Making Adult Social Care Better 1

I think I’m fairly good at griping and raising ‘problems’. For the next week, I want to try and take a positive approach and look at solutions as well as problems.

A few conversations I’ve had over the past week have focused on what is wrong with adult social work and mental health social work at the moment but more importantly what can be done to make things better.

My frustration is that for all the discussions that take place in the sector, so few seem to focus on those of us who have worked and are working at the so-called ‘front-line’. A home carer knows about the ways that contracts have been managed and awarded at the lowest cost and they will be able to tell you with far more insight than any contracting manager about the effects of 15 minute ‘spot’ visits and the lack of dignity present in the care for older people. They would also be able to give you an amalgam of ideas which branch from consideration, knowledge and experience of a wide range of service users.

Are employed home care workers ever invited to discussion forums and debates about the future of care? No. But you know, maybe the feedback would be the most valuable.

On a more personal level it feels as if the conversations about service design and delivery take place around and above us – with us being the people at the front line of support. Yes, there are discussions  with service users and carers but how much effort is made to seek out opinions that do not fit in the model that the consultants want them to express? How many of the people who attend these meetings, discussions and debates become self-selecting.

If you create a service user group, for example, in a particular borough, it seems to me obvious that you are most likely to engage will be those whose voices are already heard through different means.

I like to set myself up as some kind of advocate in terms of having an understanding of the needs of people who don’t often have their voices heard in these kinds of meetings and debates because the discussions I have are mostly with people who are at their lowest ebbs on the scale of health and need.

For me, it is crucially important that these people are not left behind by commissioners and service design but my experience and understanding of the sector suggests that they are.

I don’t want to keep harking back to the roll out of personal budgets on the back of the model of direct payments but I will. The voices of those without support and without advocates are understandably quieter and the way that the services have been designed focuses quite rightly on choice but what is not present is a way for an equitable service to be delivered to those who aren’t for some reason able to express choice.

So things that can make things better

– Use of advocates in a more formalised manner throughout the system. Volunteer advocates have a role but I see more mileage in professional advocacy with extensive investment in non-directed advocacy as that is potentially where the greatest need lies. If I weren’t so tied to my job in terms of needing a salary to pay the bills, I would, at a flash, try to establish some kind of enterprise to focus specifically on support planning and advocacy for adults with dementias. I hope there is a role for independent social work in this area in the future – in the meantime, if anyone wants to jump on my idea and run with it, I am happily ‘open sourcing’ it.

– involving front line practitioners in conversations, debates and discussions with the local authorities relinquishing some of the reins of power in respect to conversation. Recognise our professional vigour and competence. We see people and have discussions with people that will never attend forums collectively. We can signpost and support commissioners and contracting officers but we are never asked and never given the time to think more creatively outside our little boxes of control. We have ideas and a happier, more connected workforce is an engaged and interested one.

– speak to home care workers too – those with agencies and where in-house services still exist, with them. They will have good ideas about the ways that their services are failing.

– home visits to facilitate discussions – why have all meetings in a central hall when it can be limiting regarding those who have greater physical and mental health needs.

Technology can facilitate greater conversation and communication with two-way flows but face to face discussion is still very important as technology and keyboards can alienate some people – perhaps exactly those people whom it is most important to connect with.

-Practitioners have to be more engaged with developments in the sector and unfortunately I don’t see BASW or the embryonic College of Social Work being particularly engaged with social workers. Why have social workers become so disengaged from professional organisations and unions? Is it to do with a fear of employers? I think some more group action could really build the strength of social work but it is hard to shrug off the feeling that we are a disengaged and disenfranchised profession that like to feel sorry for our collective selves and wallow in our diminished status. I think if we took a stronger political stance and stood up to our employers and their political agendas and displayed more independence of thought, we would be able to demand more respect.

I have decided that while I can moan and groan with the best of ‘em, coming together with ideas for improvement is by far the best way of making our voices heard.

Human Rights, Home Care, Personal Budgets and Cost Saving

I read on the BBC website among others that there is a report suggesting that care provided in the home by local authorities to older adults may be overlooking human rights issues.

Old man exmouth market

Daniel2005@flickr

An inquiry into this  was initiated by the Equality and Human Rights Commission in November 2010 and will report in December 2011 but some interim findings have already been published.

I think the context in which the inquiry is taking place is crucial in times that Cameron trying to pretend that he invented the personalisation agenda and rebrand it as a version of ‘Big Society’.

The scope then of the Inquiry as to determine where the responsibility of the ‘public authority’ under the Human Rights Act actually lies and I’m going to quote directly from the EHRC (Equality and Human Rights Commission) as I think this is a crucially important point in the progress of personal budgets and home care provision (n.b. the underlining is my own).

The nature of social care is changing rapidly with a greater emphasis on personalised services and choice.  The majority of social care services are already delivered by private sector agencies, either via contract with local authorities or directly with individuals through a mix of public and private funding.

This complex web of transactions is combined with a narrow judicial interpretation of the meaning of ‘public authority’ under the Human Rights Act. This combination has created a confused picture concerning the duties and obligations of the various groups involved in respecting, protecting and promoting human rights.

Further, an increasing number of care transactions are likely to take place at the margins of, or even outside of, regulated care. There is the possibility that these transactions are beyond the present human rights obligations of the State.

We are also seeing the emergence of new on-line care marketing and brokerage services aimed at people purchasing social care with either ‘individual budgets’ or private funds. These marketing and brokering services are currently completely outside of the regulatory system with no means of monitoring the quality of the advice and services they offer. The Government wants to accelerate the pace of reform even further. While personalised care and support has many potential benefits, this is uncharted territory. There are concerns that human rights protection (and other issues) could fall between the gaps.

I’m going to come back, I’m afraid, to my perennial bugbear of people who lack capacity to make choices regarding care provisions and care delivery and wonder again how this group of people without family members, friends or advocates will be able to secure their own well-being in a world where responsibility of the state and the public authority is being discharged to private individuals. Will it become the responsibility of an advocacy service to determine that the support package and the provider of the support package are of a good quality? Or the carer/family member? Hardly the same as a protection under the Human Rights Act.

Food for thought and while I am extremely happy with the forward march of personal budgets and direct payments to those who are able and happy to manage their own budgets, the way that local authority managed budgets provide ‘more of the same’ regarding cheaply bought, block contracted social care remains floating fairly close to the edge regarding what is acceptable and what isn’t.

My fear is that the roll-out of personal budgets has not led to choice for all. It is a false choice and a false impression of the so-called ‘success’ of the roll-out. It has led to great benefits and more choice for some, yes, but I worry that this is actually at the expense of those without the louder voices to shout who have, again, been pushed to the bottom of the pile when quality services are being distributed.

So back to the reports findings so far.

Back to the BBC report

The Commission describes cases of people being left in bed for 17 hours, or more, between care visits and a failure to wash people regularly.

It received reports of people being left in filthy nightwear and bedding after a homecare visit, or without a wash or hair wash for several weeks.

Visits are sometimes so brief, the report says, that people have to choose between having a cooked meal or a wash.

The short visits also mean that staff have to rush tasks like washing and dressing, which frustrates elderly people and care staff

That doesn’t even bat an eyelid with me. This is what I have dealt with for the years I have been working in adult social care. Complaints and apologies about the time we can allocate for specific tasks due to budgets. Apologies on behalf of private agencies who have block contracts that cannot assure any kind of continuity of care.  That’s not even mentioning the  missed visits, the non-payment to staff of travel costs so they are cutting short visits in order to make it to the next ones. This is the reality of social care for older adults in the UK. Not the ‘season tickets to football matches’, not the ‘let me choose nice Mrs Walters’ daughter who I know from church to be my home carer’ kind of idyll that we are presented in the personalisation literature.

The reality for the people I work with and for is increasingly rushed visits and yes, choosing between a cooked meal (but only if it is a microwave meal because there is never ever time to cook a meal more complicated than tinned soup or beans on toast from ‘scratch’) and a shower.

The way to solve this problem and promote dignity is to increase and not reduce budgets for social care in the home. But budgets are being cut and cut hard.

Local authorities use block contacts with private care agencies to save money. The private care agencies generally pay staff at minimum wage. There are some fantastic carers and some fantastic agencies but they are penalised if they don’t offer their services at the very very lowest cost.

As for personal budgets? It is a wonderful reality for some but for most of the people I work with and for, it is a pipe-dream for people with a different kind of disability and with different kinds of support needs from the ones which are mostly promoted in our training programmes and in our policy documents.

If the government truly and genuinely means what it says about increasing and drawing out the personalisation agenda and increasing personal budgets delivered by direct payments there have to be ways clear and research undertaken to help us to create protective and interactive systems for people who are not at the forefront of the march because they don’t realise how much they are being penalised for not having a family member who is able to help with choosing and designing a care package and because they are not able to do this for themselves.

There has to be money spent on developing ways to allow those who at the moment are most at risk of vulnerability to be protected and cared for.

There are so many problems with a society that treats older adults or, in fact, anyone in the way that older people who are in need of care are treated currently. No-one wants to address it because no-one wants to pay. And it will cost.

No-one wants to lose their homes. No-one wants to lose their savings. No-one wants to pay higher taxes. No-one wants to lose weekly bin collections. No-one wants to pay insurance premiums.

The people who hold the reins of power will never be subjected to the humiliations which become a part of daily life for older adults who have need of support that is provided because they’ll be able to buy in their own ‘help’ privately.

Older people in need of assistance are less noisy than younger adults and less emotive than children in poverty and need. Ultimately we shouldn’t ration compassion and there’s no need for a choice to need to be made between one group or another

In the roll out of direct payments and then personalisation and personal budgets, it is the more able younger adults who have led the march and those who have been setting the policy and agenda seem to have completely forgotten the group of older people who don’t have involved family members and who  might not have the capacity to take decisions about care needs for themselves in the rush towards pushing the responsibility for support planning and choice of care routines. They  have forgotten amid the wonderful stories of attending football matches instead of day centres that some peoples’ reality is more about choosing a microwave meal or a shower.

Until those issues are addressed and the protection of the most potentially vulnerable groups of people is managed, the new system will not be equitable and it will not be fair. But perhaps that suits this government that wants shift responsibility from the state to the individual – which is fine to an extent but there are some people who really need that protection.

I look forward to the final report of the EHRC in December.

Personalisation and Professional Disillusionment

Yesterday, Community Care published the result of a survey they had undertaken about ‘personalisation’ among social care professionals.

The headline figures while wholly unsurprising, make for interesting reading where only 41% of respondents felt that service users would benefit from the implementation of personal budgets and 83% felt that cuts would impede the progress of the personalisation agenda.

To which my first thought was ‘only 83%’?

Anyone who has read some of my previous writing/ranting about personalisation will be pretty clear where I stand.

While the idea and the concept of introducing more person-centred support planning and opening up direct payments to a wider range of people is absolutely fantastic as a concept, the implementation has been dire.

There has been a complete side-lining of service user groups that don’t fit into the ‘easy’ mode – namely those with mental health problems, older adults and those who might not have capacity to involve themselves fully in the support planning process, the same figures and quotes that the government and her agencies roll out again and again about the man who pays for a PA to go with him to a football match instead of a day centre are so completely off the radar when the smaller pool of money available for care services exist that they are almost insulting to those for whom a) the thought of having enough money allocated to pay for two tickets to a football match would equal 7 showers a week – so it’s football or cleanliness and b) that group of people (because, yes, much as the government don’t want to accept it, they do exist) that actually WANT to go to day centres.

And so we plough on.

But even though I have had many criticisms of the way that personalisation and particularly personal budgets either managed centrally by the local authority (where the end effect is exactly the same for the service users in most situations) or delivered by direct payments (where someone has to have capacity and desire to take on the direct payment and employ assistants or have someone who is willing and able to do that for them) – there is more to the personalisation agenda and process which is in danger of being lost in the process.

Personalisation as a value base and an approach to work and social work in particular with people who need or who are eligible to receive services for care ties in perfectly with aims of re-addressing the power differential between provider and ‘receiver’ and the imbedded dichotomy between ‘giver’ and ‘taker’ in society.

That model of giver/taker which is bound within the welfare state system can create an imbalance and the potential to give back some of the ‘control’ and some of the decisions to the person who receives services may, in some way, redress elements of this balance. There is no way that my training and experience has taught me better than anyone else, what YOU as a recipient need. Yes, I learnt my theories and my models and understand that building social networks is important but if you prefer to do that at a coffee morning at the local museum instead of at a day centre that’s perfect. If you want your neighbour’s granddaughter to help with your personal care rather than an anonymous and frequently changing ‘carer’ from a local agency who is paid at mimimum wage and has a day full of appointments and who isn’t paid for travel time by her agency so she needs to cut short on some of the time – perfect.

But we already had that system with Direct Payments. Where is the difference?

Ideologically, the difference was that everyone would know how much money they were ‘getting’ – whether directly or managed and they would be able to be consumers. Our society tells us that money is power. Money creates consumers and the market will right itself.

Even, theoretically, when a personal budget is managed by a third party (and I include the local authority as a potential ‘manager’) you will know how much is ‘allocated’ to you so that you can ‘spend’ it in the way you want.

This doesn’t happen in practice though because local authorities need to save money and are still tied up into procurement contracts that make agencies unequal when ‘bidding’ for the funds that have been allotted via personal budgets.

I know this is getting a bit technical and complicated but it’s important to understand. I don’t think anyone can oppose ‘personalisation’ as an approach regarding empowerment and ideology.

The implementation, however, reeks of money-saving and penny pinching. It also has pushed the responsibility for services away from the local authorities and onto individuals and their carers.

You have £100 per week, find the care yourself – then we (the LA) aren’t responsible anymore.

I’m wholly in favour of contracting out assistance and advice on self-assessments and support planning to local voluntary sector organisations. My own LA tried that. We referred lots of people to them.  They withdrew because we were referring too  many people to them and the local organisations didn’t have the resources (or the contract) to undertake as many support plans as were being referred – but the idea is not one I have any problem with and in fact, I rather like it.

But this wasn’t offered to people who do not have the capacity to lead in their own self-assessment and support planning. The organisations couldn’t do that because they were not experienced in non-directed advocacy work – it takes longer.

It is hard to see through the budget cuts as well towards a future where, as Burstow as said he wants direct payments to be the ‘preferred method’ of delivery of personal budgets.  I don’t want to detract from the fact that this is and will be fantastic for some, perhaps most people, we move to a model where there is – again – a ‘one size fits all’ approach.

The true tragedy of the personalisation agenda is that is has and is coming to fruition during a period of cuts – the government (and the previous Labour government too) want to pull back the responsibilities of local authorities and with the criteria for accessing any support is rising rapidly it may well be that more and more personal budgets are delivered directly from peoples’ own savings or disability benefits (while they still exist).

I am fearful of the future for adult social care but I’m not necessarily unhopeful.

I think there is potential for change and development but unfortunately the ways I see of improving systems come at higher cost.  There has to be some major research and debate about the delivery of personal budgets and the way that personalisation encompasses people who lack capacity and lack advocates (family and friends) and how they can best benefit from this process – perhaps access to additional funds to pay for the trust fund type system of management we were assured would happen but in practice is not feasible for a relatively small sum of money as it costs more than it might deliver.

We need to see more about how support planning can work in the voluntary sector as, speaking personally, I genuinely don’t have time to do the process of support planning any justice as a part of my day to day job. It ends up being rushed because I can’t devote a couple of visits of a couple of hours to talk through and develop a truly person centred support plan.

The process of self-assessment needs to be reconsidered because while the idea is fantastic for some people – our self-assessment forms are biased towards physical disabilities and look scarily similar to a DLA form where people are asked to explain how they are on ‘their worst day’. That doesn’t really help with confident-building when you are working with someone who has very low self-esteem and depression/anxiety. The process of self-assessment in itself can and has been traumatic – let alone the person who is not able to engage with the assessment process due to a lack of mental capacity where questions about ‘dreams, hopes and wishes for the future’ while well-intentioned, can be hurtful and hard for families to listen to when they are asked to their parent who has advanced dementia.

I fear we have allowed a great conceit to be steamrollered into simply another ‘one size fits all’ approach to developing social care. It doesn’t have to be like this but that seems to be the government perception about what ‘personalisation and personal budgets’ are.

Choice is fantastic of course, but sometimes people want quality as well. It shouldn’t ever need to be an either/or. It does feel like it at the moment with the promotion of choice above all things.

So where are we going? Personalisation isn’t going away and nor should it. Personal budgets aren’t going away and nor should they.  Local authorities, however, might be going away – further and further away from social care and the responsibilities that they hold towards it.

We keep up with the advocacy and with the systems that are failing because we owe it to those who are reliant on these systems to make them work as best they can but we keep trying to pinpoint and pin down the flaws in the implementation with the hope that sometime, some day, someone will listen.

As professionals we don’t oppose personalisation. We have always been trying to use person-centred approaches. We just dislike injustice and inequity and that seems to be painted all over the current implementation and the frustration is that so few people (if any) in government seem to be aware.  Am I disillusioned? Yes, definitely. We were promised new ways of working in a more person centred way.

Desperate, no, not yet though as long as there’s some fight left in the belly to keep banging on and on and on about what personalisation SHOULD be and why it isn’t working yet. Not for everyone.

Personalisation in Mental Health and Older Adult Services

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Vision for Adult Care – a few brief thoughts

I’ve only just had a chance to read the ‘Vision for Adult Care’ published yesterday and wanted to offer a view very initial thoughts although I haven’t any doubt that it will be referred to continually for many years to come.

Having read it my initial response was a little underwhelmed. I don’t know what I was expecting. Perhaps that was just it really, we knew exactly what to expect. There wasn’t anything in there that should surprise anyone at all.

We know that there needs and will be a genuine desire to push the personalisation agenda and move towards personal budgets where service users and carers have greater control over the budgets that they are assessed to need with services rather than directly provided and commissioned services being chosen ‘on their behalf’.

I have always attempted to care plan with rather than for people. That has been the policy for about 20 years arguably since the 1990 NHS and Community Care Act. What stymied the ‘choice’ element back then was the realisation that services have costs attached and ‘block contracts’ are cheaper and provide more services are cheaper costs to the councils. My understanding is that block contracted care with little choice in the provider was never the goal of the reform to legislation 20 years ago. That was supposed to, and did, open up the ‘social care’ market. It has just led us down this prescriptive path because the prescriptive path was cheaper than the choice and user-led path.

That should be the lesson for the government of the day – but enough with my cynicism.

I can wholly embrace the desire to move everyone to personal budgets and moreover, I absolutely welcome and appreciate the acknowledgement that having a personal budget is not the same as having a direct payment.

The language of social care seems almost designed in some ways to alienate and obfuscate so I apologise in my use of jargon.

Managed personal budgets seem to be a way that some local authorities have ‘dodged the issue’ of blocks to direct payments or when people have been reluctant/unwilling to move to direct payments. The government seems to have made, at least an attempt to understand this.

As the document says

We want people to have the freedomm to choose the services that are right for them from a vibrant plural market. That is why this vision challenges councils to provide personal budgets, preferably as direct payments to everyone eligible within social care within the next two years’

That ‘preferably’ offers the councils some get out within the target of ‘two years’ but it will be interesting to see what outcome measures (because there will be new outcome measures) are going to be taken up in my council, at least and what kinds of pressures and supports will be rolled out for that broader ‘direct payments’ issue.

I wonder how many people accept and understand that these ‘direct payments’ and ‘personal budgets’ are all means-tested and can all be charged. I mention that because sometimes in the press there doesn’t seem a complete appreciation of that. I say that as someone who has recently assisted to set up a direct payment personal budget to someone who is paying full cost. He is paying as much as he is getting back. Sounds nonsensical? Not really, because this way he is able to ‘buy’ into the support package and information that is given in the same way it is to those who don’t pay for their own support. Apparently, according to the government though, we don’t provide the same levels of support for full cost users, that is also rolled out as a goal for the future. I wholeheartedly welcome that. Access to support, information and care planning should and will be a universal service. I’ve always believed it is inherently unfair that people who are charged full-cost have sometimes been denied that support – indeed, I have personally provided it and argued successfully with my managers that I should wherever it has been possible but I am aware that too often the local authority has washed it’s hands of anything that it does not have a direct responsibility for – mostly due to cost rather than callousness. But back to the ‘vision’..

The paper sets out a number of principles

Prevention

‘empowered people and strong communities will work together to maintain independence’

Wonderful. No-one can deny statements like that. The vision specifically explains (quite rightly) that early intervention promotes better outcomes (and lower costs) in the longer term. This is what we have been saying for years – as the eligibility criteria have increasingly tightened. Therein lies the so-called rub. The way the ‘vision’ ducks this is by emphasising community support and action alongside paid care services. The ‘Big Society approach to social care’. Gulp. I honestly still find it difficult to understand ‘big society’. Does it mean more people doing voluntary and community work? I am sceptical even though I don’t want to be. My concern is that it means a greater pressure on family and friends as carers.  The vision mentions the ‘scheme’ in Japan where families ‘swap’ care responsibilities in different areas of the country. I worry that too great a reliance on informal and ‘free’ support will lead to un inequitable access to equivalent services for people that don’t have large support networks or live in supportive communities. Time Banks are also suggested as a way of providing support which is good, I like the idea but too great a reliance on hours given willingly may not be the best safety net.

I absolutely agree that commissioning needs to be closer to the ground. I see some of the craziest commissioning decisions being made and can’t believe anyone in those service areas have any clue about what  the local community needs or wants.

The vision does state clearly that ‘Carers are the first line of prevention’. Good. And it goes on to explain ‘Councils should recognise the value of offering a range of personalised support for carers to help prevent the escalation of needs that fall on statutory services’.

I have set up a lot of carers’ direct payments myself and have a few carers who manage them. In some ways, it is very easy to ‘sell’ direct payments to carers as there is a much greater degree of flexibility but there is actually very little money allocated to carers’ direct payments presently. I hope this ‘vision’ and appreciation of the longer term saving that carers are contributing that we will be able to offer them more money through direct payments themselves. Carers Allowance is some kind of evil joke that is, in my view, insulting. Carers Direct Payments potentially can ‘make up’ for it but the local authorities have to loosen the poor upper limits on the carers’ direct payments.

We are promised a forthcoming carers’ strategy. I await it will much interest.

Telecare and technology is also mentioned. We have been promoting this for a few years. It can be very successful but it cannot replace human contact.

Personalisation

I’ve mentioned this above and am very glad that the document acknowledges that ‘A personal budget alone does not in itself mean that services are automatically personalised’. In some ways, that has been my cry in what I thought was the dark. The document mentions the areas that have been slow to pick up in the roll out of direct payments, namely older adults, adults with mental health problems, adults with learning disabilities and adults who lack capacity.  Regarding one of the ideas for managing direct payments for people who lack capacity, one of the suggested ‘solutions’ is placing the control of the budget in the hands of ‘another suitable person’. Interesting. I wonder what this means – informal care and support, a trust fund type project, a professional. All have potential costs and as the criteria for eligibility tighten, the money itself will be less. Higher quality care and m0re choice with less money. Sounds perfect.

There aren’t really any solutions offered but at least acknowledging some of the difficulties is a start.

Interestingly, there is a line about increasing choice to people living in residential care which is a fantastic idea. I am very curious and excited to see how this might happen in practice.

Again, the examples offered in the Vision relate to people that have capacity, support and ideas.

There also seemed to be a suggestion that the IMCA (Indepedent Mental Capacity Advocate) role might be broadened. This is a joy to my cynical self. I  have worked extensively with our local IMCA service and I couldn’t praise them highly enough. I really really hope we can use them more but they will need to be paid.

Plurality and Partnership

The vision emphasises an idealised support ‘partnership’ between individuals, communities, voluntary sector, private sector, NHS and local councils. Probably in that order of preference.

We are told the aim is ‘a broad market of high quality service providers’. Absolutely fantastic. This is my vision for social care as well. I am just a little cynical about the high quality=low cost possibilities but I am willing to be proved wrong, indeed, nothing in the world would make me happier. I want to be able to advise and promote high quality care from many different providers. But that was what we were promised 20 years ago.  The vision promotes a move away from the ‘block contracts’, again, personally, I feel in general they have been negative and have limited choice but there has to be an acknowledgement that they grew out of a necessity to reduce costs.

Protection

Safeguarding concerns have often been raised about the roll out of direct payments and a potentially larger, unregulated workforce of Personal Assistants as well as issues regarding management of finances.

The vision seems to have a great deal of faith in CQC (Care Quality Commission) to inspect services where safeguarding concerns have been raised. Anyone else notice the slight problem here? That’s a bit like closing the door after the horse has bolted – I apologise for the cliche.

There is also the suggestion of a type of ‘neighbourhood watch’ scheme for people in communities to ‘report’ and ‘look out for’ people who might be being subject to abuse. Honestly, I hope this is happening anyway. Fine, it doesn’t do any harm but it doesn’t replace a strong safeguarding structure and culture. I noted there is a particular statement that

‘Local government should act as the champion of safeguarding within communities’ which suggests  that whatever the new ‘practices’ outside the local authorities will do, it won’t be safeguarding. There is a consideration to put this function on a statutory basis. Please, please, yes, yes. Vulnerable adults need the same protections as vulnerable children. This is long overdue and a real failing of the current safeguarding system that at times feels too toothless. It is very hard to get police involved sometimes where I can’t imagine there would be the same difficulties if we were talking about children rather than adults.

Productivity

The vision goes into greater detail about the financial package the local authorities and social care has been ‘gifted’. So be it. It is unprotected money and we all have doubts as to whether it will be enough but noone is getting any money at the moment. There is a focus on efficiency savings.

One of the elements that made me happiest actually is hidden towards the back of the document where it states that ‘The Department of Health will amend the ‘Payment by Results’ tariff from April 2012 so that the NHS pays for reablement and other post-discharge services for 30 days after a patient leaves hospital. From next April, Trusts will not be reimbursed for unnecessary readmissions to hospital’.

Hopefully, this will mean that discharge planning is more coherent and less rushed with the Trusts knowing there will be cost implications of readmission if they ‘get it wrong’. Good.

On the other hand, the vision wants councils to rip apart any remaining in-house services. I understand their point that this is potentially narrowing choice but often, certainly everywhere I have worked, it has been the best quality service when compared with private sector care services. This makes me sad. Goodbye, in-house support. I miss you before you have even gone.

People

And so we move to the social care workforce. Sigh. Yes, the government say ‘care workers, nurses, occupational therapists, physiotherapists and social workers, along with carers and the people who use the services’ and you get the impression they put the list in order to importance in their own minds’ eye.

The vision explains that

‘New and continuing professional roles will be developed for front-line social workers, occupational therapists, nurses and others’.

And then goes on to explain the problems there are with sickness and absence in the sector. I wonder if all the reconfigurations have been an issue about increased stress and uncertainty, never mind. I’m sure the government hadn’t considered that.

Interestingly there is mention of working with Munro’s review of children’s services in social work to allow social workers to have more ‘decision-making authority’. Huh? I thought the decision-making was to lie with the service users.

I am thrilled that there seems to be a linking of social work with community development. Seriously. I think this is absolutely the best area for adult social work to place itself and I am genuinely excited to think there could be a role for social workers in community-based growth. However, the skills sets may not quite be there and there will need to be some additional support given at first.

Generally, it’s a mixed bag that tells about lots of hope and plans as expected in a vision. There isn’t much suggestion or explanation yet but that will come with time. Some elements are clearer, some even foggier than they were before and my brief thoughts have been less brief than I imagined.

I find it very hard not to be cynical and I find it very hard to trust this government to be honest. There seems to be a worryingly high dependence on ‘free’ care provided by family and community and no explanation of where the support will come from when these community supports don’t exist.

But I do want the system to be better. I want everyone to receive a better service, not just those who are able to actively engage with the process of receiving a direct payment and I want the changes to work. I don’t care much for the government but I do care desperately for the sector.

A vision is nothing more than a promise until it delivers though. I want the central government, a government without  a mandate, to deliver on outcomes and promises as well as local government officers.

And with that, I sign off the longest post I have ever written for this blog – thanks for staying till the end (if you did). It terrifies me that the word count for one post I wrote in 40 mins is the same as the word count for the essay (currently taking a PQ module) that has taken me about 4 weeks to write… .. . . .

The Disgrace of Individual Budgets

I have a few words for Paul Burstow, the Minister responsible for Care Services, who is appalled, according to Community Care, about the low take up and roll out of personal budgets in Adult Services – the take up is so far only 13%.

He said to his party’s conference

“It’s disgraceful. We need to be far more critical of public services. Why are they not willing to let go of control?” He was speaking at a Liberal Democrat conference fringe session on social care and the government’s Big Society agenda.

Excuse me for a moment while I scream with frustration.

Back.

NOT WILLING TO LET GO OF CONTROL?

What does he think that the lack of roll-out is to do with a nefarious political plot to hold on to the control aspect?

No, it’s not. It’s all to do with poorly adapted and poorly administrated systems and piloted exclusively in teams and departments that were ‘easy’.

Where are those 13%? I can bet they are with adults with physical disabilities and adults with learning disabilities where a lot more resources and efforts had been pumped into direct payments so they had a sound base to start on.

That 13% is also likely to include older adults who have capacity and families to help advocate for them.

We have some quite rightly wonderful accessible easy read documentation for the forms with beautiful pictures that show who effective support planning can be in the learning disabilities field – but where is the real research for people who may lack capacity to make decisions due to dementia – for whom the same type of documentation is not relevant because in general, those who are support planning will have much less time and much less money to ‘be creative’.

Where the systems have not picked up is with those who do not have the families and friends who are able to invest a lot of time into creating personalised packages – of the people who do not have the capacity to manage and organise their own care – for whom the system of individual budgets will not change anything too dramatically.

I wish Mr Burstow would meet and talk with people who actually DO the job to understand the difficulties, rather than meeting and talking to people who manage people who do the job or people who write the policies or people who audit accounts.

I want to give up control. Believe me I do. It might mean some respite in the constant stream of care management duties that spring up incessently. Sometimes though, it isn’t all about retaining control but maintaining quality as well. Sure, if a capacitious decision is made, all is well and good and the right remains, as it should, with the end user, but where there is a decision that needs to be made on behalf of another person, the choices are already limited.

Why should someone have a potentially poorer service through a provider agency because they are not able to manage a bank account and do not have anyone who can assist them – sure, theoretically the local authority can hold the account but who makes the decisions about PAs and flexibility?

There is little doubt that high quality regular care provided by a small group of people or person is the favoured option for those that have successful care packages. People whose direct payments have been most successful have worked because of the people they have employed directly as often as not. However this is not a service which is offered through this system to people who lack the capacity to act as employers and who either don’t have families or don’t have people who can do this on their behalf – they still remain with agency providers which most people agree offer a poorer service.

This is my gripe and my main upset with this system. It is inherently discriminating and providing a poorer service to people who don’t understand the systems. If social workers had caseloads of 10, we might be able to do this on someone’s behalf but it is not possible with the workloads that are carried in older adults services.

So the people who ‘can’ get a gold star service and the people who ‘can’t’ get exactly the same as they always got.

That is both demoralising and unfair. It makes me cynical of the whole system and those who advocate it because perhaps if this could have been thought through at the time, we wouldn’t be lagging so far behind of targets.

Sure, I’ve been to the training, I know about the trust funds that can be created to manage care but how many people in older adults’ services are going to have packages that pay enough to establish and operate a trust fund as well as paying for it’s maintenance. The answer is not very many.

The way the  roll out has been managed, stinks. For people it works for, it works very well – but there are many people whose needs and wishes have not been able to be accounted for in the way the forms have been written and the way the processes work. That might be unique to the local authority I work in – it must work well somewhere.

But these lavish statements of Mr Burstow, they grate incessently and I say that as someone who would love this system to work but who is ground into dust by the ways it has been implemented.