On Kindness and Compassion

This weekend, I’ve been reflecting a lot on kindness and the way it impacts on my job. On Friday,  I had a conversation with someone I work with (in a different organisation) in which they demonstrated a level of kindness towards me that I was not expecting in the context of our previous conversations and professional relationship. It surprised me. They could have dealt with the situation in many different ways, as could I, but the kindness took me aback and I’ve been thinking about it ever since.

We hear a lot about the need for compassion in health and social care. There has been a ‘lack of compassion’. After the Francis Report publication, organisations within the NHS but on a broader level have been asking about whether there has been a deficit of compassion shown in services. I’m far from convinced of it. Cruelty happens. Neglect happens. Organisations develop toxic cultures. Does that mean there is a general lack of compassion by staff who do their jobs on a day to day basis? I don’t think so. I’m also confused by the language that is used.

I like to think I’m a kind, compassionate person. I try to be. I wonder though, what kindness/compassion is in the role that I have and have had and whether they are the same thing. Wikipedia tells me

English noun compassion, meaning to suffer together with, comes from Latin. Its prefix com- comes directly from com, an archaic version of the Latin preposition and affix cum (= with); the -passion segment is derived from passus, past participle of the deponent verb patois, patī, passus sum.

Whereas kindness is again, according to Wikipedia

a behavior marked by ethical characteristics, a pleasant disposition, and concern for others. It is known as a virtue, and recognized as a value in many cultures and religions (see ethics in religion). Research has shown that acts of kindness does not only benefit receivers of the kind act, but also the giver, as a result of the release of neurotransmitters responsible for feelings of contentment and relaxation when such acts are committed

Would we rather, on these definitions, that someone treat us with kindness or compassion? Personally, I’d go for the first. I have no desire for someone else to feel my pain or suffer with or alongside me. When I was working with people on a daily basis, we used the rule of thumb about treating people as you would like to be treated or as you would like a member of your family to be treated. As a simple baseline, it’s a good start and it’s easy to understand but perhaps we need to look beyond the self and beyond the ‘compassion’ which is about putting yourself in other people’s shoes or imagining they are in your shoes, and thinking how we treat people to create a better, more caring, kinder society as a whole. Compassion, perhaps, is about the individual but kindness can be broadened out to a wider group of people that we might not ‘feel’ for.

If we are looking at the word, compassion and compassionate in terms of the care I delivered when I was in a social work role, I’d like to think that I regarded everyone I worked with respect and kindness. Was I always able to feel their difficulties and suffer with them? I hope not as it would have burnt me out far earlier but I think I did my job well and tried to remember that I was in the position of power that flitted in and out of the lives of others having significant influence on their wellbeing and making fundamental decisions which I never took lightly. However, I had bad days too. I remember one time when I was annoyed with someone whom I was working with. It was a family member of a man I was working with and they had acted in a way that I thought had not been helpful. I remember actively biting my tongue and being short with them. I returned to the office and had a long chat with my manager. I phoned them and apologised. I was not compassionate. I was not kind. I don’t think it made me a bad person but gives us an awareness that people who see themselves as compassionate (however that’s defined in the context) can act in ways that aren’t. Does that mean the system is broken or that the people in the systems are human and have good days and bad days? Of course, cruelty and neglect are not ‘bad day’ things but I have never come across anyone working in health and social care who has not considered themselves ‘compassionate’ or ‘kind’ but sometimes that isn’t necessarily what I have seen in their actions.

So telling people to ‘be more compassionate’ doesn’t work. Telling people to ‘think more’, doesn’t work because we all think, to a large extent that we are doing our best.

Teaching Compassion

I’m far from convinced that organisations need to buy in external agencies to ‘teach compassion’. My gut feeling is that there is something of the snake oil salesman approach to those who peddle the ability to ‘teach’ organisations how to be compassionate. It’s not rocket science, as we like to say. I don’t think anyone (apart from the few who fall into the ‘cruel’ group for which no teaching will work) believe we are not kind or don’t want to be kind. We need space to develop kindness and in my view that comes through reflection. Just as I’ve spent a day or so, reflecting on a very simple act of kindness towards me, it has led me to think about how I can be kinder, in unexpected ways, to and with those people and organisations I work with. So one act towards me has had a ripple effect. Similarly others, if they have that space, can think about how they have been influenced by kindness and thought from others in professional and personal settings and how that can be passed on.

Are organisations needing to buy in external consultancy firms to do this? I hope not. My hope is that any organisation in this ‘trade’ has sufficient professional expertise to grow their own reflective practice. It’s far cheaper and more productive to ask your own staff what would help them than getting a consultancy in to tick the ‘done compassion training’ box and tell them. I’d have far more confidence in any organisation that sourced the space and time to embed reflective practice over one that bought in a firm and got 100% compliance with ‘compassion training’.  The key is that kindness and thoughtfulness start at Board level. If staff feel engaged with an organisation and a part of it, they want to do their best – sometimes they do, even if they don’t feel connected but it’s better for everyone if we do.

Kindness needs to drip down. Focusing on value based recruitment for health care assistants is great. Blaming health care assistants for all the problems in organisations when a lack of compassion has been identified is not. Staff treat people how they are treated. I’ve worked in different organisations and seen that those that have the best cultures are the ones that have most visible and responsive leaderships. Then the rest will follow. Staff teams that are well-led will filter out the team members who are less thoughtful in their approaches. Those that are poorly led will embed poor practice and culture. It doesn’t need any fancy training sessions to ‘teach’ that. It just needs, in my opinion, thought and time to reflect.

Reflection

I’m aware that I can sound like a broken record at times, but fundamentally, I think the gap that is perceived to exist in kindness and care can be solved through reflective practice. The problem comes with the space that is given for individual staff members and organisations to reflect and the value given to it within the world that is driven by cuts and outputs. To ignore the need for reflection and consideration though, leaves individual practitioners and organisations at a far higher risk of delivering care that is thoughtless. The wellbeing of staff knocks on directly to the wellbeing of patients or people who receiving services from an organisation. A stressed and anxious social worker will by less effective, less kind, perhaps, than one who feels that they are a part of an organisation that shares their values. I know it’s easier said than done. In my previous team, we took time to talk through cases with each other, even when we were at our busiest because it made us stop – and think – about what we were doing and the impact that it had. The skills we learn to reflect and reflect well and often are imperative to good and safe systems. Reflection should also allow space to challenge practices within organisations which are faulty or unkind. We need to look after ourselves as practitioners and we need to demand it from our employers if they do not provide it.

Kindness

So back to the initial kindness that was shown towards me. It made me realise what a difference it can make especially when it comes from an unexpected source. In my theme of hope for the new year, I think that I’m going to try and be kinder, if I can, for as much as I can, to those I work with and around. While kindness cannot solve the financial difficulties the sector finds itself it, it might be able to make the work environment more pleasant and more caring for those who use the services proved  but also for those who work within them, at all levels.

Looking back and looking forward

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

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

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

Power

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

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

Constructive Criticism

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

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

Change management

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

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

Hope

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

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

Happy New Year

RIP NHS?

Andrew Lansley, British politician and Shadow ...

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A truly national health service as conceived in the post-war years has been tottering on the brink for a number of years.  As the previous Labour government sowed, so the Liberal Democrats and the Conservatives will reap today as the NHS and Social Care Bill reaches its last stages in the House of Commons  and the Conservative Party  institute their idealised version on a market-led health service which will deliver profits into the hands of investment companies and will place efficiency above effectiveness in treatment delivery methods.

Yes, I feel bitter, very bitter. I don’t see the Labour Party hauling us out of the mess that the both the Liberal Democrats and the Conservative Parties have conspired to leave us with because the Labour Party in their previous guise very much laid the groundwork for this to be done.

I find it hard to believe the audacity and the incompetence of our political elite as they push through a hugely unpopular bill tonight but then, as I pause, I wonder if it is truly incompetence as they are ‘getting away with it’.

We have been confused by details and have been tricked into believing a ‘consultation’ process has taken place. It has taken place very much on the government’s own terms and the listening that has been done has been very selective.

I try not to have a blanket opposition to the ‘private sector’ and ‘profit-making’ in the health and social care sectors but I’ve been burnt by experience. There are some companies that may well be able to improve some aspects of service delivery and I completely accept we all need to move away from the blind public/private being good/bad depending on where you stand on the political spectrum. That’s quite hard for me to ‘get my head around’ as I feel instinctively that profit should not be made from ill-health but equally the government’s obsession with public being bad is equally short-sighted and damaging.

What really sticks is the way that Cameron has blatantly misled the country in the quest for votes. ‘No top down reorganisation of the NHS’ he said, lying openly to the nation and yet we have to accept the mishmash garbage that he is now leading through Parliament as the Health and Social Care Bill and it moves towards it’s Third Reading in the House of Commons today.

I feel angry at the way that language has been turned and stolen from us.

‘Choice’  has become a catch-word but as I have discovered through the ill-spirited and contemptuous way that ‘individual budgets’ have been delivered in social care – choice mostly a luxury of the ‘worried well’ or the more affluent middle classes – in whose ranks sit all those MPs who vote on these changes today.

Choice means very little if you are not in a group that can cost a company money rather than increase their profits.

We have been hoodwinked into believing that ‘choice’ will genuinely exist when these private companies rip up our public services to deliver profit to their shareholders? I think we should ask whose ‘choices’ is it that the government and the health companies that support then, they will be?

Let me turn to the social care sector again because that’s an area I am familiar with. I am very familiar in the ways that privatisation has worked or rather, not worked and the way that ‘choice’ has been promoted – falsely – as the achievable outcome for all end users.

The pushing of the public sector from social care delivery has decreased ‘choice’ in many instances. In the areas I’m familiar with, local authorities have been pushed out as providers of residential and home care services to be replaced by companies such as Southern Cross (RIP), Bupa, Care UK (always worth repeating that they donated to fund Andrew Lansley’s private office)  and homes have closed, block contracts have been signed to provide care at the cheapest costs which increases profits for the private companies of course and limits choice for individuals who need these services.

Anyone who claims that the roll out of personal budgets has or will change this and has increased ‘choice’ I will point to those who have capacity issues – those without family or friends to support them – those who are more marginalised have far fewer choice than the ‘mainstream’ who are able to engage in the process and that suits the government and the propaganda machine just fine.

That is what I fear for with the Health Bill (I am not sure why it’s even called the Health and Social Care Bill as Social Care is so obviously a troublesome ‘aside’ for the government).

Choice may well be nice for making decisions about which hospital is most convenient for a scan but what is being done to assist, support and advocate for those who are not able to make choices?

We are all in this together? Really? I doubt it.

As for me, I’m off to the vigil outside the Houses of Parliament tonight with my local Unison branch.

The TUC have also organised an ‘online vigil’ to oppose the passage of this Act.

And then.. to the Lords. But I will take careful note of the voting as it happens tonight. And I won’t forget.

Panels

Since I’ve been employed as a social worker one of the constants in my working week has been the presence and existence of ‘panels’ in many different forms. There was a brief stage when we were told not to refer to them as ‘panels’ but rather meetings but it’s all the same thing at least, in the setting in which I’ve been working. They are groups of managers and professionals of a variety of provenances making funding decisions on behalf of the local authority or health service.  Of course sometimes they say it is about joint decision making (which is why the word ‘panel’ is frowned upon now) but that’s really a facade. I make recommendations but I have little authority over funding decisions.

Different local authorities often have different mechanisms so my explanations of the panels that I might attend come with the proviso that things are arranged and organised in a variety of ways.

We have panels which primarily make decisions about packages of care that exceed a particular baseline cost. That baseline has changed a variety of times but generally managers in each team are given a certain ‘threshold’ to which they can approve funding requests but above that and any application for funding for residential or nursing respite or long term care have to navigate a ‘panel’.

We have separate panels for high cost personal budget packages which would be provided for care at home and those which approve residential and nursing care/respite and continuing health care (which authorise applications for long term payment for care by the NHS )

Going to panel generally involves the transfer of reams of paperwork. I’d probably say it’s the most obvious way though that I provide the function of advocating for a particular service user or family member when I ‘present’ the situation to those who make the ultimate funding decisions.

Contrary to what some people might think, I have absolutely no vested interest in the local authority or NHS ‘saving’ money by not agreeing to a particular package – indeed, I won’t tend to bring something to the panel if I don’t wholeheartedly agree with it myself. I am a great advocate of money being spent where it is needed.  I have a general wish to see public money well-spent of course and I understand the need to ration resources but if I bring something to the panel and authorise an assessment, it is because I believe that that is what is needed according to my professional  judgement and as far as that’s concerned, balancing the rest of the local authority’s budget is not an issue I consider (which is obviously why these panels exist!).

Similarly with the Continuing Health Care Panels  I cannot conceive of a situation where I would bring someone to that panel if I didn’t absolutely want and believe that they should get that funding.  If I attend and collate a report it is because I and the multi-disciplinary team behind the report, believe in it.  I absolutely want people to get what they are entitled to and have no ‘secret instructions’ to try and deny the funding. The rules though are not altogether clear but it suits the funding parties and the governments to keep the rules complicated and unclear. There’s a lot of money at stake.

The panels are open to service users and carers but for me, personally, it’s very rare that service users or carers attend with me.

I have more often  had family members attend Continuing Health Care Panels with me and found it is a much better way of working as it allows a lot more transparency and removes one of those bars between me trying to put the words of others in my mouth.

By now, I know the people who sit on the panels and they know me. That’s a massive advantage in being able to persuade and cajole. It makes me realise how useful it is to have built up links and a reputation among the more senior management. I like to think that a trust develops.

Panels used to scare me because I’d be questioned, often in detail about the proposals that would have a substantial monetary implication for the local authority. My paperwork and assessments are examined in great detail and a level of scrutiny applied. Now that I’m more confident, I tend to take pride in presenting my reports and welcome the questioning as I know what to prepare, what to highlight and what to expect.

I’ve had panels where paperwork alone is assessed and where we are not required to attend in person.  I prefer being there ‘in person’ especially when there are any question marks that I feel I can clarify.

One of my favourite tasks in my work is feeling that I am genuinely able to advocate and navigate a person or family through the muddy mired waters of local authority funding streams and decisions. I wouldn’t say I enjoy the panel process although there is a satisfaction in having something approved especially if it is something you feel might be hanging in the balance, but I don’t dread them as much as I used to.

As for now though, it’s just another part of the process of seeing a paper ‘plan’ through to fruition.  I know they work differently in different areas – indeed, I’ve seen them in different forms in the local authorities I’d work for – but that’s how they work – whether they are called meetings or panels, the effect is the same.

And that’s the explanation of what the panels are – the other side of each discussion I have and each decision that is made by the faceless ‘management’ that I sit in front are that they are desperately important decisions to each person who is reliant on the authorisation of that funding to allow them to life their lives more fully, to allow their family to have access to respite services. My job as I see it, is to bring the paperwork and paper assessments ‘to life’. I am not only writing about a person on a pro forma, but I’m able to flesh out the requested questions and documents with a person, with a family, with relationships.

That’s why I don’t mind attending  these panels as much as  I used to. I’m not frightened of them anymore. I see them as an opportunity to take a crucially important role in someone’s life and to speak for them and not  just about them.

Selling the NHS – The Beginning

The National Health Service Norfolk and Norwic...

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

As The Guardian reports

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How equitable will the ‘new’ system be?

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

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

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

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

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

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

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

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.

Scrutiny, CQC and ADASS

Yesterday, I read on the Community Care website that ADASS (Association of Directors of Adult Social Services.. and Housing Departments or whatever else they direct these days) are seeking a meeting with the CQC (Care Quality Commission) about

‘a new ratings system for providers will reduce scrutiny of services, to the detriment of users.’

I see a problem.

This is Adass’ (I’m not sure where you put apostrophes on acronyms.. ) response to the government’s consultation document ‘Transparency in Outcomes – A Framework for Adult Social Care’. I’m glad I came across this article because the consultation had completely passed me by.

This is a part of the government’s push from measuring targets to measuring outcomes. I remain more than a little sceptical regarding the measurements used in these systems and neither seem to devote much credit to quality over quantity and cost of support.

According to Community Care

The government has proposed replacing the quality ratings system, under which the CQC graded all registered providers as poor, adequate, good or outstanding, with a voluntary “excellence standard” for the best providers, in consultative plans to overhaul the adult care performance system.

The article goes on to quote Adass saying that this

‘”could be particularly disadvantageous to self-funders and people using personal budgets to arrange their own support, particularly as this new system does not distinguish between ‘adequate’ and ‘better than adequate’ service or between ‘good’ and ‘excellent’ service.”

It warned that the system may also favour larger providers that had the financial muscle to apply for an excellence rating, and may lead councils to increase their own monitoring processes, increasing costs.

Quality ratings were scrapped last August, but Adass warned: “Further we are concerned that there is no timeline, implementation plan or agreement about how this system will operate.”

So we are currently in a period where ratings have been scrapped and they have not been replaced – meaning that there is no quick, easy and current way to check the standards are being met or exceeded by care services. The system intended to replace the previous one is reliant on voluntary standards which will be easier for large companies to achieve to the detriment of smaller providers.

More costs are being pushed from the CQC and the ‘central pot’ towards local government and quality assurance teams which are being cut (certainly in my own borough) due to central government cuts.

You know those ‘back office staff’, and ‘non frontline staff’, Mr Pickles? Those were the people who were checking on the quality of the services provided to your proverbial grandmother.  Why did they need to check so much? Because the CQC is a shadow of what it should be and has had all funding removed and is no longer fit for purpose and reliant on voluntary systems of regulation.

Would OFSTED be allowed to operate in this manner and haphazardly decide that they only wanted to check children’s services when they felt like it or when they fail? Or you know, that school should be ok because it hasn’t been so bad as to be reported to us? No, we demand more for our children so why don’t we demand as much for our older and disabled citizens who need  more regulation not less.

The government pushes direct payments and personal budgets but washes her hands of any regulatory support to promote quality. They are gearing up a system that will be heavily favouring large companies like Care UK – you know, the organisation that funded Lansley’s private office and is geared up towards taking over whole swathes of the NHS.

Even if you think you have no interest in adult care, you would be wise to listen and learn to the Cassandras like myself who constantly shout while the regulatory body is being stripped away.

This is exactly the way the government want to take the entire NHS.

We must learn from these lessons and not be fooled by the language of choice. Choice has to be a choice of quality rather than solely cost. Often the two are not the same. That has been the lesson of the deregulation of care services.