Exporting Care

Location, Location, Location

Yesterday I read this article in the Guardian. It reports that in Germany there is an increase in Germans being placed in residential, retirement and rehabilitation units in eastern Europe where the costs are lower.

As the article says

Germany’s chronic care crisis – the care industry suffers from lack of workers and soaring costs – has for years been mitigated by eastern Europeans migrating to Germany in growing numbers to care for the country’s elderly.

But the transfer of old people to eastern Europe is being seen as a new and desperate departure, indicating that even with imported, cheaper workers, the system is unworkable.

But before we are too quick to castigate Germany, I think it’s important that we look at what happens in this country.

Until one month ago, I was a local authority employed social worker, seconded into an NHS Trust (as I was a mental health social worker) working predominantly with older people. I made a lot of residential and nursing placements. I worked in an inner London borough.

The amount of local placements we had came nowhere near meeting the needs of the local community. Yes, there has been a push towards caring for people longer at home – perhaps it was a feature of central London, perhaps not,  but many of the people I worked with did not have family around them. The cost of housing had pretty much seen to that in terms of ripping communities apart.

Still, there are pockets of close communities even amid the high towers of the financial centres of London. Among the office blocks and fancy shopping streets, there are communities that have evolved over the decades, centuries even and those tourist spots visitors see, they are ‘home’ to many people who might not wear the smartest suits or have the fanciest accessories.

We ‘converted’ some of the residential provision locally into ‘extra care sheltered’ provision – see, that would be good, that would ‘keep people at home’ for longer.

So where are we now?

The chances of getting a placement in the local area are very slim to zero. We had waiting lists months long for some of the residential provisions in the area. The wonderful ‘extra care sheltered’ housing provision realised soon that they could not manage the needs of those who needed 24 hour residential support or maybe the criteria for residential care moved higher but they have not truly become an alternative for someone who needs a residential placement. They have become a safer environment with a constant ‘warden’ for those who may otherwise have had sheltered accommodation.

So there are fewer residential and nursing placements for people who are local to the area. If a family shouts and hollers enough they may get someone on the ‘waiting list’ for a place. Who knows when that place will come up. We don’t like saying it explicitly  but places in residential and nursing homes usually come up for one reason and that’s a death or a deterioration in physical health and noone wants to think about that.

What does a local authority do then?

It moves people out. It is more likely to move out people who have no family support and no ‘links’ to the area. You see, living somewhere for 70+ years isn’t seen as ‘link’ enough if your family and friends aren’t there. Anyway, even if they don’t want to move you out, if there are no beds, there are no beds.

So while we aren’t moving people to other countries, that’s only really by virtue of us being an island. We aren’t that much better than Germany in this respect. We are moving people to unfamiliar settings and localities on the basis of cost alone.

Commissioning Quality

How are these decisions made? Well, to absolve myself from responsibility, I’ll say it wasn’t my decision. I did and do rage against it. I raised it internally as the ways these decisions are made are purely on the basis of finances of local authorities to make placements.

Currently, in inner London we are placing frequently in outer London but soon it will be the Home Counties and further and further away from familiarity. I wonder how consistent this is with the Mental Capacity Act which demands previous preferences are taken into account. This can be ridden over roughshod if there aren’t any local placements at the right cost.

So we move to commissioning. There has been a race to the bottom in terms of providing services and placements at the lowest cost. Property is a massive cost in central London so cheaper land can push down general cost but at what price to autonomy and preference?

There has to be a way for commissioners to be accountable for the decisions they make. Families can push and make complaints on behalf of those who are not able to make decisions for themselves but there really needs to be, in my opinion, some external scrutiny of commissioning decisions made by people who really understand the social care sector. Yes, councillors can scrutinise but how many understand the needs of those who are not pounding on their doors making complaints about council services? Who understands that those who have the quietest voices or who have noone to advocate for them may be having their rights ripped away from them?

I’m not sure of the answers. All I know is that I wish the commissioners would have listened to their social workers. I wish there were a stronger, formal system of advocacy which would raise these issues with people who commission services and I wish there were an understanding in central government of the impact that geography makes on the cost of social care.

There may be cheaper and more available placements in South Yorkshire but that doesn’t mean the answer is placing Londoners there. I fear it may well be in the future.

We can’t become too complacent. Germany today may well be Britain tomorrow.

The World of Mentalists

There was a recent post over on Red Hot Liberal-On-Liberal Action which alerted me to the Inquiry into the Schizophrenia Label (ISL) , a research project that was set up in response to Professor Sir Robin Murray’s Schizophrenia Commission. Murray’s report gave 42 recommendations to improve the care of people with schizophrenia.

The ISL argues that the Schizophrenia Commission didn’t go far enough, because it didn’t consider the inherent validity of schizophrenia as a diagnostic label. They argue that it’s vague, not always related to the treatment given, and there’s a higher-than-average number of people from ethnic minorities, particularly black men, getting the diagnosis. They’ve conducted a survey of 500 people on the topic of schizophrenia, and indeed the wider term “psychosis”, which they intend to pass to NICE, the Royal College of Psychiatrists and other influential bodies. Their preliminary findings suggest that 80% of those surveyed found the diagnosis…

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A Critical Christmas

Christmas is on the critical list -yes really! The one thing our lives (in the UK anyway)  that never changes is currently on the brink of collapse with the threat of a DNR hanging over it. I hear hospital wards are not being allowed to put decorations up, school concerts cannot be in any way religious and staff  are working over the festive period without any back up or support from their managers who obviously take it as a god given right to a holiday.

Out of all the holidays we can and do take throughout the year  Christmas is the one that we all commit to take to be nice to each other, to buy gifts for each other and to spend time with each other. We all value  the spirit of Christmas whatever our religious beliefs if we have any and look forward to the traditional celebration and expectancy (or hope) of new life, in nature and time.

If Christmas dies so does the hope and recovery of a society that we once knew and cherished. Not the society that is over indulgent and selfish but the society that looked out for one another, that gave the endless gifts of time and love and could actually show that we cared about one another.

Please be alert for signs of deterioration over the holiday period (including the virtual world) and if your hear people shutting down for the festive period please resuscitate stat.

Twas The Not So Big Society Before Christmas

Since Christmas is nearly on us, and the Apocalypse appears to have passed without incident, I thought I’d take some time to reflect on the past year.

Last Christmas, The Not So Big Society was only a couple of months old. Prior to starting the site, both Ermintrude and I had been running successful blogs that we’d felt compelled to shut down due to people causing trouble for us in meatspace. As result we’d both found ourselves at something of a cyber-loose end, and agreed to set up a blog together. Since then we’ve been joined by other writers, including Abe Laurens, Politicalnurse, Gary, Bonkesoul and Z3r00n3. I like to think we’ve evolved nicely into a forum of ideas and opinion about health and social care, with the occasional dollop of small-p politics.

Over time the readership of the blog has slowly but steadily grown, from 2,648 views in October 2011 to 14,466 in November 2012. A rather unscientific browse through our list of followers on Twitter suggests we’re being read by a healthy mix of professionals, service users, students, academics, politicians, campaigners and interested individuals.

We also get a steady stream of angry, at times abusive, messages from people who believe that social workers are engaged in a massive conspiracy to steal children. If I’ve learned one thing this year about building up a readership, it’s that quality is as important as quantity.

In terms of how people are finding us, the most popular search string (apart from the obvious like “not so big society”) is, believe it or not, “tin foil hat”, probably due to this post. The most popular sensible and non-obvious search term was “AMHP training”. There’s also a very high number of search hits for information about the John Smalley case, which I used to demonstrate how appallingly under-regulated the psychotherapy industry is.  I suspect this may be because although it’s not a huge issue in terms of widespread media interest, there’s not many other places highlighting this problem.

Oh, and hello to the small number of you who found us with the following search terms.

“the queen should die”

“fascist child protection services”

“tin foil child”

“fifty ways to save pickles”

“cosmic schmuck principle”

This time last year, the spending cuts that followed the credit crunch were yet to be fully implemented. Now we’re beginning to feel the full impact, very possibly with more to come. I’d vaguely hoped that austerity would prompt a greater sense of compassion in society, that we would feel compelled to spend more time looking after our friends and neighbours in order to protect the vulnerable.

In fact the opposite happened. This year has seen a ramping-up of unpleasant rhetoric that tars and feathers the poor, the sick, the unemployed and those who work with them. Disabled people are all faking it. If you’re unemployed it’s been you don’t want a job rather than because you can’t find one. The poor need to be given vouchers instead of money so they don’t spend their benefits on fags and booze. Nurses are all lazy and compassionless. Social workers are all loony-left ideologues. Our political classes may not have been responsible for the financial crash, but they are responsible for turning the struggling masses against themselves.

I’m more angry at the government and the world in general in my mid-30s than when I was a stroppy, immature teenager. What’s that about, then?

If there is a Christmas message from this blog, I hope that it is this: despite what Margaret Thatcher claimed, there is such a thing as society. If there is a true measure of society, it is the way it behaves towards those in need of care and support. We did not create the ongoing austerity, but we live with it and face the consequences every day. We are the have-nots rather than the have-yachts. We believe in compassion and decency, and we oppose stigma and victim-blaming.

We are the Not So Big Society.

Pickles and Local Government ‘Saving’ Ideas

Eric Pickles at Conservative Party Conference

Yesterday, Pickles announced a cut of 1.7% spending for local authorities. On top of cuts which have taken place already, this leaves many public services in a precarious position.

Local government has been hit hard already by this government and the austerity measures taken and while Pickles and his ilk in the Cabinet like to promote the impression of profligacy in the public sector, the cost is made in terms of quality of life and vital support services to some of the most vulnerable in the country.

The Guardian quotes Pickles saying

“Councils must do three things to get on the right road for their residents: put our fair funding deal to work; do every single one of our 50 ways to save; and accept our council tax freeze offer. Councils that cry wolf without having done all of this are letting their residents down.

“Councils that put their thinking caps on now can save precious taxpayer pennies next year by cutting out waste and transforming frontline services that vulnerable people rely on.”

So this is ‘localism’ at play. I thought I’d take a look at Pickles’ 50 ways to save.

They are available to view here (PDF).

I’m just going to look at a few of them and there does seem to be a theme. For a government document there is some very political language lurking inside Mr Pickles’ suggestions.

Firstly he talks of ‘sharing back office functions’ and praises initiatives like the ‘tri-borough’ linking of some functions between Hammersmith and Fulham, Kensington and Chelsea and Westminster as well as giving other examples where this has been the case. While there may be scope for some services, the assumption that ‘back office’ is unnecessary can be dangerous. My understanding is that the cuts in staff do not limit themselves to ‘back office’ and the blurring between ‘frontline’ and ‘back office’ can be dangerously shaky at times.

Another of his suggestions is – and I quote because I think this language is important is – ‘Claw back money from benefit cheats’. Fine, this is fraud but why is it listed separately from the other ‘tackle fraud’ point. Of course fraud should be tackled but the use of language is very different in the two points. Pickles plays on emotion here and the now familiar government rhetorical of creating and emphasising the collocation of ‘benefit cheats’. It could easily have been termed ‘tackling fraud’ but no, the government want to emphasise this point particularly.

Another one is ‘encourage e-billing and direct debit’ – now maybe I’m on a different planet or maybe things are different wherever it is Pickles lives but my understanding is that this has been pushed pretty heavily already.

Ah, encouraging hot-desking is there too. This works in different ways in different services. Having worked in adult social care for many years, the importance of having a team around you in a stressful environment is crucial in my opinion in terms of engendering safe practice and providing team support. This is debateable and is my own experience but I do worry about the support available if we are continually pushed towards hotdesking.

‘Close subsidised staff canteens’ – fair enough but lets close the subsidised bars in the Houses of Parliament too.

Cancel away days in posh hotels and glitzy award ceremonies – this made me chuckle. The last away day I attended was in the office I worked in. My council got rid of awards ceremonies and for my ‘excellent service’ I got a £5 M&S voucher ‘to buy myself a sandwich’. I was genuinely delighted by my award because it wasn’t expected and it was something I am proud of. I’ve even kept the vouchers as a souvenir. Maybe I was never at a pay grade high enough to have the fancy away days or glitzy ceremonies but I suspect a lot of councils have cut in this area substantially already.

Introduce a recruitment freeze he says. There have been some very damaging recruitment freezes which have had a direct effect on services produced. Looking again at the LA I came from the proposals included replacing all leaving social workers with unqualified replacements. Is that what Pickles wants? Or perhaps he suggests leaving those posts unfilled, increasing stress and sickness levels on those remaining?

I loved my job. I loved doing what I did but the increased stress levels I experienced and the reasons I applied for another job were directly related to the reduction of staff in the team in which I was working. I felt we were teetering on the brink of providing a safe service. This will get worse, it seems and Pickles seems to be condoning it.

And similarly he talks about cutting agency staff used. See above. The team I worked in lost a number of team members who weren’t replaced. Agency staff were brought in to cover at a higher cost because the risks were too high. Had there been more planning initially, this would not have happened. This is what does happen when quick cuts are requested and demanded. Longer term costs.

Then we get onto the ‘scrap trade union posts’ nice little ‘saving’ he suggests. Yes, really. I am appalled by this. In the light of the amount of redundancies he is asking for, union membership and time is absolutely crucial. Does he really think that these cutting measures will engender a more efficient staff team with poor morale. I am a passionate trade unionist and this panders to the general government agenda of chipping away union power as does another of his suggestions to ‘charge for collecting trade union subscriptions’.

And he suggests they councils ‘stop translating documents into foreign languages’. Oh, that’s an easy target. He says this affects ‘community cohesion’. No, it further alienates those who don’t speak or read English. Statutory services are just that and restricting information to those who may not understand English is another way to marginalise other communities. This is downright dangerous as far as I’m concerned.

He talks about ‘ending lifestyle and equality questionnaires’. Because these are ‘intrusive and unnecessary’. I can’t speak for all of them but saying that ‘councils do not need to spend time and money on Equality Impact Assessments’ says where his priorities lie. True that I’ve seen some awful Equality Impact Assessments in my time but I’ve also seen Trade Unions in particular challenge them when they have been poor to good effect. Getting rid of them completely isn’t ‘the answer’.

We get onto a nice, snappy ‘sell services’ suggestion which I feel is at the core of the government’s agenda in relation to local authorities. This government WANTS skeleton local authorities that provide little to nothing directly. Private and voluntary sectors may move in for the more profitable services and some ‘social enterprises’ might pop up which can pick up the slack in areas like adult social care – but the terms and conditions of employment for staff will be poorer – as will the democratic accountability.

I have now left local government service but my heart is lingering on because I know what those services which are being decimated mean to people. Maybe not to Pickles and his ilk in the Cabinet but to some of those who have the highest needs. My concerns is that adult social care cannot sustain many more cuts although obviously that varies from area to area but Pickles wants to detach services from the auspices of local authorities and that’s dangerous language.

There is scope for saving in better commissioning of services and better monitoring of services commissioning. My experience within local government is that the channels of communication have been weak. As a social worker in a local authority I felt very much at the periphery of the organisation – possibly because I was also seconded out to the Mental Health Trust – but I could have been and my ex-colleagues could be a valuable resource in terms of seeing where a lot of the waste and benefits could come from.

If I were writing to a local authority a guideline for saving I would probably share Mr Pickles’ last point. Speak to your staff. Speak to all of your staff. Your staff may be your residents. They may be on the periphery of the organisation but they may also see things not apparent at director level. Value them and promote engagement with unions rather than isolating them because good staff can push improvements.

As for Pickles, his document is as much of a farce as his ripping to shreds of the funding streams for local authorities.

photo via Flickr conservativeparty

Does God Need A Make-Over?

There has been much in the media of recent about the rather fraught view of religion by other parts of society. On this occasion, I’m thinking in particular of the Church of England’s (and to be fair, most other Christian denominations) response to gay marriage and of course the well-publicised vote on whether women should be allowed to become Bishops in the Church of England.

I find it an interesting discussion for a number of reasons not least because I am a Christian and an Independent Social Worker so find myself asking whether the two can co-exist without being at loggerheads for much of the time.  On the one hand, they appear to be best friends; after all principles such as compassion, self-less giving, openness and honesty and shared between the two.  Prior to being a welfare state wasn’t welfare provided by family and caring neighbours? On the other hand they appear to be poles apart and the (media’s interpretation of) views of Christians have become the very definition of inequality and discrimination: Being reported as an outdated, irrelevant religion whose demise is imminent.

All this has led to the media and bloggers alike asking whether God has become irrelevant or in Katy Campbell’s blog questioning whether God requires a bit of PR to continue in contemporary society.

I think a part of the problem is that people are confusing religion with the Christian’s view of God.  For a Christian, God created everything in the beginning, has always and will always co-exists as Father, Son (Jesus) and Holy Spirit.  Whilst Christians identify that individuals can have a relationship with God who is perfect, religion is largely man-made and often where the problems exist. The problems don’t necessarily lie in the fact that people believe in God or any other god for that matter.

Does God need a make-over? If you ask a Christian they would say that to suggest that he does would be to acknowledge that he isn’t actually God so in itself is an absurd question.  Does the Christian church need a make-over to bring it in line with contemporary society and more in line with Biblical principles?

Another issue is the Bible which is of course the Christians’ book of choice. A Christian will tell you that it is one of the means through which someone gets to know God. It has itself been under scrutiny of recent particularly when discussions about gay marriage have been raised.  The reason being that the Bible sets out a clear framework for marriage; Christians believe that it is an institution ordained by God and a union between a man and women. That is why most Christians will be against gay marriage. Not because they are homophobic but because it is contrary to the foundation of their faith.

So, perhaps the issue isn’t that God requires a make-over or that the foundations of the Christian faith should somehow be remodeled because to suggest such a thing is surely questioning whether any religion is valid.

Reasons to be cheerful about the rise of UKIP

So, another day, and another UKIP representative has said something highly offensive and absolutely barking mad. It must be a Tuesday. Or Wednesday. Or Thursday, Friday, Saturday, Sunday or Monday.

This time, it’s Geoffrey Clark, their Kent County Council candidate, who suggested compulsory abortions for foetuses with Down’s Syndrome or spina bifida. Not that he was insisting we should, he said in response to the understandable howls of outrage. Just that it might be worth considering as a way of bringing down the national debt. A UKIP spokesman told the BBC that they didn’t agree with his views, but he’s still “a hard-working local activist who would make an excellent councillor.” Though they now seem to have changed their minds about that, because they’ve suspended him and say he won’t stand for them again.

A month or so it was going all so well for them. They were riding the tide of national scandal about a case in which Rotherham Council had removed three children from foster carers who were UKIP members. Never mind that the fuss seems to have died down very quickly, and it turned out to be almost certainly more complicated than that. They got to bask in a couple of weeks where politicians and pundits were falling over themselves to say that UKIP are a credible, mainstream party.

And then one of their candidates told the media that allowing gay people to adopt was “child abuse”, and it was right back to form. Not that it stopped them doing well in recent elections, resulting in more headlines proclaiming them “Britain’s new third party”.

As a left-of-centre progressive, how do I feel about their recent success? Absolutely great. Let me explain why.

When I say I feel good about it, I’m not suggesting in any way that I respect or admire UKIP. Quite the opposite. Back in 2010 I made the mistake of reading their general election manifesto. It felt like listening to a bunch of retired colonels having a drunken argument in the pub.

And then there’s their self-description as a “libertarian, non-racist party”. Quite apart from having a “not a racist but…” in that description, do they really believe they’re libertarian?

It’s not my philosophy of choice, but libertarians generally support open borders and gay marriage. And they certainly wouldn’t endorse compulsory abortions of disabled children. Ultimately, I suspect that UKIP has become riddled with the kind of politico who calls himself “a libertarian” because it doesn’t impress girls at parties when you tell them, “I’m very, very right-wing.”

So if UKIP isn’t having its ranks filled with staunch defenders of individual liberty, where are they getting their new support from? We don’t need to speculate, because today Lord Ashcroft published research giving us the answers. The straightforward answer is they’re getting it from disaffected Tories. The kind of people who are “pessimistic, even fearful, and they want someone and something to blame”, and have a certain set of preoccupations.

“But these are often part of a greater dissatisfaction with the way they see things going in Britain: schools, they say, can’t hold nativity plays or harvest festivals any more; you can’t fly a flag of St George any more; you can’t call Christmas Christmas any more; you won’t be promoted in the police force unless you’re from a minority; you can’t wear an England shirt on the bus; you won’t get social housing unless you’re an immigrant; you can’t speak up about these things because you’ll be called a racist; you can’t even smack your children.

“All of these examples, real and imagined, were mentioned in focus groups by UKIP voters and considerers to make the point that the mainstream political parties are so in thrall to the prevailing culture of political correctness that they have ceased to represent the silent majority.”

We all know people obsessed with this sort of thing (as Ashcroft said, these problems can be real or imagined. They’re mostly imagined.) But they only represent a certain subset of our culture. They’re also the kind of subset that can be relied upon to say something that will cause huge upset and outrage to the rest of us. Things like suggesting disabled children be aborted to help the national debt.

So, UKIP will carve themselves a nice little hard-right niche as the Even Nastier Party, but they’ll be repulsive to everyone outside that niche. As for the Tories, they’ll be left with a lose-lose situation. They can either stick with their current positions, and continue to haemorrhage their right-wing to UKIP. Or they can tack to the right, and concede the centre-ground to Labour. Either will be electoral disaster for the Tories, and a Labour landslide.

Personally, I intend to vote at the next election for the National Health Action Party, providing they stand in my constituency and there isn’t a significant risk of causing a Tory to sneak in the back door by doing so. Otherwise, it’ll be a clothes-peg on the nose and voting Labour.

So, for splitting the right-wing vote, my message to UKIP is this. Thank you and I salute your efforts, you revolting bunch of total oiks.