition’ as someone in Knightsbridge? I’m not convinced.

Even less convinced because it won’t be my GP who is commissioning – it will be a private company that is hired by my GP. It will likely be the same people who worked in the PCT re-employed by companies like Care UK (a coincidence that they bankrolled Lansley’s private office?).  So it’s likely to be the same people, doing the same job (probably for less money) but for the benefit of shareholders rather than the public purse.

I don’t want to be a grumpy naysayer. I want the NHS to work and to work better.

I am worried though.

I await the publication of the Health and Social Care Bill with trepidation.

I  have reconfiguration fatigue already. The amount of  money my Trust must have spent on change, and more change and even more change and then some more adjustments to that change would probably fund another ward. Or have retained one of the few that have closed.

I want ideas that work. I want a system that works. I am just very sceptical. Perhaps it is up to the government to prove me wrong. I hope I am wrong.