Selling the NHS – The Beginning

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Yesterday, while most of the media, fixated self-referentially on the Murdoch hearings and Cameron was flying back into the country,  Lansley began to dismantle the National Health Service.

As The Guardian reports

In the first wave, beginning in April, eight NHS areas – including musculoskeletal services for back pain, adult hearing services in the community, wheelchair services for children, and primary care psychological therapies for adults – will be open for “competition on quality not price”. If successful, the “any qualified provider” policy would from 2013 see non-NHS bodies allowed to deliver more complicated clinical services in maternity and “home chemotherapy”.

So we are led to believe that being open for ‘competition on quality not price’ will act to pat us on the head, reassure us, and direct us back to the ‘big media story’.

It worries me and it worries me for a number of reasons. Lansley’s words are couched in the words of ‘choice’ but I wonder exactly whose ‘choice’ it will be to make these commissioning decisions for which, no doubt, large amounts of money will change hands and profit-making publicly listed and private companies will be able to partake.

I admit to a bias having been exposed and having experience in the adult care sector which was subject to a similar rollout of competition which was supposed to increase choice and quality.

I’ve written many times about the end result and how it is one that has inherently favoured larger providers and companies that have been able to deliver on economies of scale rather than the poetic vision of small scale providers delivering local services. Those small scale providers were quickly priced out of the market and I fear this will happen again.

But wait, I hear, ‘quality not price’ Lansley says.. to which I reply, ‘nonsense’.

Why? Because there will probably be minimum standards of ‘quality’ that a service has to reach and beyond those, it will be a price competition. That’s what is supposed to happen in care – but who checks the standards? who will check the standards? How can we have confidence in a well-resourced and well-delivered service when regulators are so weak.

I do not want any private company to make a profit on my potential need for services for my back pain, my hearing or a child’s wheelchair.

Of course, making the publicly delivered service is clearly both too expensive and veering against the government doctrine of handing the healthcare to private companies.

I am sure the first few providers will intersperse local voluntary organisations with large multinational corporations in their delivery methods. Again, I point to the adult social care sector. We started along the path with the NHS and Community Care Act (1990) having a lot of local providers together with a few Southern Crosses and Care UKs. The local providers were eventually priced out.

Of course in the case of podiatry and hearing services as well as primary care psychological therapies, we can see these as almost discreet services. The ones that will potentially be easy to deliver and it will always be possible to find wonderfully successful outcomes for people choosing Boots rather than the local NHS for their podiatry appointments because it is more convenient. And I’m sure it seems to pave the way for Individual Health Budgets where people  are given the money to ‘spend’ on the services that they need. Choice you see. Choice is what it’s all about.

I turn back and look at what has happened in social care. Choice has been extended in wonderful ways to those with the loudest voices but in some ways those with the highest needs have been left behind. That is my main concern about the introduction of private into public.

For some people, the people in the comfortable middle classes of Chipping Norton, this is fantastic news – they can access their IAPT (or equivalent) by a local provider when they are feeling a bit down. They can have their feet checked in a local branch of Boots instead of having to travel into Oxford. All’s well.

Those will be the areas where both competition and choice are the highest.

My concern is that people who experience the degradation of poverty will have quieter voices and less choice because there may be higher multiples of health difficulties and choice is determined through power. I can’t help but think of people who are restricted in their choice by issues of capacity. Will they be given advocates to assist with the process or will they just be ignored? Will the choice by made by GPs who are courted by these private companies, just as they are currently courted by drugs companies?

How equitable will the ‘new’ system be?

If we are extending choice, we have to extend safeguards and checks.

If we are extending choice, we have to extend quality.

It hasn’t happened in social care – there is no reason to believe or trust that it will happen in healthcare.

It does make me wonder – Are we all in this together? Really? With the impact analysis projects that are carried out to ensure equality, I know there are provisions to look at ability and disability, gender etc but are social class and income level also considered?

And think – Lansley considers putting ‘quality’ in as a concession – he was happy to go ahead with the Bill and with a pure ‘cost’ factor. This is his so-called concession but it is no concession at all if we don’t have a definition of what ‘quality’ is. After all, the CQC – too look at the Health Care regulator – defines ‘quality’ on the basis of paper documents and paper inspections given to them by provider services.

If that doesn’t wave any red flags, I don’t know what will.

This is a government of interests rather than representatives. The shame is that the last government was too and likely all the future ones will be as long as we allow our heads to be turned more quickly by celebrity gossip than the tragedies unfolding in our adult care services.

On Failing Care Homes

Today, the BBC report on a statement by Unison, who represent the inspectors who work for the CQC (Care Quality Commission), explaining how failing care homes will be able to thrive under the ‘cost-saving’ exercises which are the utterly despicable ‘desk based inspections’ that I’ve been railing against for over a year.

This is one of many areas that I don’t want to be right. I don’t want to be a ‘Cassandra’ type figure but I do want people to care and know that elderly and vulnerable people are not being protected by the current regime of inspection and that things are going to get worse unless there is a massive change in the way the CQC is run – remember the Chief Executive is Cynthia Bower, the same woman who was responsible for the West Midlands Strategic Health Board – which covered the Stafford Hospital whose problems we have become all too aware of. Hardly a glowing CV for someone appointed to a regulatory body.

The BBC article explains

Unison says the new system of written self-assessments will mean thousands of homes will avoid inspections altogether if they look good on paper.

But the Care Quality Commission, which introduced the system, said it would let inspectors focus on failing homes.

Which would be fine if they DID focus on failing homes. I  am, for the record, currently in the middle of a really unpleasant safeguarding investigation at a so-called ‘Good’ residential home. It only takes one day or one person for a ‘good’ home to turn into a really bad home. This is the point that is utterly and comprehensively missed by the ‘new’ system.

The BBC go on to explain

The new system replaces yearly automatic inspections for all homes.

It came into force in October and now means that homes which provide a good written self-assessment may not be inspected again, unless there is a serious complaint made about them to the commission (CQC).

For me, this is a horrific institutional abuse and dereliction of the duty of care that the state has towards adults who rely on us to provide high quality care for them. Firstly, I know for a fact this has been the system for way before October, as I have spoken to an inspector directly about care homes that I am worried about and have been told that they haven’t been ‘visited’. This is NOT a system that ‘came into force’ in October’.

And sorry, but when it takes a ‘serious complaint’ to trigger an inspection, we are setting such a low baseline for the standards of care that we expect. If they MUST move down this route and, if it wasn’t very obvious, I think it is a cruel and horrendous path to tread – then surely only those homes which provide faultless and outstanding care would be able to produce self-assessments, not ‘only those that don’t have serious complaints made about them’.

The CQC is not able to manage the work that is being generated for it – that’s the problem. It is purely and simply about cost-cutting.

According to the BBC article

Unison, which now represents about 700 inspectors, claims that the workforce numbers have halved since 2004.

And there we have it. The key to why the systems have had to change. It is not about providing a better service, it is not about more tailored inspection regimes – it is purely and simply about cost and cutting back the number of inspectors. They can’t spend two days inspecting every residential and nursing home because they don’t have the time to.

Paper-based self-assessment is as valueless as the paper it is written on. It is a completely inadequate system that produced poor quality care.

Can we rely on whistle-blowers? Perhaps but remember the people who often work in residential homes who we might rely on are often very poorly paid and this is a sector that relies very heavily on transient staff on minimum wages. Particularly the worst homes.

What about council’s own Quality Assurance teams? This is what I was told, informally, in conversation with an inspector. On the other hand, someone I know who works in our own council’s monitoring team tells me of potential job cuts they are being subject to. This is leaving a monumental gap in the checks and balances of the care home system.

Care is a big money business in this country.

Just last year, Andrew Lansley, the Secretary of State for Health under whose auspices the care sector lies, was given a donation to his private office of £21,000 by Care UK – one of the largest care ‘industry’ operators whose poor quality of care has been highlighted in the past in Panorama.

However this is not a party political issue. The previous government showed little care or interest in the proper regulation of residential and nursing care services but the further erosion of local authority budgets will lead to a worse system of regulation than we have ever had in this country.

This is scandalous in the extreme. Anyone from this government (and the last, to be honest) who claims they are protecting the vulnerable need only look to both the decimation of proper and thorough regulation of the care sector which has left the way open to abusive practices and the crushing of local authority budgets without ring-fencing which will lead to any back up checks and balances being slowly (or not so slowly) eroded.

No-one seems to care enough about these changes and what it means for quality and the CQC management seem to be able to get away with reassurances that ‘paper based’ inspections will be ok.

They won’t and they aren’t. I know. I worked in residential homes for years before I qualified. There is no such thing as over-regulation in this sector because the power imbalances are enormous and in some of the care homes, the residents, due to issues of capacity or through fear of consequences are not able to speak up about what is going on. We cannot rely on family members to be whistleblowers, it isn’t fair and it should be accepted that we can provide a good standard of care.

And, you know, not everyone has family.

And we can’t necessarily rely on social workers, like me, who go and review. Yes, I can and do pick up some aspects of care but we don’t have the powers to look at records about people we are not primarily involved with (quite rightly). We can raise concerns about individuals when we notice them but that is no replacement for a proper and stringent regulation regime.

We need inspectors, we need inspections and we need more of them. But they cost and it isn’t a price the government is willing to pay. But it should be.

National Care Service?

The Secretary of State for Health, Andy Burnham, wrote a piece in the Guardian today about his vision for a ‘National Care Service’

‘ providing personal care and support to adults on the basis of need and free at the point of use, will ensure that an ageing society remains a decent and fair society.’

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Andy Burnham and Ed Balls..

It’s hard to argue against that as a positive. Everyone wants good care and noone wants a price attached to it. All well and good so far.

He focuses on the disparity in the current system which places a burden on those who have property and savings and there is no doubt that there the current system is not ‘fair’ although the way that ‘fair’ can be interpreted is wonderfully flexible.

As for me, the rhetoric is pleasant sounding and hard to argue against. The fight will be in the details and don’t get me wrong, I’d love a system like this for all run on the basis of the National Health Service – but there is a real price to pay and trying to hide behind that fact or ignore the necessity for payment will just build unrealistic expectations.

People have different ideas about ‘fairness’ and ‘equity’. Personally, I think there is more of an obligation to help those who have the least resources to pay for the care that they need. I think if there were more focus on the money and the way the funding is divided, more money could be saved through properly thought through preventative services although there seems to be a tendency to veer from crisis to emergency at present and only providing care for the highest defined needs buys into this system – when a more substantial base of care at lower or ‘moderate’ needs may well prevent a more expensive longer term role for formal care.

On one element I do agree with him though, that the system that is churned out should not be voluntary – as the Tories ‘optional insurance’ suggests – if there is an inherent fairness, it needs to be universal. I know I’d happily pay a premium or increased tax if it were to produce a good quality system of equitable care for older adults and those with disabilities.

But there are more statements to be made and more talking to be done. Until the rhetoric morphs into concrete plans – which I have to say, I’m very much looking to – it’s a matter of waiting and seeing – and playing at politics until the election guides us to the way it might be taken forward.

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Dementia Strategies and Memory Clinics

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The National Dementia Strategy for England was launched yesterday with an impressive sounding 5 year plan to increase support people who are diagnosed with dementia and take through the different aspects that need to be worked on – from early diagnosis through to raising public awareness and raising standards in nursing homes by improving training for social care workers throughout the sector.

Some of the attention has fallen on the recommendation to set up ‘Memory Clinics’ around the country to support Alzheimer’s sufferers and carers of people with Alzheimer’s. I am not sure how much additional money is being provided.

A part of the reconfiguration of services in my own service was to allow for the setting up of a Memory Clinic. Four area CMHTs were merged into two plus a Memory Clinic. It was a what the management delightfully refer to as a ‘zero cost’ change – meaning that no additional money or posts were made available.

Of course, our new memory clinic hasn’t been running too long and setting up a service from stratch is never an easy prospect but there are a few elements that have concerned me.

Firstly – and this is a personal gripe so bear with me – the team is staffed by CPNs exclusively. Not that they aren’t wonderful, of course but there was no role for any social work input and that was a very deliberate move.

Our Memory Service is about diagnosis and then referral to adult social work departments if any kind of additional care is needed. I did suggest at the time that even having an unqualified social worker in post who could set up minor care packages at the very least, might make a more seamless service but this was seen as contrary to the ‘point’ of a memory clinic. It has a purely medical  model.

The CMHTs will take on people who have particularly complex needs or who have not been engaging with services as they always did but the staff have been moved out of the CMHTs to work in the memory clinic so we are even harder pressed.

Of course it is still early days. I am sure for some people it is a much better service. It means we, as a CMHT, are able to refer more people back to the Adult Community Care. That is seen as a bonus. I don’t think it is though. I came into my job from the Adult Community Care Team. I know that they have much higher caseloads than we do. They simply do not have the time to provide the same level of support that we can. Anyway, as I said, that’s a personal gripe with the way that our service was set up.

According to the BBC, Alan Johnson, the Secretary of State for Health, states  that

The clinics would be “one-stop shops”, offering expert assessment, support, information and advice to those with memory problems and their carers.

The clinics could be housed in hospitals, GP surgeries or in the high street, and patients could refer themselves, he added.

I’m not sure that our service has reached the ‘patients referring themselves’ part yet. We get most referrals  as always from GPs. These referrals still need to come in and when you work in a particular locality you get to know the various GPs and to be honest, almost all of them are great and refer if they have any doubts or concerns.

It still needs someone to actually make that trip to the GP in the first place though – whether an individual themselves – or a family member.

I can’t be the only person this has happened to but twice in the last couple of months I have made referrals myself to my own team when I have visited a couple at home and while visiting Mrs X have noticed that Mr X seems to be having memory problems. Of course the families involved have noticed but sometimes diagnosis is a scary prospect – even when, in reality, it is just a confirmation of something that everyone knew.

With all my cynicism though, more money is now going to be pumped into dementia services which is no bad thing as long as it is targeted money. If I were able to distribute it myself, I’d put much more into carers’ support, carers’ services and carers’ allowances.

So much of a patient’s quality of life depends on informal care networks. It is important that professional networks are available and most importantly are responsive but sometimes, providing actual cash to carers is much more important.

I would say some of the more valuable work I do is with carers and supporting them, at least psychologically, through some of the paths of dementia and the expectations of what may lie ahead when it reaches that point and gently nudging them to  make plans, make arrangements and preparations so that when the time comes at least they do not feel completely isolated or alone.

I see that the strategy is going to pilot a new role of ‘Dementia Advisor’. This, I think, seems to fall into this role but it can’t be a time-limited one. Someone does not need a dementia advisor solely at the point of diagnosis but it is important that there is a consistent through the process of deterioration and change. The strategy mentions that these advisors will be a place to turn for support for the person with dementia and their carer throughout. I assume additional funding will be available for these workers.

Some more and important positives of the strategy though is the recommendation for better dementia awareness and care in general hospitals. Having a team in a hospital that will advise and support patients who have dementia and improved training in care homes who are managing patients with dementia. It is hard to think that this can be a bad thing.

And there is also more money (if I have understood correctly) being put into research. Which can never be a bad thing.

Raised awareness of dementia, it’s broad reach and the implications and paths of care are all very positive. Some of the details – well, I’ll reserve judgement.

Just a reminder too, in the UK anyway, that tonight on BBC2 there is ‘Living with Alzheimer’s’ at 9pm –

Determined to prevent it if he possibly can, Terry Pratchett takes a personal journey through the science and the reality of what it’s like to be diagnosed with Alzheimer’s.

This two part documentary follows Terry’s race to find a cure as he endeavours to find ways of slowing, mitigating or even reversing its course.

I, unfortunately, won’t be watching – well, not live anyway. The snow flurry has blown my TV aeriel down  (which, if any of you knew me, you’d know how distressing this is as I’d say ‘TV watching’ is one of my prime hobbies (!)). At least I will be able to catch it on the iPlayer though .

Follow The Sun

Yesterday the make up of the shiny new government Task Force on Social Work was announced. This is a focus group who are to be involved in the ‘root and branch’ review of front-line practice of the Social Work profession as a whole in the UK.

The ‘team’ has been put together by the Secretary of State for Children, Schools and Families – Ed Balls and the Secretary of State for Health, Alan Johnson and are due to report back to the government this summer.

That doesn’t leave them a lot of time. Of course, I am sure there can be a million different views about the rightness or wrongness of the composition of this committee. Social Work runs across childrens’ and adult services. Social Work covers a wide gamut of interests and experiences. It is difficult for a committee which is small enough to function effectively to be large enough to address the differing aspects of the profession so the hope is that those groups not having a place specifically on the task force will be considered and represented by those who do have a voice.

The task force (I don’t know, that just brings back memories of the Falklands Invasion to me) has the usual members, some front line workers, some academics, some chief executives – but there is one member whose presence really is staggering.

Deirdre Sanders, the agony aunt of The Sun – remember, the same tabloid newspaper that carried out a vitriolic witch-hunt against individual social workers and organised a petition against them – has a place on this Task Force.

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I’m sure Deirdre is a wonderful human being. She writes very sensible letters in the newspaper (so I’m told). Am I the only one to be staggered that the social work profession has to engage journalists to discuss the future of their profession though at this level? Sure, if it were a task force on the ‘perception of social work’ or ‘improving the way that social work is reported’ she would be a valuable member of the team –  but honestly, a committee which is tasked with making changes to the social work profession?

It feels a bit like Ed Balls playing (again) a public opinion game with a profession that has had too much political interference for its own good.

Emma Maier considered this at The Social Work Blog and looks at both the positives of Deirdre’s appointment, namely that

giving The Sun the inside track on the taskforce could be a clever because it is always more difficult to slate something you are involved in. Having the popular press on side would help convey some of the important messages to come out of the taskforce. And the rest of the taskforce seems to offer a good spread of stakeholders from children’s and adults’ services.

It is something I hadn’t considered initially but then, why should a team of professionals who are conducting a serious review of the needs of social work in the 21st century have to get ‘popular press’ onside. Why should we, as social workers, need to work hard to involve tabloid journalists in our professional goals and developments. We should look at how social workers can work most effectively and beneficially for the public good and for the individual users of services rather than pandering to public agendas created by popular journalism.

Can we imagine a task force of any other professional group involving an ‘agony aunt’? OK, excepting a task force of journalists.. I guess that would work.. User involvement is represented quite rightly on the task force so why appoint a paid employee of the Sun newspaper. Will her presence, as I’m sure she is extremely articulate and able, overpower and detract from the serious discussions that need to take place about social work. Is this a true and honest attempt to improve and create a fundamentally workable system or is it a publicity stunt by Ed Balls. Again. Who seems to like using social workers are political footballs.

As for me, I feel honestly, insulted that my profession cannot be given the respect should command by the government.

I await the report in the summer with interest and no little trepidation.