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.

Moving on Individual Budgets

And so it starts. Currently we are still in ‘pilot’ phase of the Individual Budget roll-out – the forefront of the personalisation and self-directed support agenda and if that sentence made little sense to you – you can probably count yourself lucky!

Very basically there is an ideologically  welcome move towards more control by users of services around the services they receive which is a very noble and worthy cause. We are trying to work through some of the details and our local authority is trying to put systems together through the pilots that have been running. While I’d like to hide my head in the sand and pretend nothing is changing, not because I don’t think it is a worthy ideal, but rather because of the intense increase in bureaucracy and the time needed to work through the new and somewhat shaky systems being put into place.

I decided that I really needed to be positive and try to actually understand what was to be happening because it isn’t going away  and so, in conjunction with a service user and her daughter (main carer) who want to engage with the process and ‘see how it works’, I am doing what I can to work through the systems as they exist.

The main pilots so far have focussed on younger adults with disabilities, people with learning disabilities and older adults with fairly straightforward care packages.

Although at the time, I explained I felt they needed to tackle some of the more complex examples at the time, mental health services were very much left out of the ‘loop’ of information.

Currently, I have assisted in the completion of the self-assessment questionnaires and have validated them. As the service user in question as fairly advanced Alzheimer’s type dementia, there was a significant input from her family and carers and I assisted considerably myself – so the ‘self-assessment’ idea was somewhat lost through that process but I felt it was important to work through the ‘processes’ with a person who has little capacity to engage actively with the assessments and realistically, it will involve many of the users of our service.

I tackled the RAS (Resource Allocation System) although I’m not entirely confident it is ‘correct’ and so my next task is to take the documents to a meeting to discover what the ‘indicative budget’ is and then, assuming all goes well, to return to patient and carer (I am running two different applications side-by-side – one for service user and a different one for carer in her own right).

I might have messed the entire thing up of course, but as I expected to user and carer themselves, the worst thing that could happen at this point is remaining with the status quo while I spend time working things out. The positive outcome would be more flexibility to choose carers and tasks that are more appropriate to their individual circumstances and to have more input into the support packages that provide the best outcomes.

But.. and this is the big but.. so far, getting as far as we have, namely writing up all the documentation and putting the forms, assessments, resource allocations etc has taken me the good part of a couple of days. That’s not including the three specific visits each of at least an hour to work through the actual assessment forms. Which would be fine and dandy if that linked in with the time taken on other work, emergency assessments, people being discharged from hospital,  rushing to court to get warrants etc.

Suffice to say the team isn’t overly heartened by the lack of support in implementing these new systems – the local authority has put a lot of support into the Community Care teams with additional workers and weekly support groups  but in the bleak and distant mental health teams, we are left increasingly on the periphery and detached further from the general information streams and planning but my thought is that at least by attempting it, we won’t be completely left out and if I make a mess of my attempts, at least I am identifying a genuine training need!

Hopefully, I’ll be able to update the process as I go through it.. .

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A future for adult social work?

Community Care carried out an investigation a couple of weeks ago which found that vacancy rates in adult and children and families’ teams were roughly equal therefore the news that the Migration Advisory Council have dropped specifically adult social work jobs from their list of ‘shortage professions’ while children and families jobs have remained may seem curious.

Further investigation though makes the move seem a little more nefarious.  The Guardian reports that

The decision to remove social workers involved in adult services from the official shortage list follows the introduction of new initiatives to increase the number of students on social work courses and to improve the retention of more experienced workers.

The decision to ban recruitment of international qualified social workers, however, will not apply to those involved in child and family services, where it is considered that a national shortage remains. The MAC’s report says recruitment difficulties in this area have been exacerbated by the negative media image of social workers responsible for children.

Understandable but it does beg a lot of questions. Are all the proposed new graduates expected to go into adult social work jobs? Or are there just going to be less qualified jobs to go round..

Hilton Dawson the new Chief Executive of BASW (British Association of Social Workers) writes in Community Care that

BASW regularly receives complaints from members in adult services who speak of major reductions in social work jobs and, significantly, of a devaluing and lack of understanding of the social work role. Social workers are beginning to feel excluded from personalisation. The unique and vital contribution that social workers can bring to this crucial agenda is being dismissed and ignored.

The Personalisation Agenda remains largely mysterious. There are a few pilots usually with capable adults who benefit massively from being able to design and determine their own packages of care and where the money should be spent but little of the literature (that I have come across – and I have looked) seems to approach those user groups that were and are poorly served by Direct Payments – namely older adults, adults who lack capacity and those with mental illnesses who have not benefited to the same extent as other groups. It makes the right noises though – user choice is, of course, an incredibly positive goal – more holistic, devolved power and services.

Although the aim of the NHS and Community Care Act was to create a role of ‘care managers’ who could help to pick and choose services from different providers and put together user-centred care packages in a holistic manner – and look where that ended? With councils bidding each other down to provide ever cheaper services from private companies who pay a minimum wage salary to inexperienced care staff to rush in and rush out of many homes and houses on tightly implemented limiting packages where there is no scope for any ‘leisure’ activities apart from local day centres – is that was what envisaged when it was laid before Parliament? I don’t want to be over-cynical but it’s hard not to be.

So where does that leave adult social work?

There is likely to be a continuing need in adult protection but the sizes of teams will not be equivalent. In mental health teams which move more progressively towards generic roles, Approved Social Workers have transmuted into Approved Mental Health Professionals – and although the place of a voice for the social model of mental health care remains more than necessary, there is a move towards job adverts more generically calling for ‘mental health professionals’ rather than Social Workers, or CPNs or Occupational Therapists.

There is no doubt in my mind that a signposting role has significant importance for older adults and some people, even those who might not fit into the criteria for a mental health team, do need more outreach work  but is that a place for statutory services?

Perhaps the future of adult social work is actually in the voluntary sector?

It isn’t surprising that protecting children is seen as more ‘urgent’ but really the levels of abuse of older adults is often overlooked – and although it shouldn’t be a case of ‘compare and contrast’ it is difficult to ignore the push to marginalise further vulnerable adults when honestly, abuse of a person is abuse of a person – cruelty is not dependent on age.

As care services become more tailored to the ‘30 min’ rush-in rush-out visits that rarely last 30 minutes there is a greater scope and need for a more cohesive protective and preventative service in a sector that has almost no lee-way to work on any preventative measures apart from for a very small group of people who might fit into specific criteria in a specific service.

All the focus and interest remains very much in the domain of those who work with children and understandably so – it is more emotive and of more immediate concern to the general public.

I wonder why it is so few people are actually concerned about the services or lack of them, provided for older adults. Personally, I think it’s because we don’t want to think about getting old – young people, children – they are ‘other people’ – older adults, they are our parents, and us – eventually. Sometimes we just don’t want to be reminded but one day we are going to have to be.