The Disgrace of Individual Budgets

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

He said to his party’s conference

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

Excuse me for a moment while I scream with frustration.

Back.

NOT WILLING TO LET GO OF CONTROL?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Into the Deep End

While I’m still recovering at home, my thoughts are turning over a number of things as they come up and I suspect while I am still off work, I’ll be considering some more ‘memory’ posts to keep me on top of things.

After I qualified, well, actually a couple of months before I qualified as a social worker, I lstarted looking for work. This was before the GSCC registration when a DipSW/Degree were enough to start working immediately as a qualified social worker.

Agencies were literally snapping off our hands to work for them. There was a massive shortage of social workers in every field, in every area. Many people were recruited directly out of college. I decided to sign up with a social work agency. Partly because I was very impatient to earn money after a couple of years of part-time working and partly because I was far from resolved as to which area of social work I wanted to move into and I felt the agency option might leave me some greater flexibility.

Perhaps times have changed now – this was almost exactly 10 years ago – but at that point, when I explained to the agency and subsequently in the interview, that I was a freshly qualified social worker equipped with a lot of experience of hands-on care in the voluntary sector and one statutory (first) placement there was an understanding that support would be given. There weren’t NQSW programmes but there was a desperate need for bodies at desks.

I went to work in an inner city borough in London – not the same one I work in now. Process of elimination will determine that there aren’t THAT many boroughs that count as ‘inner city London’ but I’ve now made my way through a few of them..

I was working in an older adults’ team. It was a large team and a large office. Fortunately, for me at least, there were some familiar faces as that borough has some sponsored students on the same MA course as I’d been on so went into the office already knowing a couple of people which definitely helped.

I was struck by the friendliness and the willingness to help. Yes, I was a brand new, young (relatively!) agency social worker but honestly, the team bent over backwards to assist and answer all the stupid and not-so-stupid questions I had.

I immediately was grabbed by the upping of pace between placement experiences and ‘qualified’ experiences but as regards to training and access to support, I might have been employed through an agency but there seemed no obvious difference with those who were directly employed. The caseloads were very high and the output was expected to be high. As I learnt later though, and in different teams, it could have been a lot worse. I only had my placement experience to compare it to though as all my pre-course experience had been as a hands-on carer/support worker in residential homes.

In retrospect, I realise I was very lucky to have had a good team around me. There were a lot of things I was worried about. Manning the duty phones filled me with dread, probably for the entire time I was there.

I’d like to say my manager was fair but he wasn’t desperately. While team members were friendly, competent and helpful, he seemed to have an over-fondness with appearing to be doing the ‘right’ things to his immediate managers. Since then, I’ve realised one of the most valuable assets of a good manager is to be able to fight for the things that they believe it and stand up what is ‘right’ even if it is not something that fits in with the ‘higher management’ model.

The geographic area I covered was one of immense and obvious poverty. The high rise blocks rose as trees do in thick conifer forests. Sometimes there would be glimpses of true loveliness when reaching the top of a high rise and looking out at the view of the entire city as it pans out below you. Then there was the abject despair of the broken lifts and the graffiti in the stairwells. Graffiti would be the best of it. The vomit, the bloodstains, the urine and faeces – human and animal. But there were also some of the most beautifully kept houses I’d seen as well. Sometimes, in some areas, the stairwells became places to congregate and trade all manner of illegal goods and substances with the residue very obvious – discarded needles, used condoms. There seemed to be little dignity in the external presentation of some of the estates which often contrasted acutely with the dignity retained within the flats that I visited.

I have always been fascinated by stories and peoples’ stories. By trudging the streets (I don’t drive and mostly walked from visit to visit), I would pick up the history of the city and the neighbourhood, the familiar noises and smells. People would tell me their own and their families’ histories. There would be the histories of families who had been living in the same areas of the same city for generations and the recent arrivals from other parts of London, other parts of the UK and other parts of the world – each with a story about how they had arrived at the place they were.

One of the things that struck me was the way that all these stories intermingle in the same communities, sometimes crossing and sometimes taking themselves on different strands.

I had been leaving in various shared houses in various parts of town myself and the opening up to the true meaning of community was something that had been fairly new to me. I heard stories that I would never have been privy to in any other circumstance and the streets, as I trudged through them, took on different colours and hues. I knew, through my discussions and conversations which shops had been there for decades and which had been new arrivals. I knew where the old Bingo Hall and the old Dance Hall had been. I knew where the different community groups met and what support they provided for ‘their own’ and how to tap into these resources.

Covering duty scared me at first as I was unsure what I might come to expect and thought I was expected to ‘know everything’. Fortunately, I had many experienced people around me who didn’t mind my constant questions too much.

I remember when the first service user that I had been working for a while, died. I had been trying to arrange a residential placement for her. I had been coordinating with family members and had been to see a number of homes. We organised the move and within two days, she had died. I remember the abject sadness that welled over me. I pondered the influence of the move and the way it had happened. How anything might have changed. Discussions with more experienced colleagues helped me to think through the matters logically and I know, particularly now, working with older adults, you do see death up close, but it is still something that touches one profoundly, especially when you have spent time building a relationship with the service user and the family.

Things worked differently then as well. Care management as a model which had developed from the NHS and Community Care Act 1990 and was still at it’s earlier stages – services hadn’t necessarily been pushed to large block contractors at the same levels as they were subsequently. FACS hadn’t been introduced and each authority had their own guidelines. When I drew up care packages, I would have to cost each one on a different form before submitting it. Computers were still shared and forms could be handwritten. It seems so archaic in a lot of ways.

Some ‘new’ databases were just being rolled out but few people used them, certainly not as many as the managers wanted. There was some resistance to change.

I learnt a massive amount there though and took some very strong lessons with me. I made a lot of mistakes but fortunately none with grave implications. I learnt to love working with older adults and relishing the richness that a long experience of life can bring and what can be shared as a result. I saw my share of loneliness and heartbreak but also the joy of kindness and community that is brought to other lives.

It was a good place to start.

A Home to Fit

I have worked with Mrs G for about 18 months. She has a degenerating dementia and is becoming more physically frail. Unsurprisingly this is not an uncommon basic scenario that rears it’s head at work. Mrs G has no surviving family but she was a very active local politician – involved in lots of causes and has wide and varying groups of friends who have endeavoured to keep an eye on her and provide substantial care and support for her over the last few years. It just goes to show that sometimes the links of friendship can be just as tightly bound as those of family.

A conference of friends was called yesterday. There were a fair few people who all have an interest in her wellbeing. We talked about residential care. I first raised the prospect of residential care for Mrs G shortly after I was first involved with her. I felt that things were not going to improve and that she really needed more support than could be provided at home. I was wrong and happily so. Friends came out of the woodwork and banded together to augment a formal care package with lots of informal support.

As I spoke to Mrs G yesterday, she wasn’t really able to follow the conversation or the flow. She is a sociable person by nature who, I think, if we can find the ‘right’ fit of residential care home – may actually enjoy an aspect of it. I know exactly what type of care home I’m looking for – one with a bit of spirit to it and character. Preferably one that might have room for a cat as well. It isn’t an impossible call because I’ve known it to happen but I have to say the prospects aren’t looking too hot.

Sometimes I despair at the generic nature of some care homes. I know there is an optimum economic way of providing care to the most people at the lowest possible cost. I also know some care home managers that care enormously for the quality that they are able to maintain for those who use their services. It can seem like looking for a needle in the haystack at times though.

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Looking forward to retirement?

Yesterday, I was at a meeting with a few of my more senior colleagues, and I mean that in terms of age. A couple of them were joking together about looking forward to early retirement. Although I’m at least (depending on government policy!) a comfortable 30 years away from retirement age as it stands at present, I was able to wistfully dream along with them, only half-jokingly, about my wish to retire early as well.

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So I found this article in the Telegraph today and thought it related an interesting point. Basically, it highlights some research made that retirement can affect both physical and mental health adversely.

Truthfully, although I can dream of days when I don’t go into work anymore, I know it’s the case on a very non-scientific study of people whom I work with. I have been allocated and worked in a few men who, just past 65 have retired and then have been dogged by significant and debilitating depression.

The article relates to financial difficulties faced in retirement. I’d venture a guess that there is also a relation to a loss of a significant role and social environment that work can give. With men, in particular, ‘of a certain generation’, there is an expectation to work and to provide for the family. There is significant time spent out of the house working and away from the spouse that when both can be together day and night can lead to tensions that might not have previously been apparent.

Of course lower spending power is an issue but also not having the same structure to the day and purpose to respond when people ask ‘what do you do’ to mean ‘who are you’ in social settings.

The study claims that some of the answers can be found in part-time work and perhaps voluntary work, even in an area completely unrelated to that in which the career had been focused.

You know, I’d take that kind of retirement. That’s when I think I’ll start my flower-arranging course.. (I know, I know, but honestly, it’s something I’ve always wanted to do!).

Medication and Care Homes

Today, the BBC is reporting on a research study from the University of London which finds that seven out of ten residents out of the 256 residents in 55 different care homes were subject to errors in their medication regime.

The summary of the report suggests that the reasons for this are

inadequate information, over-worked staff, poor teamwork and often complex courses of medication

I wonder how much of these issues could be addressed by better training and better staffing levels – the things that often can be the most costly.

I spent 7 years working in residential homes before I qualified (and while I was training). I know that however good the regulation is, there is always scope for errors and rushed jobs because unless CCTV cameras are placed in all areas, there is a lot of scope for people to work individually and to make mistakes – sometimes the mistakes are honest and due to wholly understandable issues, noone can legislate for human error, but sometimes they are due to tiredness due to packing in tons of overtime as the pay is so poor, sometimes because there is a lack of knowledge and system management to ensure that medication management is prioritised and sometimes it is down to staff just plain not caring enough to do a good job although that is by no means the only reason.

Looking at the errors picked up most frequently in this study, they are

wrong dosages, insufficient monitoring of residents after medication had been taken and people being given the drug at the wrong time

I’m not sure how wrong dosages can be explained away but I can understand insufficient monitoring and drugs given at the wrong times because those can often be matters of staffing levels, especially in some of the larger care homes. I worked in a small home where there were five residents and there were always between two and three members of staff on duty at any given time, so medication management could be individualised and monitored but in some of the care homes I visit now with up to 80 residents, the level of staffing may not allow for such individualised care. It isn’t right, but it is cheaper.

This is also an issue which is brought up by the changing and more complex needs of those who are needing residential and nursing care. Whereas in the past, the idea of a convalescent or rest home was more of a longer term stay issue, now it is only people who can no longer be supported at home due to complex needs that are accessing residential care, meaning that there are more extensive medication needs.

At least a report that highlights this can focus some more attention on the needs of those who do need residential care. Hopefully, it will concentrate the minds of those who commission services and provide placements as well.

Revisiting Best Interests Assessments

Last week, I carried out a Best Interests Assessment for a man whom I had first assessed six months ago.   In fact, he was the first person I had assessed under the new Deprivation of Liberty Safeguards. I had, at that point, recommended that the Deprivation of Liberty that he was experiencing in the care home in which he was placed be authorised – and I recommended that the authorisation be for six months.

So I was asked back. It makes a lot of sense. Although it was one visit six months ago, I had, at that point, made contact with and discussed the situation with his family members, his care team and his CPN, as well as having a meeting with him directly.

I had made some recommendations the last time I visited but they were not binding conditions, just some aspects of his life that I thought might make a difference to the quality of his life and was pleased to see that these had been actioned almost immediately that I had left the previous time.

It is obvious to say, but it is much easier, reassessing than assessing the first time. Immediately on seeing him, it was obvious to me that he looked physically better, less troubled and agitated. Although I only see a snapshot, by conversation and discussion, that was the picture that was painted for me all around.

My initial choice of six months was because it just felt wrong to me to go for a full year authorisation – especially as I felt that there were a number of adjustments that could be made in the short-term.

In retrospect, I’m glad I did it. I’m glad I was able to go back and see things having improved.

Some aspects of the Deprivation of Liberties Safeguards are flawed, I think. We have not  had a lot of referrals coming in, certainly far less than were envisaged.

Partly I think this is due to the policy guidelines and thresholds being adjusted upwards to more narrowly define what a Deprivation of Liberty is.

I think it is also partly due to a reluctance of managing authorities to make referrals, perhaps seeing it as a criticism or a failing, instead of a positive.

I placed someone in a care home a couple of months ago and I felt immediately on placing her that the placement would be an unfortunate but necessary deprivation of liberty. I informed the home manager that I felt this was the case and recommended that she refer to the Supervisory Body. She was horrified and assured me that the resident was happy at the care home. It took a bit of nagging and the involvement of her IMCA (Independent Mental Capacity Advocate) to facilitate the Deprivation of Liberty Safeguards process but I wondered if her reaction was typical of home managers.

We have also had a number of requests for authorisations come from our psychiatric in-patient wards – particularly those for over 65s. A number of people who have been referred have failed the ‘eligibility’ part of the assessment process meaning that they meet the criteria for a Mental Health Act Assessment rather than the DoLs process.

If anything, it has led to more people being detained formally in hospital. I’m of the mind that this is no bad thing as the Mental Health Act has more robust appeals processes in place than the Mental Capacity Act and the DoLs process which has very weak appeals processes.

Then there is the sticky issue of the right to (free) care under Section 117 of the Mental Health Act – so if a person has been subject to Section 3 of the Mental Health Act, the authorities are responsible for paying for after care services. I should probably devote a whole post to this at some point. It has become a major issue in our Trust and most, I assume, as older people who might not have been formally admitted previously, are now entitled to free aftercare – often through placements – which is some of the most expensive aftercare possible.

I often ponder if people, in general, are aware of their rights to free aftercare but as I said, that’s probably another story for another day..

A knock-on effect of the new safeguards, locally, at least, seems to be that there are more formal admissions.

I’m not sure this was the way that things were ‘meant’ to work but lots of interesting issues being thrown up..