Age Discrimination and Language – or why I don’t like ‘The Elderly’.

What is age besides a classification? When do we become old? What language is used in relation to people who reach certain points in their life cycle. Does a child become an adult at 18?  Legally perhaps but in a sense these are rough brush strokes which relate in very different ways to different people.  When do we stop being ‘young’ and start being ‘middle aged’? When do you move towards being ‘old’?

Wise Ones

maureenshaugnessy@flickr
I’ve had growing feeling over the past years really, that our society does not value older people. Just yesterday, I received a wonderful application form from a potential student social worker. It was a positive picture of a hardworking and ethically sound potential practitioner. It warmed my heart.

But the student, although careful to detail their work with people with disabilities and children with special needs, felt that it was entirely appropriate to comment alongside this that they had worked with ‘the elderly’.

I presume this wasn’t discussed or mentioned by tutors at the university but it made me wonder how ‘the elderly’ has become more acceptable than ‘the disabled’.

I will put my hand up at any accusation of oversensitivity. I am acutely aware of the importance of language vis a vis power.  I am also aware that language shapes thoughts and reflects thought processes. If that makes me politically correct, I am proud to reclaim that label as a badge of honour.

Maybe in a society that needs to compartmentalise obsessively, it becomes more important to define someone by their age rather than their humanity but it also made me question what we mean by ‘elderly’ or ‘older people’.

Are we merely describing someone who has reached a certain age? I have worked in older adults services for a long time and some have called themselves ‘older adults’ and others ‘over 65s’ teams as a way of providing a context of age.

I read so many stories in the papers about the ‘problem’ of an ageing society and the costs of managing more dementia in society and it saddens me that age becomes another negative label and a problem for the wage-earning society to ‘deal with’. Perhaps that is the key to the perceptions that we have.

It’s natural that our perceptions of age and what ‘old’ is change with time as we and our parents, colleagues and friends move into ‘older age’ and it becomes less of an us and them type discourse and it becomes more personal.

I wonder why we, why society demands we differentiate between disabilities which are ‘age related’ and conclude that it is predominantly a cost issue. Social Security is determined by how economically productive someone is or could potentially be and when someone is past ‘working age’ their needs for social interaction and stimulation must automatically decrease?

Where is the ‘personalisation’ in the determination of Disability Living Allowance as opposed to Attendance Allowance. Look at the differences in those names.

Disability LIVING Allowance is paid to adults of working age (and children). Attendance Allowance is paid to those who are over 65. To be ‘attended to’ or ‘dealt with’. Not to live. Independent Living Fund monies were always restricted to those up to 65 (ok, now they are being wound down but the idea behind them was age-biased).

I wonder how much the Equality legislation will help? Perhaps it will but mostly I will only notice a difference when I stop seeing the ‘problem’ of an ageing population referred to and blame being assigned to people on the basis of their age.

As for me, I’m still deciding whether to raise the language issue with the potential student in their first interview with me or whether it might be something that needs some time to work on..

‘The Elderly’ No, I don’t like that. Not at all.

Initial thoughts on the Dilnot Report on Funding of Care and Support

Scheduling and exhaustion meant I didn’t have time to look at the Dilnot proposals in detail yesterday so this morning I have fired up my browser and am going to make a few initial comments on the baseline main recommendations and hopefully over the next few days can look at some of the details.

The Dilnot Report on Funding of Care and Support runs at 82 pages.  It attempts to forge a solution for the currently antiquated and inequitable system of care funding that is currently in place. Much talk has been made of the current threshold of £23,250 of assets, at which people currently become responsible for paying for their own care services but little made of the current discounting of homes in certain circumstances and the ability to raise a charge on a property to postpone payment of costs for care services. Nevertheless, this threshold was deemed as being too low. People who own houses like to keep houses for children. People don’t like those who ‘haven’t worked as hard’ or ‘saved as much’ getting something for free.

The system is broken though, don’t get me wrong, I just think the focus of the discussion has been too much around middle class fears of actually paying for something they believe should be free. Now, I’ve got that off my chest, back to the report.

The main recommendations are

– to cap lifetime costs of care between £25,000 and £100,000 – with a suggested threshold (which is used throughout the report for ease) of £35,000

– means-tested assistance will be extended to those who have between £23,250 and £100,000 of assets.

– Those who ‘enter adulthood’ with support needs will not be means-tested and care will be provided free.

-Universal disability benefits will continue but may be some differences in names regarding Attendance Allowance. (erm.. DLA?).

– There will be a cap on so-called ‘hotel costs’ in residential care between £7,000-£10,000

-There should be a national, portable eligibility framework which is more transparent.

– A government awareness campaign about planning ahead and preparing for potential age-related disabilities. And their costs.

– There should be a new information and advice strategy to help people through the confusing forest of knowledge.

– Better carers support and information.

– More health and social care integration

Of course, these recommendation run alongside the Law Commission’s report for changes in adult social care law. Together they could create a much better and clearer system than we currently have.

The ‘lifetime cap’ allows for insurance policies to be generated and probably very profitable ones too for the insurance companies. Most people do not need high level social care provision but the fear generated by the media is enough to drive right minded people into the arms (those who can afford it and who have substantial assets) into the arms of the insurance companies. I’m not sure how comfortable I am with the lifetime cap on care costs. It means the more wealth someone has, the more they are protected. I understand the logic behind it in that noone chooses ill-health and disability but the more than government spends on those who do have substantial assets, the less there is for those who cannot afford it and the higher the criteria to access support rises.

I just have a few queries which may be answered in the details. If Mrs Smith has a house worth £300,000 and she lives alone with no other substantial assets – say, for example, she has savings of £10,000 – is her house sold to release the asset worth up to the cap of £35,000 – assuming she doesn’t have an insurance policy? If she chooses to live in a care home which is private, but then the money runs out, will the local authority still move her? Will she ‘top up’ the local authority fees, paying above the ‘cap’ to do so? What is she lacks capacity and has no family?  I suspect all these answers are in the report but they will be questions I will be looking for.  The system of deferred payment is mentioned and I’ll hunt around for clarification.

The cap though, seems to be there to protect middle class votes.

I do, however wholly support the increase in the level of means-testing. I think it is entirely right to continue to means test up to £100,000 and I’d even go further than that. I don’t have a problem with mixed funding, I am just not entirely comfortable with the capping.

Again, the clarity of the coverage of those who ‘enter adulthood’ with care needs is entirely right. There is a necessary distinction between working age adults with care needs and older adults with care needs but quite rightly it is wrong to have a distinction fixed at a specific age. Indeed, Dilnot proposes that those who develop long term care needs before the age of 40 should continue to have a zero cap and costs should be met fully by the state. Above the age of 40 there will be some kind of tapering of the cap up to retirement age where the full proposed £35,000 cap would be reached.

Regarding the accessibility of universal disability benefits, Dilnot clarifies that he does not propose any reform that would lead to anyone losing their disability benefits and that attendance allowance will continue. I do wonder though how this ties in with the government plans to remove 20% of DLA claimants.

There are some recommendations though to change Attendance Allowance (AA). Firstly to change the name to something more understandable and an appreciation that many who are eligible for it do not claim it. That absolutely reflects my experience.  People who reach the cap when the government takes over payment will not continue to receive Attendance Allowance (or whatever it will be called) because the government is fully paying for their care needs – which makes sense to me.  The Personal Expenses Allowance (PEA) is proposed to continue – this is the payment that is made to people whose costs are met by the government in residential care and is currently about £23 pw – there is a suggestion that it should increase but not a recommendation.

The cap on hotel costs is excellent news in my view because I saw this as a potential ‘get out’ clause for residential homes. I do want to know how some of the private homes will adapt to these new systems though and what the cap will mean for overall quality of care provision.

The idea of clearer, portable assessments is a good one and long overdue. Eligibility criteria interpretation can differ wildly and there needs to be more transparency.   The minimum threshold would be applied at the ‘substantial’ level of care so I wonder how this portability will work for those who live in areas that meet lower levels at present.  It seems that there is some kind of recommendation to do away with FACS over the longer term.

Can’t be soon enough – a new assessment framework will be developed ‘with experts’. Please please please can front-line practitioners be involved in these developments – not just people who professionally develop policies and have never needed to use assessments in their lives. This is why we end up with unusable systems. There is also a way of building self-assessments into these new models. That’s the idea anyway.

The last recommendations about building awareness and improving quality of information seem to be sound all round. Nothing to argue about there.

I am interested in the recommendations as they relate to carers. As far as I am concerned, I want more than just an assessment for carers, I want the provision of more services. Supporting carers very well both financially and with practical and flexible support is probably the one aspect which can potentially save the government more money in the longer term than anything else – but more than that, it is an issue of ethics and morality. I know that doesn’t often come into government services but it’s something I feel very strongly about.

There is more commentary about the details of Dilnot in Community Care, the Guardian has extensive coverage (including an article I wrote before the details were known).

I also recommend Arbitrary Constant for links and discussion about Dilnot.

Waiting for Dilnot

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

Mrs J and the Mystery Bristol Care Home (update – it’s Amerind Grove Nursing Home)

There is a story on the Community Care website this morning about an ombudsman’s report relating a woman, Mrs J, who was placed in a care home in Bristol.

Bristol waterfront at night

lovestruck@flickr
This was a  care home which was not only rated ‘poor’ or had no stars under the old rating system that doesn’t exist anymore but from the time she was placed in 2005 until Feb 2009 when she finally did move (only to die later that year) , the responsible council – Bristol City Council – did not monitor or review her placement adequately.

Her son, Mr P, asked for his mother to be moved however as the cost of the identified ‘replacement’ care home was higher than the cost that the local authority would pay, he had to make ‘top up’ payments.

The Care Home which strangely is not named in the report – and I find that rather suspicious to be honest, had had a number of safeguarding alerts over the period of Mrs J’s placement there. It had received a zero star rating and there had been a couple of ‘freezes on admissions’ – probably relating to the safeguarding alerts.

The council investigated and placed the responsibility entirely on the care home however the ombudsman found that the  council had failed Mrs J as it was the commissioner of the service

As the press release on the site of the Local Government Ombudsman says

The Ombudsman considers that there was maladministration in the Council’s reviewing and safeguarding strategy and is concerned about the poor communication between the Council and the family. The Ombudsman also finds that the Council had not properly considered the circumstances around Mrs J’s move to an alternative placement, which had led to Mr J contributing to the cost.

For the pain and suffering caused by the lack of appropriate safeguarding and review procedures, Bristol City Council were ordered to pay compensation to Mrs J of £6000 and to Mr J of £500 as well as pay back the contributions Mr J made towards his mother’s care between February 2009 and October 2009 when she died.

That’s the background and now my thoughts about this – deep breath.

It’s horrific. Firstly not everyone has family that are as determined as Mr J to pursue and stand up for residents in care homes. If Mrs J had not had a son, this poor practice and abusive situation may have continued with perhaps, some perfunctory safeguarding alerts but with little action in relation to the management of the care home taking place. The care home working in conjunction with the CSCI (predecessor to the CQC as inspection service) where people living in homes that are rated as poor (of course, they are not rated at all now – easy get out of this situation?) continue to do so without batting an eyelid as long as the fees are low enough to be met by the local authority.

Another thing – what about everyone else living in the same care home? Seriously. Were they moved as well?

Why is the name of the care home not given? Surely this information should be transparent. A government (and this not not just the present one but the previous one too – I am making no party political point here) which is bound to link choice to care decisions is finding it quite handy to mask the names of inadequate and frankly, dangerous, care homes.

I did a search of care homes in Bristol which had poor ratings at the time that the rating system was abolished in 2010 and there were none listed. Perhaps they had managed to haul one more star. These are the homes I found that had one star. It may well be none of these homes but it makes pretty depressing reading looking through inspection reports from ‘adequate’ care homes.

This raises a number of issues – mostly why on earth can’t family members and social workers making placements in residential homes know which home it was that failed so appallingly? Isn’t that how ‘markets’ work? Or is it through hiding behind reports which obfuscate and confuse and seem to dance around the real issues of care – in the long periods between when they appear.

Finally, a thought or two about the way the council were criticised and censured. £6500 will not deter a council from acting in the same way again. The cost of fully staffing/training a competent review team may be much much higher than that. Quality Assurance Teams in the councils are one of those ‘non-jobs’ or ‘back-office’ jobs that Pickles seems to like to mock but in the face of a national regulatory system that is little more than a joke, they could and would provide a great service to citizens who need placement – particularly those without strong advocates and family members to stand up for them.

We need these stories to have more publicity though because there needs to be a greater understanding of the challenges faced and the poor quality that has almost become tacitly acceptable in the ‘free market’ of care.

The imposition of the market economy into the care sector hasn’t allowed the cream to rise to the top for those who are wholly reliant on support for placement from local authorities. It has allowed care homes which charge low fees to thrive despite poor care provision because it suits both parties to allow them to continue and to allow their names to be protected.

This makes me angry. I did not come into social work to deliver what I consider to be poor care or poor care services. I want everyone to be able to access good quality care and support regardless of their income, savings, property values or their family or friends’ willingness and ability to advocate on their behalf.

In a world of rose-tinted spectacles through which the Care Minister seems to envisage that people like Mrs P will have more ‘choice and control’, we have to make sure that basic minimum standards of care are respected for everyone who is reliant on them.

And we aren’t.

UPDATE – BBC have published the name of the care home  – it is Amerind Grove Nursing Home owned and run by BUPA.   Mrs J is Mrs Iris Shipway.  This is the report from 2008 which gave Amerind Grove a 0 star rating.  It is a 171 bedded home. Stop and think about that for a while. 171 people in a care home. That’s big business. That’s not a ‘home’ – that’s warehousing. Would we place younger adults in 171-bedded units. Let alone poor 171 bedded units. And what about the other 170 people living there when Mrs Shipway’s treatment was so poor. Can we see how the large companies have local authority commissioners ‘over a barrel’? They would not be able to find alternative placements for that amount of people.

The answer is less institutionalisation – more creative thinking about alternatives to residential and nursing cares – the answer is not 171 bedded homes.

Rant over.

Human Rights, Home Care, Personal Budgets and Cost Saving

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

Old man exmouth market

Daniel2005@flickr

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

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

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

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

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

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

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

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

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

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

So back to the reports findings so far.

Back to the BBC report

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Consumerism, Advocacy and Older Adults Services

icon of elderly people

Image via Wikipedia

I read a blog post on the Community Care website this morning about the need for social workers to ‘challenge consumerism in social care’ and particularly in care for older adults.

Generally, I agree with much of  that written. Since I qualified as a social worker – apart from a couple of years out of the profession entirely – I’ve worked in older adults’ services either in generic or mental health services specifically and the push towards a mixed up kind of consumerism has not served users well.

There are some elements that have been helpful and positive – from the introduction of direct payments and personal budgets to the increased support that is now afforded (quite rightly) by carers.

The post though draws some interesting points and although I think there is obviously limited space, there were some particular issues I wanted to pick up on.  The authors, Professor Keith Brown, Dr Steve Keen and Andrew Harding – write

Consumerism is supposed to be synonymous with choice, efficiency and a rise in standards. In reality, it has contributed to an indifferent attitude where abuse and neglect has been institutionalised. In this context, ‘choice’ has been thrust upon a social group who often feel either unwilling or incapable to make consumer decisions. be empowered by the decisions inherent with consumption.

While broadly sympathetic, I’m not sure that I would necessarily make a similar statement.

There are two tiers of consumerism, certainly. There are two elements at play in the process since the implementation of the 1990 NHS and Community Care Act and I think it’s important to differentiate between the effects.

The first is the introduction of the purchaser/provider split in the provision of services in adult care where directly provided services by local authorities were able to be tendered for the lowest bids.  This was the Thatcherite model of consumerism = greater efficiency.

Initially, I remember back in my first days of qualifying, completing extensive ‘unmet needs’ forms and having a greater ability to work within the budgets that we were ‘given’ on the basis of needs which we would do in conjunction with users, of course. Then the money started to run out. The flexibility and the criteria narrowed. Local authorities developed larger contracts with private providers and agencies after phasing out their own directly provided services and the choices we had as care managers narrowed substantially as we could only use the services that had been ‘block purchased’ by the local authority. Whether that was residential care or home care.  Quality did drop as although these block contracts were monitored, they were often tied up in reams of red tape which was unable to be broken and the ultimate decisions given to the service user or the care manager were very limited. Agency A or Agency B. Often with the same carers working for both agencies.

Yes, direct payments were introduced which greatly helped some people. The post in Community Care seems to have dismissed the positive response that some people have had to increased choice by talking about a ‘social group who.. feel unwilling or incapable to make consumer decisions’. The answer is not to take that decision making and flexibility away but to better implement advocacy services – whether by qualified social workers or not (I don’t see care management as being a reserved social work role) rather than ‘blaming’ the service users for not wanting to engage with what are discriminatory and ‘broken’ systems.

The post goes on to say

While it may be insensitive to assert that young disabled adults have had a relatively ‘good deal’ from recent legislation, older people certainly have not. Similarly, legislation surrounding child care provision has shown signs of evolving and learning from the tragic cases of Victoria Climbie and Peter Connolly. A comparative learning process, or evolution has yet to take place within the social work profession for for older people.’s services.

And with that, I’d broadly agree but authors go on to blame the social workers who are working in adult services for not advocating sufficiently for the user groups that we work with and I would strongly challenge that.

As someone who has, since qualification, been advocating as strongly as I can within my own service for an equality of access and opportunity for older people, I find it a bit irritating that academics who are so far removed from front line practice, lecture to me about what I should be ‘challenging’ and assert that ‘we (social workers) should be more vocal’.

Well, maybe there’s a different in societal perceptions of older people that is also working against us and maybe, you know, we need the support of the wider social work community to put the needs of older adults at the forefront of every campaign that is run. There is poor general understanding of what social work is in general but particularly social work with older adults, I’d guess, unless someone has direct experience.

There are fewer social workers working with older adults and it is important not to discount that younger disabled adults generally are better able to advocate for themselves and children, of course, get all the press attention, there are fewer organisations and less general public sympathy to pull on for those of us advocating for older adults.

And it shouldn’t need to be an ‘us versus them’ type of challenge. I think that one of the ways that older people do lose out is that ‘age related disability’ has been allowed to draw fewer funds than equivalent disabilities which may be experienced pre-65.

So to the authors of that article, I’d like to ask them, genuinely, about the experiences that they all have in delivering care for older adults as social workers because there are many many voices within the profession and within the offices advocating internally but our voices cannot be heard outside our own echo chambers because there is no one ‘on the outside’ picking them up.

I would also ask them this. How much of the social work course in Bournemouth covers working with older adults? What do university courses need to do to ensure that there is an equivalence of training in their own departments in working with the needs of older adults?

I remember when I went into my first post-qualifying job in a older adults team, some of my course mates mocked and scorned as they thought somehow my job was ‘easier’ than their snazzy front line child protection jobs. I remember saying quite passionately that I wanted to work with older adults because I felt there was so much more that needed to be done in that area and that often the needs of the user group lagged behind other ‘areas’ of social work. I wanted to make changes. I wanted to advocate. I wanted to make it a more progressive area of social work to be in and where all the brightest and the best social work graduates would immediately want to come because of the dynamic work that is being done with older adults services.

I still think that to be honest,  but I  have come to realise that I can’t make all of those changes myself. I don’t want to step away from front line practice either. I do think that it isn’t just front line social workers that need to promote and push – perhaps some of our university based colleagues can also do more work on advocacy and promotion and challenging assumptions. In the end, working together and building new models of working requires more than saying ‘you guys in the front line – you aren’t doing your job well enough – you should be challenging more’. It requires changes throughout the profession and the professional training processes so that work with older adults is not seen as second rate but as first choice. It always has been for me.

So maybe they should consider wider issues of the lack of a role for advocacy in social work before laying the task at the door of those of us who have been desperately shouting for our voices to be heard for many many years.