Choice, Control and Obfuscation – How the Personalisation Dream is Dying

In the bold move towards a transformation in adult social care, it feels from where I sit, that control has completely overtaken any pretence of ‘choice’ in the so-called move towards more idealised ‘person-centred’ care and support planning.

I hope I’ve been clear over the years in which I’ve expressed a remarkably consistent view that I love the idea of people being able to choose the support plan they like from a wide menu of options with ‘professionals’ taking less of a role.  I am a massive fan of direct payments. I want people to have more personalised care and more creative care. Desperately. The options just aren’t there yet for people who lack capacity and that is a terrible disservice and inequity that is being served throughout the care system.

Removing care planning from my role doesn’t concern me – unlike those people on the training courses who bang the drums blindly about how wonderful and bright it looks when we allow people to choice whatever they like to put together packages of care, I don’t want ‘retain control’, I truly don’t believe that I, as a professional ‘know better’,  but likewise I know that with the user group I work with, it is rare that I can just hand someone a support planning tool and a list of potential providers and tell them to ‘get on with it’.

That is as far from reality now as it was 20 years ago in my work. While I can say that everyone I care co-ordinate who has a ‘package of care’ is now officially on a ‘personal budget’ and some even have direct payments, it hasn’t really increased choice or control for any but a couple of those people.

If anyone for a moment wants to ponder the duplicitious nature of those in policy making ivory towers who dribble down policies which they want to couch in ‘soft’ language so they are difficult to challenge, one only has to read a fantastic piece of research conducted and published on The Small Places site.

It is worth reading through the piece in detail. Lucy, the author, made a number of requests to local authorities to ask about how their Resource Allocation Systems (the link between the ‘assessment’ and the ‘cash’ – basically) was calculated.  She seemed to come up against a wall of obfuscation but it’s worth looking at her research in detail.

This reluctance for me, seems to relate to the lack and reduction in spending on care and support – the key ‘missing piece’ as to why a council can ‘reassess’ someone as needing less ‘cash’ than they did last year with a more traditional care package.

My personal experience is that the council I work in (and this is similar to things I’ve heard from people in other councils) probably doesn’t want to share it’s RAS because it’s ashamed of the utter dog’s dinner that it’s made of it. It doesn’t ‘work’. It doesn’t make sense. It is frequently changed. There is more emphasis on physical health needs as opposed to mental health needs and while there can be manual adjustments, some of the figures that are ‘spat out’ just seem nigh on ridiculous (and that works for sometimes calculating care ‘too high’ as much as a figure which is ‘too low’).  It comes down to everything needing to be qualified and fitted onto a spreadsheet when actually the needs of two people who might fill out a self-assessment with the same ‘tick boxes’ might have very different needs in reality – no RAS can account for that. One person might under-score because they are embarrassed by the process and don’t want to admit to being incontinent on an initial visit from a social worker because they haven’t been able to tell anyone other than their GP – another person might be anxious and think they can manage less well than they can. Sometimes and this is what local authorities and health services seem to find hard to account for, you just have to treat people and their needs as individuals rather than the subject of outcome measures, tick box performance indicators or resource allocation systems.

Shouldn’t personalisation be about putting the user at the heart of the system? Every user should have a copy of the RAS and how the figure was determined. Which questions are weighted and which aren’t. Without that, there flow of money and the control rests solely with the local authority.

I’m fully against ‘traditional’ care packages. Having someone anonymous and constantly changing pop in for a 30 min welfare check once a day isn’t about improving the quality, control and choice in someone’s life, it’s about a local authority doing the absolute bare minimum that they can get away with to fulfil their statutory duties of care.

The lack of openness about the ways that the RAS shows the true colours of the reasons for these pushes towards the Eden of ‘Personalisation’.

While I have no doubt that for some people, as I keep saying, those with advocates, family or who are able to voice their own needs clearly, have and will continue to benefit enormously from having direct payments – it’s worth remembering that direct payments have been available and accessible for many years now.

Forcing everyone onto personal budgets has only discriminated against those with carers by reducing the amounts of money they are entitled to through the RAS (that’s my own experience of how our local RAS works) and has discriminated against those who lack capacity by promising all sorts of ‘creative’ ways of exploring third party management of support plans but without providing any real ways of accessing it (this is my current bugbear as I have been requesting assistance with this for months for service users I work with but have been told it is not possible for older adults yet as only those with learning disabilities have budgets large enough to make it cost effective – thereby clearing discriminating on the basis of age and type of disability).

I have changed from a fervent advocate of a system which was supposed to be so much better for everyone to a bitter opponent of a system which favours some kinds of disabilities over others, some kinds of service users over others, some kinds of carers (those who are willing to put a lot more time in to manage and support plan where necessary) than others and all to provide fewer services under the guise of choice.

No wonder Burstow is pushing everyone towards direct payments. He is pushing everyone towards a system which masks the way that payments are determined and discriminates openly against people who lack capacity or who have the ‘wrong’ kind of disability or family support.

Now we know that the local authorities can hide the way they make financial calculations, it becomes much more obvious to see behind the facade of the ‘Wonderful Wizard of Oz’ who promotes choice as the final goal to achieve at all costs.

I feel tricked and betrayed by the implementation of the personalisation agenda and the lack of any of the services around it to tackle directly with the problems at it’s heart.

I was deeply disappointed, for example, that the Mental Health Foundation’s ‘research’ and work with people specifically with dementia only focussed on people who either had capacity or had family.  Their advice talks lovingly of setting up trust funds, appointing brokers – well, that is a fantasy rather than a reality and exists only on paper as a choice. They merely replicated a lot of work which was done when direct payments were rolled out around lack of take up for people with dementia and they hadn’t said anything new (I happened to write my dissertation about the lack of take up of direct payments for older adults so did actually do literature researches at the time..).

Anyway, I’m getting ahead of myself.

For now, I think it’s important that we who see through the cosy policy makers congratulating about a ‘job well done’ speak up and speak up loudly for those for whom the system is a further barrier for true individualised care because these self-same policy-makers see them as ‘too difficult’.

My title explains that the personalisation dream is dying but it isn’t dead yet. To be brought back to life, all those involved need to embrace the principles of honesty and openness and not blind themselves to their successes if they can’t see the continuing barriers.

Weekly Social Work Links 30

As the days become more distinctly autumnal, I’m sharing some interesting links I’ve come across over the last week. As always feel free to share any other links you find that are related or interesting in the comments section.

I’m always wanting to find new blogs that are related to social work internationally so if you find one I haven’t noticed again, please leave a link!

Firstly, another plug for This Week in Mentalists – a now-traditional weekly round up of mental health related posts from which I stole my inspiration for these round up posts. Essential weekly reading for me and for all those who have an interest in mental health.

Indeed, it was through This Week in Mentalists that I came across the wonderful new blog ‘Veruca Salt’ who works in a CAMHS (Children and Adolescent Mental Health Service) Team and in which she discusses anger management. Rang a lot of bells with me. I really look forward to following her blog which she suggests in her byline, will share ‘views on children and adolescent mental health’.

Keep writing, Veruca, I think this one will be a corker!

I also came across this post on Blogher which is written by someone who worked as a social worker. The title says it all really ‘The Problem with handing out the Happy Pills’. She raises some excellent and thoughtful points about medication.

Social Work Soldier – another new blog I’ve recently found, shares her thoughts on her first weeks in a new job.

While Social Worker Mom looks for a new job.

And as the author of From Media to Social Work gets ready to embark on her course, she shares her thoughts of the shadowing experiences she has had over the summer.

The Masked AMHP shares part one of his ‘genesis’ story or how he got into social work. It’s a fantastic post!

On a related subject the Social Work Career Development shares some motivational quotes and asks for more examples from readers.

Social Worker in the South meanwhile shares a moving story which indicates the importance of this line of work.

and Going Mental explains that sometimes ‘the system’ works.

On Eyes Open Wider, meanwhile, some reflection and thoughts on what the innate sadness in some of the work that is done.

The Modern Social Worker shares a post about Eugenics, Race and a woman’s right to choose. Perhaps particularly timely as the abortion debate ranks up here in the UK.

SocialJerk has some fine posts as always including this one about the paranoias that exist about adults working with children and some of the absurdities that have arisen around these paranoias.

Community Care’s Social Work Blog has a post about a ‘game’ developed by the University of Kent to assist in training around child protection practice through the use of scenarios (I haven’t actually tried the game but would be interested to hear from anyone who has)

Nechakogal’s blog shares some relevant (and freely accessible) research on different subjects,  which is worth checking out. I’m a great fan of open access for research and papers.

How Not to Do Social Work shares his variation on ‘What I did in my Summer Holidays’ post with typical thoughtfulness.

One a completely different note, A Social Worker’s View draws our attention to Ovarian Cancer Awareness Month.

And The New Social Worker Online Blog considers the impact on endometriosis.

The Social Work Tech Blog has a fantastically detailed ‘how to’ post about using technology to ‘observe’ sessions and to learn from them.

Finally congratulations to Gamer Therapists who has published a book on Video Games and Psychotherapy.

Commissioning

Yesterday, I caught up with a friend of mine whom I hadn’t seen for a few months. She works in commissioning. She didn’t work in commissioning when we first met but her career trajectory has taken a few odd side steps and there she is.

We talked about commissioning for a while. She doesn’t work in a part of commissioning that affects the services that would be delivered by my part of the service so I felt fairly safe moving into rant mode as I spoke to her.

I wondered, to her, why the process of commissioning is so far removed from the frontline service delivery.

But there are service user consultations, she added. Yes, I replied but they are narrow in scope and where are the voices of those who do not ‘self-select’ themselves on ‘panels’. Where are the voices of those who may not have the capacity to make some of the decisions related to their care needs? Where are the voices of the carers who don’t actually have the ability to leave their homes because of the lack of appropriate respite – particularly older carers? Where are the voices of the voiceless?

She had a good comeback of course and spoke to me about the reams of additional advocacy support she is involved with but it made my heart sink.

You see, all advocacy apart from statutory IMCAs (Independent Mental Capacity Advocates) and IMHAs (Independent Mental Health Advocates) have been withdrawn from the services that I work in. The voluntary sector agencies that might have helped have either been axed or cut back sufficiently that they won’t ‘work with’ people who enter our services.

But back to the commissioners. I wonder why I didn’t know the name of any of the people involved in commissioning services for our local authority in the user group I work with. Why don’t they come to our team and meet with us and talk to us, I suggested to my friend, while, of course, absolving her personally – I know she is both good at her job and dedicated to providing good quality services.

Surely we, who are involved in scoping out support plans, making suggestions about which care agencies might be better than others, we who receive the day to day complaints when services aren’t available or aren’t working, would be useful people for commissioners to engage with? But I don’t even know the names of the people who work in commissioning the services we are asked to use.

They make block contracts on the basis of cost which deliver poorly. Yet when renewal time came around, exactly the same contracts were dished out. Perhaps we should meet and discuss our respective jobs a little more often.

I feel angry towards the unnamed commissioners in our service. I feel angry because they drop services on us which are basically unsuitable but cheap. They say they ‘consult’ but as I have learnt over my time in the job, ‘consult’ does not mean discuss, it means tell.

I wonder how many of these faceless ‘commissioners’ would be happy to stand alongside me in a hospital as I tell a family they will have to travel miles each way to visit their parent in a residential home because we have nothing available locally. Or stand next to me as I apologise, in my role as a corporate ‘entity’ because the provision of respite which was promised is wholly unsuitable because its all we have to offer.  Or listen to the conversations I have to take about carers rushed off their feet because they are limited to these ‘15 minute’ pop-in visits to desperately lonely people or listen to the discussions about why we no longer do a hot meals on wheels service and deliver only microwaveable meals. Occasionally, I’ve been known to tap out a grumbly email to ‘commissioning’ about particular services – and why I think they work or what I think is lacking – simply because I am not sure what other action to take and I want to ‘do something’. I’ve never really had anything other than perfunctory responses. They seem to exist in a parallel universe of contracts and submissions and plans.

Who was consulted before these commissioning decisions were made? I’m sure people were. Or were they? What backgrounds to ‘commissioners’ have in human services – I honestly don’t know. I don’t know if they have ever had any professional expertise in the areas that they commission for or have just moved up through various administrative ranks without any frontline experience.

I know ‘back office’ is important. I know there are some people that need to commission services. I understand that. I just wish sometimes I knew who they were and the ways that they made their decisions. I wish sometimes they would show their collective faces in our offices to understand better the implications of the decisions they make.

I’m very far from an expert in organisational systems but surely it can only help when different parts of a ‘group’ come to know each other face to face through discussion and understanding rather than the continual barriers that are put up between us by people who feel it necessary to stay in their safe silos.

I don’t want to mistrust commissioners. I just want to know who they are. More importantly, I want to know they understand the effect of their decisions on the people I see every day.

What does a Mental Health Social Worker do?

I think there’s a lot of misunderstandings about what I actually do at work. What do social workers who are in mental health services do? What do social workers who work in adult services do?

I hope by reading, some people get to learn a little of my day to day role but I also thought it might be useful to set it out more explicitly.

I’ve worked in adult services and I’ve worked, as I do now, in mental health services but I’ve never worked in childrens’ services so I can’t comment at all about the work that is done there. This is my attempt, not to explain social work as a whole, but to explain the bit of social work that I’m familiar with.

I work in a multidisciplinary Community Mental Health Team. We have a consultant psychiatrist attached to the team as well as a few (the amount fluctuates!) other doctors. We have occupational therapists, clinical psychologists, assistant psychologists, community psychiatric nurses and of course, social workers. We always seem to have students around, whether psychology trainees, OT students, nursing students or social work students (and even some medical students pop in occasionally).  I sit opposite a psychologist and between an OT and a nurse.

Although no week is typical, I’ll give a few examples both of the generic role and the way that social work fits into a mental health setting, in England, at least (because I’m not sure if there are differences in Scotland, Wales and Northern Ireland).

Work is allocated for ‘care co-ordination’. Care co-ordination is akin to what we would have called ‘care management’ in Adult Services although there are some differences and responsibilities under the Care Programme Approach.  It basically means we take responsibility as a kind of ‘key worker’ for individuals who are ‘taken on’ by our service.

Allocation should be done on the basis of appropriate professional expertise so for some issues that have a more ‘social work’ tilt about dynamics, organising personal budgets or residential placements might be preferred as allocated to social workers, some that are more rehabilitation orientated might be allocated to an Occupational Therapist and more medical or medication management might be allocated to a CPN but that is a very broad brush to paint and in practice – most people are a mixture of all the different needs and so are allocated generically. If I have need a of specific OT assessment for one of the people that I am care coordinating, I will ask one of our OTs and similarly, I care coordinate one person who receives a monthly depot injection from one of my nursing colleagues.

So what is care coordination/care management about? Well, we start by working with and on a care plan and this should be led by the user of the service. If there is a carer involved it would also involve them and we put together plans. In my service which works predominantly with older adults, there may well be care services needed and this is now all delivered through personal budgets so I would take someone through the supported self assessment questionnaire, the resource allocation system and develop with them and/or their carers, depending on capacity issues on a support plan and way that services would be delivered. This would be reviewed and implemented in partnership.

I will also arrange respite placements  and services when they are needed and review services as they are delivered.

Alongside this, I would also be responsible for monitoring any changes in mental state and might provide some brief therapeutic interventions mainly through basic CBT type models according to additional training which has been given in the NHS Trust I work in as they are trying to ‘skill up’ all care coordinators!  When I meet with someone, my discussion ranges for more broadly than about their care needs specifically. Sometimes it is about sourcing and finding ideas, services and people that might be able to help, namely through group work which is run across the service or through referrals to specific psychologists attached to the team. Sometimes it is much more difficulty to quantify – and log – and record.

I work with carers and work through carers’ assessments and services such as they are. Often I feel one of the most important aspects of my work is carer support as we rely so heavily on some carers. I might liaise with different organisations on peoples’ behalf if they can’t manage or need some assistance. Sometimes I help with Attendance Allowance or Disability Living Allowance claims but there are council teams that do that so it would only be in circumstances when I might know someone particularly well and be concerned that someone who doesn’t know them that well might ‘underplay’ some of their needs.

Sometimes it is about liaising with creditors, gas and electricity companies, housing etc with various degrees of success. I like to think of myself as an advocate at times.

Although at times, I am very far from an advocate. I am subject to specific ‘terms of reference’ of my job and have no control over things like budgets that can be assigned to various people with various needs. I would ‘present’ the needs of service users I work with to various internal funding panels so on that basis I need to advocate clearly.

We have to review the services that are in place regularly. I would attend meetings at day hospitals and on wards when I am allocated to people who currently attend or are inpatients.

I work to plan and organise discharges from hospitals both the psychiatric hospitals and the general hospitals when people whom I am allocated to are inpatients. There are some very obvious time limitations on these pieces of work and no-one wants anyone to be in hospital any longer than they have to – but equally no-one wants someone to be discharged from hospital before they are well enough to be – which is another very important consideration.

I conduct safeguarding investigations as well. Alerts come up with what can be surprising frequency and there are prescribed procedures through which we approach these investigations. It’s hard to generalise as they can be very different. Interestingly most of my recent ones have involved residential services in some way or another. I think I’ll come back to the process of investigating abuse in another post as it is altogether a subject in its own right. We tend to get more of these investigations in older adults services than occur in the working age adult services.

I am an Approved Mental Health Professional (AMHP). That means that I am on a rota to carry out Mental Health Act (MHA) Assessments . There is an important difference between a Mental Health Assessment which is a more generic term for an assessment of someone’s mental health and a specific ‘Mental Health Act Assessment’ which is a formal assessment under the 1983 Mental Health Act which can result in a compulsory admission to hospital without consent.

The role of the AMHP could be a post all of its own and it probably should be so I’ll condense here for clarity because it has increasingly become a part of my day to day role. I organise and arrange these assessments by arranging for ambulance service and doctors attendance (there have to be two medical recommendations written by doctors – one should know the patient (usually their own psychiatrist or GP along with an independent doctor who has had additional training). I also attend a magistrates’ court to obtain a warrant to enter if it is likely that we would not be allowed access to a property. I  arrange police support if necessary and would also organise a hospital bed if necessary.

There are legal forms to complete and I have an obligation to be mindful and respectful of legal rights and human rights when involved in these processes.  I am obliged to attend a specified amount of ‘legal updates’ every year to maintain my approval as an AMHP and every five years I have to be ‘reapproved’ which involved me taking a legal test and submitting some reflective pieces and examples of my work as well as carrying out a set number of assessments per year (no problem with the numbers – I’ve done the requisite annual number in the past week!).

I’m also a BIA (Best Interests Assessor). This means I have specific duties and responsibilities to carry out assessments under the ‘Deprivation of Liberty Safeguards’. Again, that probably demands a post or two of its own. Suffice to say that every so often I am called out to do a specific type of assessment on this basis.  I had to attend additional training to be able to do this and have to attend update workshops and training to retain my approval.

Apart from the things I’ve listed, my job involves other pieces of work. I write social circumstances reports for tribunals. I occasionally have been involved in assessments and writing reports for Guardianships and in taking part in the process of approving or extending a Community Treatment Orders. I frequently carry out Capacity Assessments for various reasons.

I’m a practice assessor too so when I have a student, well, I have a student to supervise. I tend to enjoy having students around. It does create more work though and there’s no recompense in terms of reduction of caseloads! And the universities and local authorities wonder why we can’t offer as many statutory placements!

My work is often one of juggling and trying to prioritise and reprioritise on the basis of risk management. What is more important for me to complete on any given day.

I haven’t even mentioned data input or writing case notes but takes a fair bit of time. We have regular audits of our ‘productivity’ – we have to input our ‘outcome measures’ and re-input them regularly so our management overlords accept that we are actually spending our time at work, working effectively and not just twiddling our thumbs and playing Facebook games.

The amount that we have to ‘report back’ is, of course, growing at an exponential rate.

So that is my job – as briefly as I could manage and I have missed out some of the million subtleties that might change on a day to day basis.

I generally enjoy it. I love the variety that is thrown my way on any given day. Some days it frustrates me and there are rarely enough hours in the day to get what I want done, done. This may explain some of my frustration with the bodies who all say they ‘speak for social work’.  Have they explained the role of social work outside child protection? Would you know, if you are not involved in the ‘system’ what a mental  health social worker actually does?

But really, that’s another fight for another day. For now, well, I need to go to work!

But I had over to you, dear reader. Is there anything that surprises you? What you expect? What have I left out – as I’m sure I have missed a lot of things!

Sadness, Sympathy and Self

Sometimes, some days feel filled with sadness. I had one of those days this week. I don’t like to use the word ‘hardened’ but to put it this way, in over 10 years of frontline social work practice in some of the most deprived areas of the country and in the inner city, I’ve seen a fair bit of what society has to throw in terms of crumbs to those who are some of the most vulnerable members of it.

I look at the high rises that skirt around the cities and I see hundreds of lives being lived, families existing and stories being told. Some with hope and pride. Some with desperation and despair. All different, all a part of this community and society we live in. Poverty is real. Despair is real. The two don’t have to go hand in hand though.

I have a strong stomach and don’t bat an eyelid at all sorts of things when I walk into a house. I’ve probably seen worse.

In some ways, human misery is a part of my trade. Not always, of course, because there are the wonderfully reassuring smatterings of hope but difficult social circumstances and social deprivation run a theme through my career.

Although I often emphasis that mental ill-health is certainly no respecter of social class or financial assets, it is sometimes the level of deprivation and the difficulty and shame of poverty that I see that reminds me of the way that this political class intentionally ignores and isolates some members of the community.

Perhaps the most difficult part of  my job is wrapped up in the AMHP (Approved Mental Health Practitioner) role. It is a mirror into my ethical compass and while I enjoy the aspects that were involved in training and the support and development and even community feeling I have with other AMHPs, the process of making a decision about someone’s forced detention in hospital or a forced medication regime is never one that can be taken lightly and I don’t think it is one that should ever be ‘enjoyed’.  It is power, writ large. It is control.

Sometimes people thank you retrospectively for ‘making the right decision for me at the time’ but more likely that isn’t going to happen.

This week, I carried out a Mental Health Act Assessment in a hospital. That is very far from unusual. When I read the background and the circumstances, when I conducted the assessment and made the application for detention, which I did, I was overcome with a feeling of sadness for the action that I had taken and for the life that it predominantly affected.

For obvious reasons  I won’t go into details – anyway, even if I did they would possibly sound fanciful and unrealistic. To people who think that I have a ‘difficult’ job, I would say I  have had a walk-on part among some fine and very strong people who have had to contend with sickness, pain and family circumstances that have rolled all the dice against them in the lottery of life.

And when I sign the papers and write up the report, I don’t forget. I think, I reflect and I try to learn. What could we have done to prevent this situation from having occurred? Sometimes the answer is nothing but sometimes there might have been a different path, a different action or different guidance that might have led to a different outcome.

Sometimes, some days, I just feel overcome with sadness. Sadness at the injustices that are meted out by life, fate and circumstance. Sadness at the way that this society perpetuates and builds on those injustices of circumstance. Sadness at my role my own complacency in accepting that we have created such an unequal and unfair society.

In a community where people who live on state benefits are treated with an intention to humiliate and scorn and where the government not only condones and supports this, it tries to create further barriers between the ‘haves’ (with ‘have’ meaning working tax-payer) and the ‘have-nots’ (meaning those who depend on the state for income) it sickens me as I know that the rhetoric of ‘choice’ and  ‘community capacity building’  are empty words which mean nothing without the world of privilege. By privilege I don’t mean money, necessarily, but include the privilege of having family or friends around, the privilege of being well enough to build up networks of support, the privilege of being a part of a community. There is so much more to privilege that cash assets or income.

Sometimes I want to shout against the system that I am a part of. The social care system in this country is not ‘fair’ – it reeks desperately of unfairness and the pushing of ‘choice’ in very narrow terms onto a wide range of people who in reality have no choice whatsoever further marginalises and discriminates against poverty, incapacity and isolation.

But I continue in my job. I go into work and ‘buy into’ the system. In my own defence, I fight as hard as I can from the inside and I don’t forget the names, the faces and the stories of those whose lives touch mine.

I remember, I note and I learn and sometimes, that just fills me with sadness – but when I stop feeling that sadness, I stop learning, growing and trying to create a better world. One person at a time. In spite of the system I work in and with rather than because of it.

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.

Power, Status and Professionalism

power. to protect.

 

kenyee@flickr

I was ruminating over the post I wrote yesterday about the interplay and interaction between being a social worker and being a foster carer and the one aspect that played on my mind was the differential in ‘status’.

I used to think status and professional status was very important to me as a social worker. Don’t get me wrong. I’m very proud to be a social worker but I think when I was first qualified, I was also proud to be doing ‘something proper’ and recognised.

I had, at this point, in my defence, worked for years in the care sector as a support worker and a care worker. I had had friends and family asking me when I was going to get a ‘proper’ job and tell me that my academic qualifications were ‘underused’ in a minimum wage care job.

And I listened. I began to believe. The process towards my professionalisation was one I was proud of. Sometimes if you do a ‘low status’ job or have no job, society makes assumptions about your general intelligence level so being able to prove that I could make it through a postgraduate course was also an element of pride for me. I liked the idea of ‘having a profession’.

But I wonder if I was too taken by status and if the divides and gaping holes that exist between policy makers and practitioners is because ‘status’ is a bar.

For example, yesterday I had an extensive conversation with the Personal Budgets Implementation Manager about a case I was working on. We made good progress on hopefully working on a more creative option for a service user I’m working with currently.

My colleagues were surprised that a) I had approached this ‘manager’ directly and b) that she  had listened.

I thought about this and my role in perpetuating the divides between policy and practice and how status remains such a predominant factor in blocking conversations from the ‘front line’ to ‘management’.

We are institutionalised both by our employers who determine that ‘conversation’ flows in one direction and by our society where we, as a species seem to be keen to label everything, put labels on everything and want to by our nature, know our place in the societal pyramids of power.

So back now to the foster carer and the social worker. Is the foster carer really on a ‘lower’ rung of the ladder of professionalism than the social worker that they can be ‘looked down on’ by so-called professionals? It can honestly feel that way and taking a step back to look at the way I am ‘dealt’ with when I have my ‘social worker’ hat on as opposed to when I introduce and describe myself as a ‘foster care’ is a glimpse into the different statuses that it is accorded.

Status is afforded because power is present and this is something that overrides the social work profession in whatever capacity it is undertaken. Whether it is in adult care management where it can feel as a practitioner that you are pretty reined in in terms of what care can be provided on financial levels, in the eyes of the service user you are the ‘gatekeeper’ to the mythical goal of ‘provision of care services’.

In Mental Health work there are some obvious legal powers under the Mental Health Act but even in day to day care co-ordination, you become the conduit between the multidisciplinary team and the service user. You decide what is important to feed back, what constitutes a concern or a worry and how situations may be resolved or, if necessary escalated.

And we go into people’s homes. We make appointments. We decide on timings to fit into our busy diaries. Sometimes we even cancel appointments. These are all displays of power. Power isn’t about flexing of muscles, it can be as much about sending a letter or making a phone call suggesting a time to visit. Of course, it has to exist but the important thing is never to forget the power differentials and the way that they change the dynamics between user and provider.

With my last social work student, we spoke a lot about power and I alluded that she should reflect on the power relationship between us as well as the power relationship with service users. I smile and I joke with her but there is an enormous power differential between us that cannot go unacknowledged.

And as a foster carer, I accept that social workers will turn up at any point to see the child I have in placement or to just see the home or to check up on us. That’s fine, it’s understandable and I have no problem whatsoever with that, I know it’s a part of the process and I would feel angry if foster carers were not subject to checks but there is a power differential there and it has to be acknowledged  – even if it is not openly acknowledged.

We can never have an truly equitable ‘status’ because social workers can come and check on me and are responsible for my approval as a foster carer but I can’t wander into their home or even office at will (trust me, I wouldn’t want to!).  I think without acknowledging this power differential or by pretending there is any kind of ‘equal’ status we do both parties a disservice.

Once acknowleged, issues of power can be addressed and considered but if it remains unspoken, they can be levered and used for less positive outcomes and ends.

As for ‘professionalism’ in social work, I think we could go round in circles with this one. Respect is helpful but that is a truism that can pretty much be applied to any sphere of life. Is the respect based on professionalism? Only if the professional is respectful and competent.   An incompetent professional can do far more damage than good and the converse is true for a good professional.

Thinking back to the stories of abuse at Winterbourne View,  we see much more obvious displays of power. The power was held by the care workers and exercised on the patients at Winterbourne. There is something within the care sector where so  much work is done with some who for many reasons may have little power that it can attract people who want to exercise power for the wrong reasons – to augment feelings of self-worth or to bolster failings in other areas of their lives. It is important that the power dynamic is acknowledged and guarded against at all levels and that it never ever becomes something that is taken for granted or played on to make others feel threatened or denigrated.

The status, the qualification, the experience and the practice alone don’t make a ‘good professional’ – it is a mixture of all of them and the way that power is used, acknowledged (internally) and processed that create good practice and good practitioners.

We can often talk about qualities that are important for good social workers and social care workers. I wonder if I’ve mentioned it but for the reasons above, I would put the quality of humility very high. We need to listen and be aware of the inherent power we have. We need to ensure the voices we hear are echoed upwards in our chains of ‘command’. We need to listen to experts of their own situation and the people close to them. Sometimes we have to impose and sometimes we have to say no, but we acting with humility is a rich and exceptional quality and one that makes a good social worker.

Personal Budgets, Personalisation, Thoughts and Hopes

Yesterday Think Local Act Personal (TLAP) published the results of a National Personal Budget Survey.

The headline ‘results’ are of course overwhelmingly positive. Personal Budgets work. Direct Payments Are Good. Everyone is happy.
Questionnaire

jrambow@flickr

Is any of this a surprise though? We know that people who can and are able to manage (or have family members to help them to manage) personal budgets delivered through direct payments (where money is paid directly to users) prefer them to less flexible local authority provided care packages – particularly when the scope of local authority care packages is limited to agencies with block contract arrangements.

In Control – which publishes the survey – highlights the following ‘implications’ from the findings. The bold is a direct quote and the italics are mine.

Other implications that can be drawn from the survey results include:

  • Personal budgets work better for older people than you might expect and direct payments work just as well for older people as everyone else.

Who said we were not expecting personal budgets to work for older people? Does this make an ageist assumption and lump together all ‘older people’. Of COURSE they work as well for people who are 65 as they do for people who are 64 but what about people without capacity or who don’t have family or friends involved? What about a more subtle distinction between 65 year olds and 85 year olds rather than a blanket ‘old people’ response.

  • The processes used for delivering personal budgets are more difficult than they need to be and that impacts badly on carers and on personal budget recipients.

Did this seriously need a survey over three months to discover? You could have asked me three years ago and I wouldn’t have charged consultancy fees.

  • More work needs to be done to make direct payments more accessible generally but especially to older people.

This could have been written 6 years ago. We KNEW this from the roll-out of direct payments initially so why was NO WORK WHATSOEVER done around trying to work with more difficult to reach groups when personal budgets were being ‘piloted’. I really can say ‘I told you so’ as I begged our Personal Budgets roll-out team to allow us to pilot or be involved in the initial processes and they said our user group was ‘too complicated’. Heh.

  • There is a need to simplify and clarify the rules and regulations surrounding personal budgets.

So those are the ‘implications’ and forgive me my cynicism. I love the idea of personalisation. I want it to work. I want to work in more creative ways or outsource my work if necessary to other third sector organisations but this is not ‘different’. This is not ‘new’. I fail to see the value of reports and surveys that tell us exactly what we already know again, and again and again instead of actively trying to work with people who actually understand and know what is happening ‘at the sharp end’ to try and work out ways to improve outcomes for those who are not receiving direct payments currently.

So back to the report – which used a Personal Budget Outcomes Evaluation Tool (POET)

in total, 1,114 personal budget holders  completed the POET survey, including 832 returns from the 10 local authority demonstrator sites and returns from at least 76 other local authorities. 417 of these personal budget holders also wrote in a comment about their experience of personal budgets.
In total, 950 carers completed the POET survey,including 782 returns from carers in the 10 local authority demonstrator sites and returns from at least 66 other local authorities. 434 of these carers also wrote in a comment about the impact of personal budgets on their own lives

And

Almost half of people responding to the survey were aged 65 years or more (43%); the social care needs of working age adults (aged 16-64 years) were largely split between learning disabilities (17%), mental health needs (8%) and physical disabilities (25%).

I don’t want to play too many games with statistics but it would be interesting to know what proportion of people who meet the FACS criteria in total are over 65 and whether 43% is a proportionate figure in relation to total recipients of social care services. I think as well, to class ‘older adults’ as ‘over 65s’ is a little disingenuous although I know it is done because that is the basis on which statistics are given but it shows some of the ways that systems restrict and inhibit knowledge. It would be far more interesting to know the differences of take up of personal budgets between 65 year olds as opposed to 85 year olds for example.

And to some of the headline figures, that can catch the press attention – most people who receive personal budgets find there is a ‘positive effect’.

Looking through some of the figures, it seems that older people were much more likely to be receiving council managed budgets – you know, that ‘easy’ way of just switching around a bit of paperwork and making it look like there is now more ‘choice’ when in fact, the services and delivery is almost exactly as it was before the ‘change’.

As for the outcomes the report says

In terms of social care need groups, older adults tend to report less positive outcomes than other social care need groups in six out
of the 14 outcome domains

I find the report to be honest, a bit of a whitewash in itself. It is only accentuating the positives and like all discourse related to personalisation and personal budgets, seems to be going over all the same ground again and again.

People like choice, people like flexibility. Yes, and rabbits like to eat carrots. It doesn’t need a survey to tell me that. What action and money and research needs to be concentrated on is the HOW.

HOW is there going to be an improvement in service delivery to those who are marginalised in this process.

HOW are we going to wriggle out of the sham that is council-managed budgets while allowing those who need to have others to manage their budget and support their care to have the same access to quality care and personal assistants that those who are able to choose and decide have.

I’m rapidly coming round to the view that personal budget support planning needs to be moved out of the hands of local authorities who currently have no interest in the process except for meeting the government targets. Where is the innovation within local government for change? Sure there are people, and I hope to be able to count myself among them, who want to do a better job and provide a better service but the constraints of the type of job I am doing means that I can’t devote the time necessary to truly inclusive and supportive care planning so Mr G whose support plan I am writing up (he doesn’t want to be involved in the process as he ‘doesn’t like forms’ and can generally only tolerate conversations with people for between 5-10 mins maximum and that’s only if he’s known you for at least a year) does get a rushed service because I have to carry out Best Interests Assessments, do Mental Health Act Assessments,  complete reviews and CPAs, liaise with other professionals, arrange discharges from hospital for other people. Yes, it’s a little bit of wallowing in self-pity and I wholly accept that. We are all busy but local authorities have no idea if they want a quality support plan without changing the ways of working in any other respect. Where is the time to devote to Mr G’s creative support plan? Oh, well, we’ll just do a regular care plan and a managed budget. Should it be that way? How has the march towards personalisation helped people like Mr G? Mr G wouldn’t complete a survey about a personal budget even if he did get a letter. Letters worry him and he doesn’t have a phone. I don’t want the Mr G’s that I work with to be forgotten in the rush towards direct payments.

When I first attended training we were told that any additional time we might be spending in our day to day work on these awful process-driven systems would be made up by the amount of time we would save by people completing their own support plans and assessments without any assistance. That may work for some people and I hope it does but for most of the people in the team in which I work it is unfeasible due to the amount of people I work with who have high support needs and who don’t have the capacity to make decisions about their own care needs.

The survey angered me, in a way that is probably irrational. Partly because it seemed to have taught us nothing at all. And partly because again, I see no new thoughts and ideas about developing systems that will be truly inclusive.

HOW can social care improve for everyone. That’s everyone. Even those who don’t want direct payments. Even those who don’t have advocates. Even those who are self-funding their own care packages as the criteria for receiving government support rise higher.

Those are the questions I want Think Local Act Personal to answer.

I have my own ideas. I think there will be a movement to roles for professional ‘support plan advisors’ who aren’t necessarily based in the local authority – perhaps individual social work consultancies but there has to be a separation between planning and delivery and the cost of these services shouldn’t need to be met out of the personal budget itself.

First and above all, there has to be a consistency and a transparency in the way resources are allocated and if necessary a weighting towards people who need assistance to access the same kinds of services who have been excluded from the process and the benefits in the past.

A survey of the skills-base of professionals who do implement support plans needs to be undertaken to establish what is needed and what is important to have.

Maybe it is a professional type qualification or maybe not. There is not much discussion about what the role of the social worker should be in the process. Should we be the ones support planning? I think there’s a argument that a social worker is well-placed to look at building plans together in conjunction with a user and family member if necessary and setting up things like trust funds or managed local authority budgets but only if the social worker is removed from the local authority talons.  Maybe some kind of team of people with different kinds of experience and expertise working together with some background and training in non-directive advocacy for people who do lack the capacity to organise their own support plans. Perhaps the social worker or support worker in these new roles could have longer term relationships with the users and carers and wouldn’t feel so pressured by management if freed from the local authority reins.

But who is going to suggest and discuss the new ideas? Where do they go? Who will collate them?

While I see lots of discussions around me about personalisation, I see little that says anything other than it HAS to work because it is best for ‘people’.

I genuinely believe that is has potential to deliver a much better system but and this is a big but, there has to be more creativity and different kind of research that looks at new models and methods of delivery and consults people – yes, like me – who while being critical really really do want things to work better.

My criticism isn’t because I want to bury my head in the sand and ‘retain the reins of control’. I really don’t. I want to relinquish control but I want more than anything an equitable system that doesn’t fob off ‘more difficult’ service users with a second class service.

The Price of Everything and the Value of Nothing

To continue my theme (at least initially) for carers’ week, I wondered a while on the purpose of these weeks and days and months we have devoted to various issues.  They are about celebration, gratitude and recognition for the most part. Celebrating Mothers Day, for example,  doesn’t make us less grateful or thankful for our respective mothers on the other 364 days of the year so what is it about having a special day or week that is necessary.

I’m not a cynic. It is a good focus for events and allows particular issues that can be forgotten to be drawn out into the news agenda for a discreet period of time (a week is good – it can focus the attention). Campaigns can be built around days or weeks or months and themes can be wound up in the consciousness of the ethereal ‘general public’ whose attention can be fickle and fast-moving.

So it is that Carers Week is upon us but for it to be truly meaningful over the longer term there has to be a more systemic change in the process of social care and the way it is done in this country.

I engaged in a very brief ‘Twitter chat’ yesterday with a carer, Casdok, who writes a blog here. She mentioned that since her child had moved from childrens’ services to adult services she had noticed that she was listened to less and (I’m extrapolating a little here because it was in very short messages!) the service received was less good.

A brief exchange mentioned the loss of the relationships with particular social workers – you know, when the social worker used to pop round for a cup of tea – made me wonder what we have lost in the rush towards ‘care management’ which was to be the way that adult social care was organised after the NHS and Community Care Act.

I worked in an adult social care team before I moved into Mental Health services. The office had something of a ‘production line’ feel to it. Assess, review, close. Assess, review, close. Sometimes you would linger if there were direct payments involved but that would mostly be about referring to a different agency or part of the council to set up the payments and advise about employment regulations and advertising for assistance.

The relationship was and is lost. Is this what we study for? To assess, review and close with some safeguarding thrown in with increasing regularity. The processes have been streamlined almost to the point of any independent thought and true ‘assessment’ in the sense of being able to give professional judgements being rattled out of the processes to simplify.  This process has streamlined the heart out of social work for adults.

Critical analysis and reflection, yes, there is an option but it has to be in your own time and at your own rate. When we lose the critical analysis and reflection in our work though, we cease, to all intents and purposes being social workers and become care managers.

And where is the relationship-building? The listening. The advocacy. It has been costed out of the equation. It cannot be reduced to a performance indicator and therefore it has no value.

The issue is that it does have a value. It has a value to carers and to service users but often that value is unquantifiable and in a world of measurements and costs, unquantifiable is not where you want a value to lie. Because it is discarded.

The reason I moved from adult social care into mental health social work was because I felt my brain was stagnating to a point. Of course, things may have changed with self-directed support being more available now but I hope I always assessed in a person-centred and creative way. I certainly set up a lot of direct payments packages.

For the moment, in the mental health teams we do have a little more time to spend building therapeutic relationships. We have  more time to listen. It is all measured, of course, against outcomes because we have to be able to justify every minute we spend on paid time  but the ability to build relationships and to listen are, at least, embedded more strongly in the role.

I can’t see us ever going back to the days of being able to pop in for cups of tea. And we have lost much much more than a piece of cake along the way. We have lost the soul of the profession at the sniping jaws of employers who want to distil creativity out of the job because we need to meet specified targets in specified times. Everything is quantified.

Sometimes though, we need to be less complacent as employees. There are jobs going. There are changes coming in our services. Last years cuts are only the very start. They will come more quickly. Social Work is changing. It will move out of local authorities and I don’t think that will necessarily be a bad thing. It may be the best thing for the profession as a whole, in fact, if not for individual employees who won’t necessarily have the rock solid pensions and the now laughable idea of job security.

Perhaps we need to take more responsibility for our own work and our own profession in order to retain the values that remain at its heart and move into community work and macro-social work.

I occasionally get glimmers of real hope and drive for the future and the ways in which this profession can change and be changed and then, I look at the people at the top and wonder if there is any desire for truly structural changes in the way that social care and social work is delivered. Yes, I want personalisation to work, I really do but I want the value of good (and I really mean good) quality social work to be recognised in the process.

Yes, there are coercive elements to our role. I know that only too well as an Approved Mental Health Practitioner. I didn’t go into this job to be loved and as for respect, for the most part, I can take it or leave it – except for self-respect. I have to be able to feel I am giving the best every day I am at work and that regardless of some of the more coercive elements of my work, I am able to work according to my moral and ethical compass.

Sometimes I worry that has been lost but perhaps among the structural changes that are going on around us in social care, some true change can be affected.

I hope so.