Personalisation and Professional Disillusionment

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

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

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

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

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

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

And so we plough on.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Personal Budgets in Practice

Recently, I’ve been working with a service user and his carer (daughter) to put together a  support plan or rather two support plans – one for him and one for his daughter . The two live together and without his daughter’s presence, there is no doubt at all that the man, G, would be in residential care so the personal budget is relatively substantial.  G has advanced dementia. His daughter who is a strong advocate for him and a devoted carer has given  up her job in order to care for her father. She receives carers allowance which is a pitiful £55.55. Think about that – for constant care (yes, she gets respite but that is sparse and shrinking).

As for creativity with G’s support plan, it isn’t particularly, because he has quite specific personal care needs and there is no scope for much creativity regarding tasks apart from the ability to potentially employ someone from outside the usual agencies.  Oh, we can choose the time and the ‘blocks of care’ but the type of care needed is specific so we can’t ‘skip a shower one day so there’s more time for a bath the next (seriously, that was suggested in one of the training sessions I attended!)’ as health reasons determine the need for regular visits. G’s support plan is, what we call a ‘managed personal budget’. That means that a virtual budget is assigned to G and I make the arrangements for agencies to cover the specified hours. I don’t get a choice of agencies. The agencies that are employed are those that have won ‘bidding’ contests with the local authority and are party to block contracts.

This ‘counts’ as a ‘personal budget’ for the purposes of the local authorities’ ‘figures’ even though the effect is exactly the same as it was prior to the ‘personalisation agenda’ – no, wait, there is a difference. I have three times the amount of paperwork to complete. Am I working in a more ‘person-centred’ way – well, I hope that I was ALWAYs involving service users and carers in care planning. That’s not to say that direct payments haven’t been enormously liberating and positive for a lot of service users. I absolutely don’t believe that everyone should have ‘managed’ personal budgets but it is a fallacy to believe the ‘hype’ that this personalisation agenda has brought the same benefits for all service users.

So we move to the idea that Burstow promotes that all support plans should be delivered by direct payments. We discussed delivering this package via direct payments, when I promoted even a slither of interest, I invited someone from our direct payments team round to meet the family (because they can ‘sell it’ better than me and can answer all the detailed questions about implementation and finances that sometimes I can’t) and we stalled. Why? Because G’s daughter felt genuinely stressed and frightened at the thought of employing someone directly – the agencies that accept the direct payments amounts are limited and don’t include her preferred agency and if she went with the preferred agency, her father would lose vital necessary hours of care.  She has little enough time to herself as it is and spending more time managing and planning her father’s care processes was something she felt that we should be doing.

Her father has very poor cognitive functioning to the extent that communication is very difficult.  The direct payment option, was, she saw, a way to push more stress onto her as a carer.

This is a reality that some of those who are implementing the wonderful new world of everyone receiving direct payments type personal budgets really have to address.

However I do have a more positive story to follow up on. That is that she, (M’s daughter) has a carer’s personal budget for herself which is delivered via a direct payment. While I won’t go into the details about what has been provided, you’ll have to trust me on this as I say we have been able to be incredibly ‘creative’ with the support planning of the carer’s personal budget and it will have an immediate positive effect on her quality of life. So all’s well that end’s well.

Generally, I have had a lot of success with carer’s personal budgets being implemented and I think that has been because the money provided (although not very much) is money in addition to the core care needs for the cared-for person.  There is a scope for more interesting ideas of things to use the money for.

It’s hard to see how more creativity can be instilled without more money and as long as the figures allow ‘managed’ personal budgets to be ‘counted’ we won’t have a real idea of how ‘ground-breaking’ these programmes are.

I don’t know the answers to these problems – I hope some of those consultants who are paid multiples of my salary and can spend all their days in discussions and consultations are able to come up with some genuinely practical responses rather than the usual ‘try harder/work harder/involve users (as if we don’t do all this already’.

Let’s see.

And on a final unrelated point, I saw a link to this blog yesterday on Twitter. It is written by the 18 year old son of someone with Alzheimer’s and I found it excellent and insightful.

Cuts – a personal tale

A couple of weeks ago, I had one of those deeply depressing moments that will generally punctuate a career in social care.

I had to go and tell a woman, who cares for her mother with enormous patience and dignity, that we could not increase their personal budget although her mother’s care needs had grown.

I suppose I went to my manager in a relaxed almost casual way and explained how the needs of the older woman had changed and to ensure her well-being, she needed additional time.

I was told, with a degree of equal sadness and regret that there would be no increase. If we were to provide what I felt was a necessary increase in care, the time had to be taken from the the hours already allocated.

She did, to her credit, try to have a discussion about this with her own manager but there was no budging on budgets. Despite the change in various situations, there would be no extra money. In fact, she added, the plan really needed to be cut.

It had been my first personal budget implemented. The council, in an attempt to encourage and prod us to implement these personal budgets had promised us and by extension, the service users and carers we work with, that no-one would be disadvantaged by moving to a personal budget so even if the RAS (resource allocation system – the way that figures are attached to needs through the personal budgets  system) did not ‘deliver’ enough money to provide an equivalent package of care that had been delivered under the ‘old’ system – it would not be reduced (and here’s the key) at least, not initially.

Now this particular service user and her daughter had what was a high package of care. It had costed much  more than the ‘RAS’ had spat out.

After making the promises, after the move to personal budgets is no longer an optional roll out of volunteers – the cuts are coming.  There is no longer the carrot to offer of ‘equivalent packages of care’ because we now offer everyone as a matter of course a personal budget and those who were not receiving them are being transferred over to the new system regardless – they don’t have to be self-managed, of course, but they have to exist.

So I visited the family and we looked at ways of shifting around hours.

The hours that were cut were the respite hours.

I suppose it was inevitable.

Family carers are invisible. The work they do is not costed. Of course the daughter was sacrificing her own needs for a few hours respite to her mother’s needs for additional personal care.

This is what the cuts mean to one family.

I had to tell them and negotiate with them about what to cut from their own package of care.

Not the Prime Minister. Not the Millionaires in the cabinet. Not any elected politician or Council Chief Executive. No councillor had to sit in that room with me and look the service user and carer in the face and ask them what they would prefer to give up from their package of care.

I’ve known this family for many years. I have a good understanding what is at stake for them and how much these cuts are hurting. I also know they won’t complain or grumble or shout from the rooftops.

They are not going to be going on any rallies or demonstrations against the cuts – not least because the respite hours have been cut.

We who can, have to demonstrate and shout and scream on their behalf.

And you know, as I know and I say this with a heavy heart – they’ll be much more of this to come.

Respite, Disability and Personal Budgets.

Rivan Vincent has been prominent in the news over the last day or so.  She has a six year old daughter, Celyn, who has quadriplegic cerebral palsy and epilepsy. In the face of additional respite services being denied to her, she expressed her frustration on a Mumsnet forum stating she had asked social services to take her daughter into care because she could not cope anymore.

From this forum post, a campaign was generated which has led to coverage in many national papers.  The Mail, The Guardian, The Telegraph, the Mirror, The Independent,  – they all cover the story.

All, quite rightly broadening the debate to concentrate on the wider issue of access to respite for those who care for people (particularly children) with disabilities has had welcome ‘column space’ in the news agenda.

I really hope that Ms Vincent does receive the additional support she needs and it is possible she will due to the intervention of the Prime Minister in her case.

What I hope, far more, is that the debate is continued and that it is not only Ms Vincent, and not only the carers of children with disabilities that benefit from this flash of publicity.

I am concerned that the government have batted back criticism of their promises to promote respite by claiming that they are pushing extra money into these services.

An extra £800m apparently. Not ring-fenced. Going to local authorities. So in effect, it is money that is going to be swallowed up with other care costs and the government can claim the moral high ground – but pushing an additional £800 million into respite care while taking hundreds of millions of pounds from local authorities in other areas doesn’t really cut mustard, so to speak.

I wonder how long it will take for the government to blame local authorities for not providing care services. Not too long.

The Telegraph leader which urges us not to blame Downing Street for these matters

South Gloucestershire council, not Downing Street, has declined Mrs Vincent’s request. No doubt its social services budget has been cut – but is there no money to be saved elsewhere? The council’s website is heavy with the jargon of environmentalism and diversity. Perhaps its “equalities team” could be slimmed down to free up money for Celyn. And perhaps other local authorities should start dismantling similar initiatives before cutting front-line services and putting the blame on the Government.

So we see the rub. It is the council that is spending things on anything that isn’t ‘front-line’ that is ‘to blame’ for the current situation.

For me, it’s important this opportunity isn’t lost to create more interest and focus on the role that carers play not just carers of children with disabilities but all carers. If the government really wanted to help more broadly, they could look at the insult which is Carers Allowance. That would put more money in the hands of carers.

The problem is that for every Celyn who has public focus, there are hundreds of thousands who don’t have the same media access and spotlight. Saying that it is important that this becomes and remains an issue in the public consciousness.

The fact is, it comes down to money. Better care costs.

It also seems almost woefully ironic that in the face of cuts to Disability Living Allowance and Employment and Support Allowance, the government seems to have found a conscience for disabled children.

Cameron would be as good to remember that children grow up and continue to need support and continue to face higher costs of living than people who do not have disabilities.

There’s an article on the  Guardian’s website from the mother of a disabled child, who writes, in the context of her frustration about the process of assessment by social workers

Instead of strangers with clipboards, the first stage in an assessment could be made by the disabled person themselves. My daughter could have been asked to keep a detailed diary of what she did and what she needed help with. It needn’t be written down; it could be recorded or dictated. This would allow her to paint a rich portrait of her teenage life, which includes going out to see The King’s Speech with friends, as well as someone helping her on and off the toilet.

This baffled me because that is exactly what is and has been happening through the roll out of personal budgets and self-assessment questionnaires. People DO write their own assessments now. They shouldn’t need to be written. They can be recorded, drawn, dictated – that is what we were promised in theory.  This is exactly what the Putting People First agenda should be doing and encouraging – instead of generating a whole new pile of forms.

This week I had to have a couple of support plans for users of  Personal Budgets approved. They were both for older adults with dementia who unfortunately were not able to take as full a role in the decision process as would be ideal due to a lack of understanding, however, I spoke extensively to family members and gained a good feel for the situations at hand and provided advice as to what I felt might be useful.

Family members while involved felt confused by some of the details so I tried to simplify as much as I could.

Infuriated by the paperwork, I pushed my ‘forms’ to one side and wrote out the support plan that we had discussed extensively on just a plain piece of paper. I was frustrated by the level of repetition that was expected of me.

After all, I remember training I had been on about wonderfully creative support plans and all the nodding and smiling about that’s what we should be using. Let’s work in new ways and break out of local authority mentality.

I took my ‘new style’ paperwork which involved just free form writing. No questions answered.  No exposition about what could or could not be done.  My manager thought I was having a joke with her and I responded, no, I hadn’t filled out ‘x’ form or ‘y’ form. This was the support plan that I was presenting.  They nodded and agreed.  Then told me to copy out all the information into one of the local authority forms.

I did because if I hadn’t the services might not have been provided in the same way and to be honest, it didn’t take me too long but it is indicative of the type of way that people have been working for so long.  This happened to me two days ago.

Local authorities have had lots of ring-fenced money to promote the shift to personal budgets. I think some of the focus and project management has been aimed at wasting as much of that money as possible.

We are left with systems that are barely shadows of what they could have been. Sure, they work fantastically for some people but the rest have to pick up the dregs that are left behind.

Hopeful thoughts  for the day.

a) It’s Friday

b) Ms Vincent’s desperation and plight will lead to greater insight and better services for all disabled adults and children and their carers.

The Death of the Independent Living Fund

Yesterday was quite a day for adult social services. As well as the more obvious announcements of the cuts to local authorities and the unveiling of a so-called ‘Localism Bill’, Maria Miller, the minister for disabled people announced that the ILF (Independent Living Fund) would be ‘financially unsustainable’ after 2015.

Financially unsustainable.  It didn’t need a whole lot of foresight to see this coming. Back in June, the ILF was closed to new applicants after running out of money – so the budget for this year lasted between April (when applications opened) until June (when they closed).

Community Care writes that

Miller said that the ILF would stay in place to fund existing users until the end of this parliament in 2015.

Its payments would most likely be transferred to councils to administer as part of personal budgets, though Miller’s statement does not specify whether funding would be protected at existing levels after 2015.

And so it starts, the shaking off of responsibility of central government to provide additional support for disabled adults and the move of the responsibility for the additional funding to local authorities.

There are a few things that it is important to bear in mind at this point. The ILF is only or has been only accessed by people who are most disabled and have the absolute highest care needs. It was set up in 1988 although the rules regarding eligibility were reviewed in 1993. The purpose of the ILF was, as it’s name suggests, to maintain and allow for people with high care needs to remain living independently in the community rather than the alternative which was and is residential care.

The current rules state that someone is eligible for ILF funding when input from a local authority reaches a current level of £340 per week, the ILF funding will match that amount that the local authority on a pound for pound basis.

In my current incarnation, I don’t come across people who have ILF payments frequently – it has, like DLA only been available for people between 18-65 and over 65s can only claim if they had an existing award prior to their 65th birthday.

In the past though, particularly when I was in a generic adult social services team, I had a number of dealings with the ILF. On a personal level as well, my father received money via ILF.

It’s worth remembering that the model for ILF payments in 1988 was revolutionary and one that has and continues to have a major impact on the progression of adult social care. The ILF gave the money for the first time, directly to the disabled adult to choose their own service providers and/or employ their own PA (personal assistant). The Independent Living Fund was very much the forerunner of the direct payment/personal budget progression and the model for both monitoring and extending budgets directly to adults with social care needs themselves was trailblazed by the ILF.

The money provided by the ILF had, of course, guidelines attached regarding what it could be used for but it was money given in addition to the very bare needs met by local authorities. It was and is money that contributes to providing a better quality of life for people with high level needs because, believe me, you don’t get to £340 per week level of needs if you don’t have very high level of support needs.

The difference that the ILF money made was for a carer to accompany a service user to the local shops rather than go out and do the shopping for them. It was the difference that allowed a carer to take a service user to the local swimming pool rather than relying solely on day centre services. There is no doubt in my mind that ILF money contributes precisely to quality of life differences rather than the life or death care that local authorities provided.  These are the examples that are often given for ‘care planning’ with personal budgets provided by the local authority – the difference is the amount of money that you have in the ‘pot’ and the potential doubling that happened when the ILF contributed – acknowledging that those with very high care needs had.. well.. the need for care over and above the bare minimum to retain a positive quality of life living at home rather than in a residential setting.

This is my main sadness is seeing its demise. It’s hard to stomach for the government but quality support and quality of life costs more money. Yes, the money has to come from somewhere but it shouldn’t  be a ‘burden’ . We, as a society,  should be prepared to pay the cost of it.

I know exactly what will happen when Maria Miller shifts the burden of cost of care back to the local authorities – the levels of care provided will fall through the floor and although  for some people (those currently in receipt) that money may well be protected for a period of time,  for those coming up through the ‘system’ who don’t have access to this additional support, it will create a group of people who may be living at home but on whose family the burden of care may well fall more heavily – removing the independent from the idea of independent living and replacing ‘living’ with ‘existing’.

As Lord Morris is quoted as saying by the BBC

“This will not save money. If you make it harder for disabled people to live at home, it will cost more because more of them will have to be in hospitals and other places of full-time care.

“It will mean far more of them having to be in institutional care at far greater cost to the taxpayer.”

It’s so horrifically ironic that as policies shoot away into the distance taking the goal of ‘personalisation’ as a mantra, that the very first forerunner  of that policy  which was revolutionary at the time – is being put down with no evidence that there will be any central government funding to replace it.

That’s not to say that the idea of the ILF needed to stay the same. I have no doubt it needed to develop – not least because I felt the age limits were at best arbitrary and at worse discriminatory –  but by pushing the burden back to increasingly pressed local authorities the government has alerted us to its real intentions about the cost-saving implications of the move towards personal budgets.

A Vision for Adult Care – a few brief thoughts

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

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

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

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

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

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

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

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

As the document says

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

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

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

The paper sets out a number of principles

Prevention

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

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

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

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

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

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

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

Personalisation

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

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

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

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

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

Plurality and Partnership

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

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

Protection

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

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

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

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

Productivity

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

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

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

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

People

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

The vision explains that

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

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

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

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

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

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

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

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

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

Personal view of personal budgets

Just a quick link to an Guardian piece by a recipient of a personal budget. Go and read the article and then come back!

It’s always more interesting hearing about services and policy implementation from people for whom the services are created rather than from professionals who put the policies and the procedures together.

A few interesting snippets leapt out at me and I suspect it is partly because the way the implementation is different in different local authorities.

This point in particular

Every social worker is aware of how much political capital has been invested in personalisation by the government, and it cannot be seen to fail. So social workers cherrypick service users who they think will be the best candidates. Yes, prejudice and social bias even extends to disability.

When I asked my social worker what the drawbacks of personalisation were, he was candid. He admitted it was a process of self-selection. Only those who were erudite, well educated and well organised were encouraged to apply for personalisation and those who led chaotic lives – a euphemism meaning that anyone with drink, drug or mental health issues was not put forward.

While no doubt that was the case when some of the pilot schemes were running, now we have no choice whatsoever (quite rightly). Everyone assessed for a service is going to be receiving a personal budget. Everyone whose service is reviewed will be transferred to a personal budget.

This point raises one of my bugbears as well. I begged our implementation team to include people with more complicated needs on the pilot. I personally spoke directly to the project manager and explained that until the scheme had been piloted fully with people who did not have ‘straightforward’ needs, people who may not have the capacity to make full decisions about their own care needs and older people who might have the same high needs for services as a younger disabled adult  but with a LOT less funding available, we could not be able to create a system that worked across the board.

Of course, I was told that no, the pilot needs to be straightforward so we can work out the glitches.. THEN we will introduce some of the more complex aspects. The problem is that we have been left with documentation and assessments that are focussed on physical care needs while the mental health services were left behind as they were not involved in the pilot – being ‘more complex’.

So yes, the self-selection occurred (not in our team as we weren’t a part of the pilot – despite my pleas!) but it does not occur anymore – not in my authority. Now it is a blanket approach.

The part of the article that cut to the core was this, in my opinion

It is suitable for anyone who is organised, methodical and lucid, but it helps immeasurably if someone else is able assist on your behalf and make sure you are not making any accounting mistakes.

Honestly, that made my heart sink. Not because I am not thrilled for people like the writer of the piece who is, without doubt, getting an infinitely better service – but because it further sidelines people who are NOT organised, methodical and lucid and people who do not have someone else to assist on their behalf.

In an ideal world, independent advocacy both directed and non-directed would be a wonderful tie-in for those who need assistance with details and management and for those who might not have the capacity to manage some of the details – however costs are being cut. Our own advocacy services now have a massive waiting list. The expectation again falls on statutory social services and honestly, I don’t say this because I’m proud of it but because it is the reality, in the day to day workload, there will not be the time for a social worker or social work assistant to provide the same level of support putting together an individualised and personally focussed care plan – maybe there would be in a learning disabilities team but in an older persons’ team where a much faster throughput is expected – it’ll likely be the same usual agencies that are used for the same, usual tasks.

I see personalisation as a wonderful thing in theory. In practice is has made a lot of care much better for the ‘organised, methodical and lucid’. The massive challenge is how to ensure that equal and better services are delivered to those who are not ‘organised, methodical and lucid’. Those who do not have networks of support. My fear is that the funding will be siphoned to those who are better able to articulate their own  needs.

I promise I’ll try to stop with the personalisation posts soon. I get the feeling I’m being somewhat repetitive but they are very much on my mind at work at the moment as I’m running through a few and so I keep thinking of more reasons to be frustrated with the implementation (as opposed to the ideology which I support completely).