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… .. . . .

Last night’s TV

There were a couple of TV programmes of interest on last night. One was on ITV, called ‘Behind Closed Doors’ and was about childrens’ social services in Birmingham. I didn’t watch it because.. er.. we were watching Beethoven… you never grow too old for cute animal films!   Living the Social Work Dream writes up a brief account of her impressions and it seems like a sympathetic view.

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The other programme, which I did watch was ‘Undercover Boss’ on Channel 4 about Kevan Collins, the Chief Executive of Tower Hamlets. I  was curious to see what the perceptions of services on the ground would be from a local authority Chief Executive. I thought it was an interesting programme and quite enjoyed it. Of course, I’d have loved to have seen him in a social work office but the scope of the work of the council is so broad that it would take an 8 hour programme to cover all the different departments. The one thing that struck me at the beginning, where the filmed the Council Executive meeting (I assume) was how the ‘suits’ seemed all so worthy and nodded away when they talked about the usefulness of getting ‘front line’ workers to give input as they knew what was going on ‘on the ground’. I wonder it takes a television programme to emphasis this. I think they would all do well to ‘get their hands dirty’ to some extent and to actually listen to some of the ideas that would filter up.

Collins spent some time with the meals on wheels service. As I mentioned to my partner, Tower Hamlets is lucky to an extent as my local authority don’t deliver hot meals anymore and all the services have been contracted out. It was painful to watch how much that simple human contact can deliver to a person living alone at home who might not have the personal care needs to warrant a care package, and yet it is denied due to the costs of meal delivery systems. I hope it means that Tower Hamlets retains and promotes this service.  He certainly came out of the programme positively and I hope it was more than a just-for-the-cameras interest he was showing and will continue to show in the services in that Borough.

I jalso wanted to highlight this post from a US social worker who came to London with her college to learn about social services in the UK. She visited Waltham Forest and gave an interesting view ‘from the outside’. One of the things I have enjoyed most about the blogging experience is learning more about comparative systems of social work, particularly in the US, It makes a fascinating read to see how a British Social Work team is viewed and is something quite different from the usual navel-gazing that we occupy ourselves with!

Failing Students

This week, Community Care prints an article about pressures on universities to pass students who might not ‘meet the grade’.

This has always been a concern of mine as there is an incentive on universities to ensure students graduate rather than ensure that high quality social workers are pumped out into the ‘system’. The needs are conflicting as a student can be very able academically (or not.. )  and that does not necessarily imply good practice but for as long as the degree in itself is the gateway to qualified status, the decisions are left in the hands of the universities.

Practice placements exist to ensure that it is not only on academic levels that students are assessed however there are well-documented difficulties with placement and there is not necessarily an equality of experiences between students at the same university and the way they have experiences and assessments on placement.

This is particularly heavy on my mind at the moment as I will imminently be taking a student from one of the local universities into my work place and have turned my thoughts to preparation for this.

I know from a colleague’s experience how difficult it has been to try and ‘fail’ students who have not met the standards expected to practice on a final placement and the practice assessors who have been in my team, have been leaned on heavily to keep giving more and more chances to students they felt were not achieving well enough.

I’m all for second chances  but some people are not cut out for the profession and trying to force too leeway into the framework of assessment does noone any favours.

The article presented in Community Care draws parallels with the Teacher Training programmes where

‘The Training and Development Agency for Schools, which funds teacher training, has chosen to remove any incentives universities might have for retaining students who were not likely to pass the course or become competent teachers … this should be the same for social work.’

Personally, I think the proposed year following qualification in which newly graduated social workers will have to practice will help in this area. I think that the universities have not been able to be trusted with the process of training social workers – especially as concerns about appropriate placements have grown. If social work students cannot spend substantial time with social workers ‘on the job’ during their courses, then they must be compelled to subsequently.

Noone wins with a dilution of the quality of entrance to the profession and as well as rigorous academic standards, a certain amount of confidence, assertiveness and thoughtfulness is required.

If there is anything that will raise the status of the profession – something which the Task Force seems to be particularly focussed on – it is a good quality, effective workforce who are able not only to advocate on behalf of service users but also able to advocate on behalf of themselves and their profession when they see poor systems in place.

Students

image wonderlane at flickr

Over the past week,   I have submitted an application to a practice teaching programme. It was always a part of my long-term plan – for many years, I’ve mentioned my interest in taking a student within the service that I work, in fact, even in my interview for my current job, I stated it was a ‘career’ goal’.

During that self-same interview, I was told by the service manager that the service need would dictate that first, I train as an ASW (as was..) and when I had completed that qualification, then and only then would I be able to take the practice teaching course.

I pondered on the ‘Enabling Others’ shorter course to take a student on, but settled on the full Practice Teaching award. I enjoy learning and training and can see definite advantages in the longer programme – as long as my local authority are happy for me to take it (which they are).

The training manager who is responsible for social workers’ post-qualification training has been pestered repeatedly by me for the last couple of years, asking her to give me details of the available courses – so much so that she mentioned it to my manager at a time I had more or less forgotten that the deadline was advancing.

And so it was that I submitted an application.

The borough is fairly flexible and being in London, there is access to a number of different universities with which they have links. I had the choice initially of three different programmes run by three different universities.

The ideal one (I felt) involved the longest travelling distances so I caved and as of next year, I return to the university at which I first qualified, myself as a social worker. I had a number of reservations – mostly built on memories of the university 10 years back – but one of the things that nudged me was the recollections of myself as a student at X University and how much I would have loved a placement at the place where I am now currently working…

I have no doubts it’ll be a tough period. I am finding work hard to balance at times, especially as some of the work can come up so suddenly – but that is pretty much how the work is and I think it will be a useful placement to someone out there!

And on the subject of student social workers, which I wasn’t really.. I had one come to shadow me earlier in the year. I was actually asked because she is currently doing some home care work for one of the service users I am allocated to. I offered to have her come in because it can be hard to find a social worker to shadow and I quite like having students around.

And so it was that she asked me to write a report about her time with me. It didn’t help that she had shadowed me in March and requested the report in July but I’d been on holiday so I ended up writing the report the day morning my father died. It was sitting on my desk when I left work at speed. I didn’t send it.

When I returned to work 10 days later, I  had a string of telephone calls and emails asking me when I was going to send the report to her – quite grumpy really – and another call telling me she was going to fail her portfolio because I had never sent the report.

I was sorry but I wasn’t terribly impressed to be honest. I sent her a curt email explaining that I had been off work on compassionate leave and would send the report immediately.

Yesterday, as I was trying to re-arrange some care package for the service user that she visits, he mentioned that he was sorry to hear about my father and that –insert name of social work student- had told him why I’d been off work.

As it was, I wasn’t too bothered about him knowing – but if it had happened before I’d written the glowing report – I’d have had a few things to say to the university about confidentiality, professionalism and appropriateness.

So there’s a lesson I’ll no doubt be able to share with my first student, when he or she arrives, probably in the new year..

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.

image mysza831  at Flickr

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.

Reviewing Social Work

This morning, Ed Balls, the Secretary of State for Children has announced review of Social Work. Seeing his job description, I wonder how much effect this will have on the generic nature of Social Work training.

Some of the headline changes ‘demanded’ are that senior managers in ‘Social Services Children’s’ Departments’ (I put that in inverted commas because a lot of the Children’s’ Departments are now Social Services and Education Departments) have to have experience in a Social Work setting. This was one of the criticisms of Sharon Shoesmith – she managed a department that covered Education and Social Services for Children. She had an allegedly glittering career in Education but no experience of Social Work or Social Services on any more than a perfunctory level.

image mikelens at Flickr

My understanding was that the purpose of merging the Childrens and Education services’ directorates was to create a more cohesive and communicative department after the first Laming Report. People still compartmentalise and how much is it worth fighting this? Just give the jobs to people who are able to do them and who know what they are doing. These are no positions for ‘career’ administrators with no idea of what actually happens on a day to day basis.

The need to change training processes is more interesting to me. Balls says that more practical experience is needed in Social Work training courses. Granted, I trained before the latest change in the system but what is without doubt is that the practice teaching and the placement system is already falling apart. There are not enough placements for the amount of students currently training. I know it’s certainly the case at the universities I have contact with and I understand it’s a standard across the country. Of course more practical experience is fundamental to the provision of well-trained and therefore, effective, confident and  independent-minded social workers – but just saying it should exist won’t help the people who are already desperately searching for placement.

There has to be room to fail students who don’t make the grade too. A colleague of mine had a student who was frankly not competent. She was pressured to keep giving him chances over and over again until he eventually and against her recommendations, passed his placement. It is not an ‘easy’ subject and there is absolutely no room for students who aren’t up to it.

What do you need to learn to be a social worker?

A clear view of the background of social services provisions and social work as a profession and a good grounding in social policy and the history of social policy.

Knowledge of the place of culture and identity in a persons’ life and the role that it has in the society in which we live.

Critical analysis of policies that are presented to you. There is a role for academic writing and investigations and research work. Hands on experience is vital but never at the expense of thorough academic learning and intellectual strain. This cannot afford to be a ‘soft’ subject. We need competent, well-trained and well-educated staff.

The ability to write clearly and coherently – with or without spell check (ok, that’s a bugbear of mine, I am really frustrated by the quality of some of the reports that are placed in front of me by colleagues – it is almost embarrassing).

Independence, bloody-mindedness but also empathy. You can’t take what you are told at face-value. Not service users, not carers and perhaps most importantly not managers, but you can be bloody-minded without being confrontational. That isn’t the same as not trusting people or believing – but rather about  accepting that perceptions of reality aren’t always the same as an objective reality. You can’t afford to be complacent  – it is not fair to people who expect a service.  That’s the skill. Nudging at details, having conversations with people that they don’t want to have but still being able to maintain some kind of therapeutic relationship.

When I carry out Mental Health Act Assessments, the first thing I have to say to someone is the purpose of the assessment and that it may lead to a compulsory detention in hospital – I then have to try and do a 180 degree turn to create an environment for a constructive conversation – that’s a bit of a dramatic example but it happens.

Humility – You can be wrong. Please please please accept you can be wrong. The most frightening social work practitioners are the ones who can’t go to colleagues or managers and say ‘I’m not sure about this’ or ‘I have done something wrong here’ or sometimes (and more frequently in my case!) ‘I don’t know what to do’. And what do we need? Managers who WELCOME social workers asking and telling. I know someone who is terrified to tell her manager about things she is not sure of because she doesn’t want to seem incompetent. THAT is the most dangerous type of social worker. If I ever do supervise a student or even manage another member of staff, I would be happiest if I set them on their way without being afraid to discuss concerns, misjudgments, thought processes and errors for fear of chastisement.

People skills can’t be taught always but they can be practiced. The fear as well is that being pushed around from pillar to post by political inquiries and ‘layman’s views’ on what can be changed isn’t always the best way to instil a confidence in a beleaguered workforce.

Just some initial thoughts – I may add some more over the week when I’ve had a chance to read a little more about the proposals but I was watching the Breakfast News and felt the need to respond. It is a subject that matters to me.

If anyone has any other ideas about what should be in this report, feel free to add!

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