Goodbye Southern Cross, Hello Open Public Services

So Southern Cross – the largest private care home provider in the UK will be closed.

What of the 31,000 residents who live in their properties? Well, the government has given us its assurance that they will be ok so that’s alright then.

Or not.

Goodbye, Hello

m kasahara @ flickr

On the day that the Open Public Services White Paper was published  (which can be found here – pdf) – which couched in the comfort of positive words like ‘choice’ , we would do well to heed the warnings of the way in which social care was sold off in chunks, from public to private and reflect on whether it is better to allow care homes to ‘fail’ in order to prove that the strongest will rise to the ‘top’.

The problem is that Southern Cross WAS the strongest. It did rise. It also speculated on property and ownership transferred away from the core business base of providing care and homes for those who needed both.

But on a more pressing issue, what will happen to those who live in Southern Cross homes and work for Southern Cross homes.

As the Independent says

Analysis by the GMB union revealed the names of 80 landlords who own 615 of the homes, many of which are subsidiaries of larger companies registered overseas. This makes it much harder to obtain financial information about the companies as rules governing accountability and transparency, especially in “tax havens” such as Jersey, Cayman Islands and British Virgin Islands are significantly more lax.

In addition, the GMB was unable to trace more than 120 landlords, which mean thousands of people are living in care homes where the identities of the owners and directors are unknown.

In the absence of full company accounts and other relevant information, such as the names of directors, it is “nigh on impossible” to assess whether they are suitable to run care homes funded in large part by public money, according to Andrew Craven, GMB statistician and researcher

At least the ‘Department of Health’ spokesman says

“Whatever the outcome, no one will find themselves homeless or without care. We will not let that happen. Today’s announcement does not change the position of residents. The Care Quality Commission will continue to monitor the services provided… We have been in constant contact over the course of discussions and remain ready to talk to all parties.”

That’s reassuring. Or not. Would that spokesman or anyone in the Department of Health want that level of uncertainty lying over their head or the heads of one of their parents? The residents of the homes will not know who their landlords are or whether they are fit to run care homes at all. Of course no-one will find themselves homeless – it will be the local authorities, the elected local authorities who will have to spend and fret themselves out of this one – nothing to do with the Department of Health’s reassurances – unless the Department of Health is going to compensate those local authorities for the time and cost they spend to ensure the welfare of residents of Southern Cross homes that may close.

As for the CQC, I think we have established that it is unfit for purpose and unable to regulate a care industry that has grown too large and too costly to be regulated efficiently. How about an idea? The Department of Health invests very heavily directly in the CQC so that they can provide at least twice-yearly, unannounced inspections together with a host of lay visitors attached to every single residential and nursing home?

No, the Department of Health is weedling out of this crisis as it will weedle out of the cost of ensuring that the residents of Southern Cross Care Homes are not made homeless.

Now, I want to link some of these issues to the Public Service White Paper that was published yesterday and particularly one or two sentences I picked out.

Firstly

In the context of rolling out more extensive ‘choice’ in other areas of government, the paper says

‘We will ensure that individual service providers are licensed or registered by the relevant regulator for each sector (e.g. the Care Quality Commission) so that those choosing services can known that providers are reliable, without stifling cost”

Does that not lead to a tiny little shiver down ones spine? The CQC is being held up as a reason to trust in this extension of ‘choice’.  Has noone mentioned the cost of good quality regulation, either.  It’s worth reading this post at The Small Places for more consideration of the way the CQC regulates social care services. The CQC has failed to regulate and the care sector is failing to deliver on personalisation so far. The care sector has had time to learn as well. We had direct payments for many years and before that the ILF (Independent Living Fund) which allowed payments to be made directly to adults with disabilities to choose care. The system should be sophisticated enough by now to deliver good quality, equitable services but it has taken many years even to reach this point. There’s a long long way to go.

Secondly

“The wider public sector has much to learn from local authority successes in commissioning, for example, in adult social care”.

See, look at us, government, we’re a success! Success. This is the end-result of success. Adult care commissioning is not a success. It has not extended choice unless of course (and I think I’ve found the key) success is based on the principle of privatisation and provision of contracts to the those who deliver at the lowest cost regardless of quality. That is the adult social care ‘success’ that the government is lauding in the Open Public Services White Paper.

We are dazzled by words such as ‘choice’ and ‘open government’  but they have no meaning outside ‘lowest cost’ and ‘discharge of responsibility’.

Think of Southern Cross. Think of Adult Social Care. It’s coming to our homes, our hospitals, our high schools and our highways.

So much for my week of positivity!

The State of Healthcare and Adult Social Care in England – a brief glance and thoughts

Yesterday the CQC published their report ‘The State of Healthcare and Adult Social Care in England’.

I have to try and put my criticisms of the CQC and their increasingly lax regulatory process to one side, although I couldn’t help a snigger when they claimed in their statement on the front page of the report to ‘Act swiftly to eliminate poor quality care’. Not exactly my experience when they rely on members of the public to actually alert them to poor quality care rather than carry out their own random and regular ‘on the ground’ inspections but it is the only report we have and there are some useful pointers in it.

The CQC inspection remit is very broad and obviously the quality of their inspections vary.  This report relates specifically to the 2009/10 year.

The report covers four distinct areas – safe care, choice and control, person-centred services and standards of care. All the areas are very broad in their scope.

In summarising the report, I’ll look at it in those same areas and highlight some of the issues that arise.  I will also focus on the areas in which I have a particular interest – namely adult social care and mental  health but there are lots of pointers and lessons for healthcare outside this remit – I just don’t have time to comment on them all!

Safe Care

This covers physical safety such as safety from infection risks as well as safety from neglect and abuse.

The first ‘headline figure’ that the CQC lauds is that 80% of care homes met ‘safe working practice standards’. It does make you wonder about the other 20% though and add this to the fact that this is a self-reporting standard.  Those care homes which met the ‘medication’ standard were 72% for older adults compared to 79% for adults under 65. I wonder what the variation would tell us about the different ways of management and attitudes towards older adults.

In the ‘maintaining dignity and care’ standard which includes responses by local authorities to safeguarding alerts, there was a growth in ‘better’ outcomes as there was an increase in local authorities performing ‘well’ as opposed to adequately (from 89 to 113). There were still 3 LAs performing poorly though on this fundamental duty. Unfortunately they aren’t named.

Safeguarding alerts increased over a third to 103,030 nationally across all client groups but the largest part of these referrals came in relation to older adults. No surprise there. No surprise at the increase either if you’ve been working in adult social care. We’ve noticed a real tightening up of the procedures and ways that we report and investigation abuse allegations.  There was though a significant increase in the reports relating to adults with mental  health problems (up 34% – same as older adults).

CMHTs

There was a fairly low response rate for users of Community Mental Health Team services (17,000 patients in all).  Only a third were asked about physical health needs over the last year. I suppose I have a slightly different attitude as in an older adult’s CMHT we have a lot more interplay between physical and mental health so it’s something that might be more obvious for us to discuss.

Surprisingly only 56% of users had an out of hours telephone number to use.

MHA detentions

There was a large increase in detentions under the Mental Health Act over the last year and the CQC report that only 21% of wards visited met the Royal College of Psychiatrists recommended 85% occupancy rate.  29% were over-occupied and 7% had a 125% occupancy rate.  I’m not surprised by this. My own experience is that wards are closing at a fairly rapid rate and have been over the last couple of years. They cost a lot of money. This will get far worse and it is worth holding Trusts to account over this. I hope the CQC does this.

Choice and Control

This banner is about increased knowledge for users about options available to them as well as greater use of personal budgets to choose care needs and use of advocacy services as well to promote choice.

The number of residential care home places fell but the numbers of nursing home places rose nationally and particularly there has been a growth in provision of places for people with dementia. This is patchy at best across the country with the highest proportion of additional beds in the North East and the lowest in the South West.

I was concerned that the base figures of people on personal budgets was the indicator of how ‘good’ a council was at providing choice. My experience of implementing personal budgets is that all too often it seems like an empty ‘paper exercise’ in upping the councils’ figures for surveys such as this rather than a real and concerted change in mentality towards providing choice to those who require additional professional support to seize more ‘creative’ outcomes.

According to the report, which remember is dated 2009/10, only 3 councils are proposing to increase their eligibility criteria for services this coming year from substantial to critical and one was planning on reducing the eligibility criteria from substantial to moderate. I find that really hard to believe but figures are figures.

In relation to mental health service users, 48% of users said they definitely understood what was in their care plan. That’s a fairly shoddy figure!  And 53% felt that their views had definitely been taken into account when putting together care plans. Perhaps we can see some of the potential difficulties for self-directed support in mental  health arena when these figures are already so low but it is important to note that the low response rate of users is possibily another variant.

Regarding medication and information about medication 29% of respondents said they were not told about the side effects of medications that they were on.

Regarding inpatients both those detained under the Mental Health Act and those ‘voluntary’ patients, the CQC identified that the hospitals had been increasingly focused on security and ‘rules’ and that, more worryingly, more ‘voluntary’ patients were being held on locked wards and potentially were being deprived of their liberty.  The report mentions that they were held neither under the Mental Health Act nor the Deprivation of Liberty Safeguards but the use of the Deprivation of Liberty Safeguards in psychiatric hospitals is generally not done. It may and should lead to a greater number of patients detained under the Mental Health Act for their own protection. I wonder if there will be any affect on numbers from this report.

Person-centred Services

A couple of interesting trends to pick up in this section which will no doubt, be a sign for the future. Firstly that less people as a whole accessed community care services – a fall by 4.7% from the previous year (that’s 83,930 fewer people). The report suggests that in the face of research showing an ageing population, it could be due to increasingly stringent application of criteria for assistance. Add this to the fact that people who benefited from help from grant-funded organisations (often those people who fall short of meeting the council ‘criteria’) also fell, there is a potential for a large unrecorded unmet need to be ‘falling through the gaps’ in service provision between the statutory and the third sectors.

Generally though there was satisfaction with the way that assessments were picked up and the involvement that people had in planning services.

The provision of telecare has grown over the last year, again, unsurprisingly – and I expect it will grow for many years to come and technology and care overlap in  more creative ways.

Demand for the provision of ‘extra-care’ sheltered housing – which is sheltered housing with additional care services attached – was growing, sometimes beyond the provision of some local authorities. I see this as a potentially massive growth area and am often frustrated by a lack of provisioning particularly for those with mental health as well as physical  health needs. If I were to be able to approach our commissioners with any one piece of information it would be that.

Worryingly only a quarter of councils demonstrated a strength in supporting people with complex needs and only seven displayed a strength in specialist services.

Regarding services for carers, there has been a large increase in carers taking up direct payments. This reflects my own personal experience as I have done a lot more carers direct payments this year and this amount grows every year however,  the report worrying raises issues regarding money which was provided to improve the outcome for carers and was not ring-fenced and wonders aloud where this money might have gone. Sign of the times with the elimination of ring-fenced funding.

Standards of Care and Support

It’s interesting that the CQC explain how they judge that a care service is of a good quality or not. Their ‘evidence base’ is interviews of providers and users of services, information given to the CQC by the service, surveys given to staff, users and professionals (I have only once ever received such a survey),  a key inspection (how often? Announced? I know a lot of services that haven’t been inspected for over a year), and information held about the history of a service.

My scepticism shines through because some services can ‘game’ the systems by having all the information required by the CQC written up perfectly but how they perform on simple human care levels differs enormously. I strongly believe that frequently (at least twice-yearly) unannounced thorough inspections are the way to truly judge quality.

Unsurprisingly the highest quantity of top level ‘excellent’ services were provided by the voluntary sector and the local authority. Private providers lagged behind. A sign of the times, perhaps as the government pushes the purchaser/provider split into the health service. Look to the care sector and be warned.  Today it’s the care homes for your parents and grandparents. Tomorrow it will be your hospital services for you and your children. Perhaps then, we as a society, will care more.

Smaller care homes were more likely to be judged highly than larger care homes.  Care homes for younger adults were more likely to be judged highly than care homes for older adults. No surprises here. But anger, a lot of anger. It’s about money, of course and there is less money available for the provision of care for older adults on a per capita basis. So larger homes and poorer quality care is the message given to providers.

The problem as well is the way that ‘good’ and ‘excellent’ are defined by the CQC as well though. I know poor ‘good’ homes and great ‘adequate’ homes. That was always the failing of the ‘star’ system but worse, to have no system at all and out of date ‘stars’ still on the website to give  a wholly inaccurate view of what the level of care is like at any given home. The CQC should be ashamed of the way they have destroyed robust and transparent  regulation and the previous government should be ashamed of how they allowed this to happen.

Finally and perhaps one of the most telling figures to take from the entire report is the one in the final sentence of the last page.

Only 16% of councils demonstrated low absence and vacancy rates and high recruitment and retention rates, which confirmed staffing issues continued to be an issue for 2009/10.

We can only imagine what the effect will be on these figures for 2010/11.

Or 2011/12.

The use of these reports is that it brings to life the importance work that is done in local authorities and the effect that good quality support and provision has on peoples’ lives. Yes, of course service provision is essential and too frequently, commissioners are detached to an infinite level so they have little idea about what is needed ‘on the ground’ but often to, it is the human contact, the ‘being listened to’ and having views acknowledged that also makes a difference and that is dependent on quality staffing, quality training and having the time to spend with people.

My own experience in a pushed, under-staffed team is that I am spending less time instead of more time with people as I chase from emergency to emergency and the outcomes for those people who would otherwise had more intensive face to face contact is falling. This leads to sharper deteriorations, more likely readmissions or admissions to hospital that could have been prevented and eventually higher costs.

But with councils and NHS Trusts looking towards the immediate cost cutting of the next year and not at the longer term costs in 5, 10 years, this is the way we will go.

We shouldn’t be satisfied with delivering lower quality care. We aren’t. We need to speak up and speak loud and build links actively with user groups and carer groups and other professional groups to ensure that the government never forgot whom exactly they are betraying and to remind them over and over again that we aren’t going away.

Regaining Radicalism

An issue that has been swilling around in my head for a while concerns the ‘reclamation’ of the radical tinges of the social work profession and whether or not we are moving into a potentially more dangerous era as the government whittles away at some of the assumptions made about the welfare state and an implied social contract to provide and sustain those who are least able to in a civilised society.

I wonder to myself what the role of social work is in this right-ward shifting of the national political agenda and by extension, what I can do while preserving the job that I genuinely love.

There has always been the undercurrent of ‘care v control’ in the social care sector. Where can we place ourselves when the ‘care’ is cut to the minimum and we are agents of rationalisation of funding and the ‘control’ implies a forced manifestation of a political will which we feel may be counter-productive?

I have a couple of main thoughts about this. One concerns communal actions and the other about personal actions.

I have been a member of Unison – the public services union since I joined the profession (excepting the years I spent overseas and the brief period when I had a personal spat with a shop steward and resigned in disgust – only to rejoin a couple of months later after he had apologised profusely – I know, childish but I WAS right Smile with tongue out)

Mostly I saw union membership as a protection against mendacious managers. Although I can’t praise my current managers highly enough, I have worked in teams where there has been some poor, verging on bullying practices and it is best to know the union can support and guide in such circumstances. More recently, though, I am espousing myself of the wider political ideas of unionisation and the communality of experiences across the public service sector.

I don’t always agree with everything Unison (and particularly said shop steward) does and says personally, but I strongly believe that the best way to focus political activism and engagement is through the union as – working in a local authority – the lines of communication are pretty clear and the ties are fairly well bound between the union and the employers.

I am sure that somewhere BASW and the embryonic College of Social Work have a place to pay in the regaining of political purpose and will of the profession. I hope there will be some kind of blurring and possibly merging of roles as they seem to sit in the same place professionally.

I have also been actively following SWAN – the Social Work Action Network. Indeed, I went to an event held in London a couple of weeks ago and was impressed by the strength of feeling on display. One of the attendees specifically asked about how we retain our radical roots and work ethically while retaining our jobs as practising front line social workers. That was one of the elements that shaped some of my thoughts about the issues.

I did note that most of the people attending the SWAN meeting seemed to be students. It was great, in a way, as we need (and this was discussed) a radicalised student base. Perhaps social work students (through their lecturers) increasingly see the role as one of a lackey of the state because the ‘care management’ and ‘procedural’ roles are emphasised through both training and placements and with increasing fees for training and courses being able to produce ’employment-ready’ social workers but I feel it is ever more important to ensure that there is scope for radicalisation within universities and colleges and that the profession actively promotes social  justice.  There is a role for social work outside the statutory sector but that seems to be forgotten in the hunt for statutory sector placements as ‘gold standard’ on courses.

Perhaps the social work course should be a route towards a new kind of social enterprise entrepreneur? Theoretically and logically, the studies that we partake in should be the best ‘lift-off’ point towards a career in the ‘third sector’.

But even within teams the place for radicalism does not have to be lost. It can be rediscovered through discussion and debate. Yes, we have a statutory role but the need for people who have a strong value base in implementing even quite cruel policies is all the more important.

Does it compromise my values to be the person responsible for implementing restrictions on access to services according to criteria? Well, that’s debatable, I’m sure some would say it does. I say, and I use the same argument to myself when detaining people under the Mental Health Act, that if the task is to be completed, when working with people who may be vulnerable for whatever reason, it is better that the job and the role is taken by someone who is compassionate and who is mindful of the impact of every intervention they take rather than a faceless bureaucrat who might not have an active interest in the implementation and effect of social policy.

I believe that being ‘on the frontline’ gives me a certain power to argue on behalf of those whom I work with, both service users and carers. Can I make differences to macro social policy? Probably not but I can ensure that my voice is not lost to those at more local levels and that I constantly feed up my concerns.

One day, we’ll be listened to but without us, crying up from the bottom of the ‘career ladder’ the authenticity will be lost.

A part of my bleating against management cultures is that I believe that  (and I am aware this is my own prejudice talking) a lot of people can’t wait to get away from the front-line and into cosy management positions (and academic positions) quickly enough. I fully understand that is an irrational and unfair accusation  but it just feels like that sometimes.

I think that the best way of social work changing and making and effecting changes is by work on the ‘front line’ and a strong and experienced workforce ‘at the front line’ who are not afraid of our own managers and will be able to engage in debate and conversation about policy without needing to ‘move upwards’ professionally.

I once applied for a senior post. The post itself was actually deleted before the interview so it didn’t end either in success or failure but was one of those posts that just rattled along and is unlikely to be reinstated.

I applied partly because I felt I should. I meet people who started before and after me as they climb up the professional ladder and partly felt an element of competition but I’m so glad now of exactly where I am. It has allowed me to distil a lot of my thoughts. It gives me a very powerful voice to express the needs of those whose homes I visit every single day and I can’t remove myself from the relentless nature of the work – because I’m doing it.

My hope remains with the potential ‘advanced practitioner’ professional development route which we have been promised through a new (hopefully improved) career development structure.

As for radicalism, it needs to take different routes and we need to fully embrace the social media in a way that hasn’t yet happened across the sector. Just through writing this, I know I am able to get the message from the ‘front line’ out to a far wider audience than I would by relying on verbal communications and perhaps collective activism.

Perhaps the true change will come when it doesn’t have to be done anonymously but I do think we have the power to embrace widening and broadening social networks to use our expertise, knowledge base and engagement with the issues across the social spectrum to affect, promote and encourage policies that promote social justice across the whole of society, not just the ‘middle section’ that the government seems to obsessively pander towards.

A few months ago, I attended one of the ‘College of Social Work consultation events’. Amongst social workers from very different sectors and different local authorities, I was somewhat depressed when I was involved in a discussion where my colleagues were telling each other how they wouldn’t want their own children to become social workers. Partly due to the pay and hours and partly due to the feelings of powerlessness and stigma of working in the profession. I never even considered not encouraging people to go into social work. We absolutely can thrive with good people in the role. OK, the pay could be better, that’s true but it could be a whole lot worse too (perhaps that comes from my background as a care worker where I was paid poorly but as I didn’t have anything to compare it to and just felt grateful to have a job, I didn’t really consider it). I am actually comfortable with my salary. I have somewhere to live and can live comfortably with enough left over to put away some ‘rainy day savings’ so perhaps different people just have different expectations. As for the powerlessness and stigma about being a social worker – we absolutely have the power to change that. We must if we want to be effective in our role. I often say I never went into social work to be loved, and it’s true but being respected would be a fine start.

Powerful and independent voices from within social work have the power to nudge, prod and appeal to the social conscious of the nation. You CAN be independent minded and comfortably (and happily) employed by a local authority. I am.

In fact, we are obliged to do so in order to work actively towards promoting social justice.