A look at ‘Caring for our future : reforming care and support’

paper stack 1 SQ BW 500X

A rapid chase through the Care White Paper

The government published it’s long overdue Care White Paper yesterday. There’s been time for a significant amount of coverage to push through to the media and I don’t want to repeat information that’s out there but rather provide a response/analysis from where I am and where I see it. There is a good summary on Community Care though.

It’s a hotch potch of a document. The words are pretty but there’s an underlying tone of ‘saving taxpayers money’ which shines through from every good intentioned statement. Saving money isn’t a bad thing but I wonder how much the intention is to change the way the market in care is delivered in line with the NHS Bill and how much is to actually change the philosophy behind the process of care. I doubt the government’s good intentions.

The White Paper divides into eight chapters. So I’ll follow that pattern in my review of them.

Chap 1: The Case for Change

Here, the paper itself sets out the current difficulties in the system as it is at present which is reactive to crisis rather than focused on prevention. I can’t help feeling a little cynical in noting even the current system wasn’t intended to be this way, but has developed as such due to the pressures on funding.  The government line is to prove the point about crisis response but that’s not really been the agenda all the time.

Believe it or not, there was a time we met ‘low’ needs and while accepting there is a financial limit, the demonisation of the system is hardly a true reflection of what was envisaged and more should be learnt about the ways that systems imposed develop into a ‘race to the bottom’.

So the paper suggests that the answers will be found by providing more services sooner in the process of ageing or a disabling condition.  We will have more support for carers and will be promoting communities to provide support within themselves.

People need more information, without doubt, and that will be provided. That’s hardly revolutionary but too much has been down to local differences – the old ‘postcode lottery’ arguments. This will be clarified so people can move around the country and know what they will be able to expect.

Interesting that the ‘opportunities from reform’ all seem to revolve around financial benefits. It’s a valid benefit and opportunity but an interesting angle so

‘Promoting people’s wellbeing and independence’ will ‘limit future demand for care and support and help to ensure taxpayers’ money is used for effectively’.

Support for carers will enable them to ‘remain in the workplace’ which will ‘support economic growth’. So THAT’S why they are so keen to support carers – don’t want anyone to think that ‘caring’ without pay for a family member isn’t a valid and essential economic contributor.

and ‘Supporting businesses to grow’ – which is maybe what choice is all about.

I’m not against these agendas but I think the framing in economic terms is very very interesting.

Chap 2: Our vision for care and support

Understandably and quite rightly there is a high proportion of ‘control’ wanting to be distributed from top down to users in this section of the White Paper which is all well and good. It’s been (rightly) the movement of travel and needs to go further. As someone who works with people who have not been able to benefit fully from the ‘choice and control’ agenda, I was particularly looking for things that would help and support the people that I work with here.

There’s a lot of focus on promoting communities in being active and enabling to those living in them. There’s a need to promote better information streams – quite rightly – the system is enormously complex and I spot a little line on page 19 about ‘supporting the transformation of the social work profession’.

So the role and place of the local authority to provide care and support will be changing as it says

‘instead of purchasing and providing care and support, authorities will increasingly be expected to take a leadership role in a local area’. That should be interesting.

Chap 3 ‘I am supported to maintain my independence for as long as possible”

So in looking at prevention of isolation and needs the White Paper turns to communities to look for support, quite rightly. There’s a lot of potential here and social isolation is specifically targeted with some wonderful local models explained in terms of the way they work with isolated people to bring them into communities.

Not everyone wants to be a part of a community and there are some people communities tend to be less eager to support but it’s a great initiative for some people and there will be a lovely new Outcome Framework which will identify measures of loneliness for us to work on while local authorities managers and accountants look at ways they can meet targets at low or no cost.

Commissioners will be ‘encouraged’ (whatever that means) to draw on community support networks rather than moving people into ‘formal’ services. I read that along the lines of finding services that are provided at low or no cost but perhaps I’m a cynic.

There’s a line here too about social work pilot schemes which will  ‘liberate’ (I’m VERY suspicious of the word ‘liberate’) social workers from case management. It looks like a push towards more community based social work but I have some concerns. Firstly, case management is only bad if it is implemented badly as a process rather than as a collaboration. Poor case management can have an enormously detrimental effect on someone.

I’m not convinced by social work pilots but will wait for the outcomes of these pilots to see before I make a final judgement. I like the idea of more community work but am worried at what cost it may come in terms of privatising delivery of service and moving responsibilities for provision away from a democratic mandate.

I do like the idea of connecting care homes with their local areas. That is enormously positive and where I’ve seen it happen locally, it has made a big difference. It does seem like a lot of ‘use volunteers’ as the answer to problems but honestly, that’s not a bad thing where there are volunteers. I just wonder if all communities will be as engaged and where there is such a great reliance on community to provide support, what will be done in those areas that aren’t as supportive.

As regards housing, there will be significant investments in housing for older and disabled people. I hope this will encompass people in mental health services and is not limited to those with physical  health needs. There is a muddle over extra-care sheltered accommodation which is described as a way to meet low level needs but also as an alternative to residential care. Oh, I mean a ‘cost effective’ alternative to residential care. Missed the key point there.

Chap 4 ‘I understand how care and support works and what my entitlements and responsibilities are’

Information, information, information. It’s crucial in order to make choices and the government sets out ways, particularly websites, that will provide more information about services and facilities to all rather than just those eligible for them.

Interestingly the NHS 111 number will roll out support for social care. I wonder how this will work as a national helpline when provisioning is so different locally and there will be an extension of services like NHS Direct and NHS Choices into the social care sphere. Look forward to seeing that. I genuinely hope it works.

Local authorities will also be obliged to provide more information online but also in other formats, to those looking at services and providers but it looks like there is intended to be a default move online for many access points – including self assessments online as ‘they provide a better customer experience’. I wonder how this marries with the issues around the digital divide. There will be paper and telephone options available at least.

There will be a national eligibility framework and it seems (although this will only be confirmed later) that it may well be set at ‘substantial’ under current FACS guidelines although there will be a move to a new framework of assessment and eligibility.

People will also  have more options about who assesses them.

‘Our ambition is for many more providers to offer assessment services’. Good business opportunities there and a role for the social work pilot schemes.

Carers will have an entitlement to assessment (which exists) and to the provision of services (which doesn’t at present). I’m glad to see that.

Chapter 5 ‘I am happy with the quality of my care and support’

There’s an interesting diagram on this chapter on page 38 with circles of ‘roles and responsibilities in care and support’ around the ‘service users and carers’ at the centre, with Government, Commissioners, Providers and CQC around them. Interesting that there is no place for social workers. I expect we come into ‘commissioners’ but sad that the profession doesn’t seem to have a place around this diagram and is not even mentioned.

There is talk of better regulation by the CQC with inspections annually (scandalous that they were ever anything but in my view).

Looks like they’ll be a return to some kind of rating system too. Strange that just disappeared.

Statutory Safeguarding Adults Boards will be convened by local authorities with police and NHS organisations inputting to them. There will be further consultation on powers to access someone who might be at risk of abuse or neglect.  Personally, I’d like to have seen more on safeguarding.

Commissioning on quality is emphasised (good) and there seems to be a desire to look at some kind of outcome model to judge this. There’s also an acknolwedgement of the failing of some private care homes such as Southern Cross and

‘Local authorities have a duty to provide accommodation to anyone – publicly or self-funded – who has an urgent need for care which is not otherwise available’ and noone will be left homeless if a provider were to fail.

I don’t doubt that would be the case anyway but more public protection for private companies failing can only lead to additional costs.

Chapter 6 ‘I know that the person giving me care and support will treat me with dignity and respect’.

Here there’s an emphasis on building skills in the social care sector. I don’t believe people go into this field of work to be oppressive or uncaring but the system dictates it and a bullying workplace leads to poor and dangerous service delivery to people who have higher needs.

The government claims to be committed to the plans of the Social Work Reform Board and that the College of Social Work will play a heavy role in improving standards of education and training in social work in universities.

The White Paper supports the position of Principal Social Workers in Adult Services and part of that role will be coordinating feedback from frontline practitioners. I look forward to having one locally as I have a lot to feedback.

Chapter 7 ‘I am in control of my care and support’

Ah, personalisation, that bittersweet word which means everything and nothing. Everyone entitled to care and support will have a personal budget – I genuinely thought that was already on track and didn’t think it was anything new. And look

‘We will push further with our ambition to support as many people as possible to enjoy the benefits of a direct payment’.

I hope that support is extensive and looks beyond the current models which have served some exceptionally well but many others very very poorly.

I won’t mention the ignorant way that advocacy is included in the White Paper which evidences a lack of knowledge by those who wrote the paper but will merely reference Martin Coyle’s (from Action for Advocacy) blogpost which says it all.

There’s some more in this section about integration between health and social care which is becoming more distant in practice rather than more evident.  Use of the term ‘care coordination’ is confusing as it is a generally used term in mental health services and has different technical meaning to the way it is used in the White Paper in terms of physical health. That has already caused us many confusing conversations locally as to someone having two care coordinators – one for physical health and one for mental health – which kind of proves the point about duplicating work and having unfathomable systems. The terms should really be clarified and separated if necessary.

Chapter 8 ‘Making it Happen’

A draft bill was published alongside the White Paper. I haven’t read it yet. I wonder that some organisations seem to have thrown their lot in wholeheartedly with the government which makes me a little nervous. I want to support positive change but I don’t want to be blinded by good intentions and words that lead to little that changes the lives of those who have the most need for support.

Interestingly the ‘financial context’ is stuck at the back of the White Paper like a growing tumour. There are mealy mouthed words about the government putting money into social care but while taking away in the other hand, from local government, they have contributed directly to the ‘crisis management’ only model that they criticise.

Conclusion

I see little if anything revolutionary in this paper. I see nothing that explains a change in the direction of travel and means of delivering social care. I see some positive signs and some acknowledgement of difficulties but we were moving down the path of personalisation at a rate that it could only continue. While there was mention of personal budgets for residential care, I saw nothing about ISFs and developing ways of promoting choice for those who are excluded from communities and who may lack capacity. I saw nothing about changing legislative frameworks. I saw a lot of gaps, not least, the massive funding gap.

Nice words though, fluffy and helpful and a lot of the language of ‘choice’ (where possible), ‘community’ (where free) and ‘market’.

These things are always filled with the right words. I think a lot of opportunity to restructure and rethink adult social care has been lost although there are some springs of hope – there aren’t by any means enough.

Pic by wintersoul1 at Flickr

Children In Care Are Big Business

The encroachment of international venture capital into the private provision of residential and foster care for looked after children is hardly news. It’s been covered regularly over the last couple of years but yesterday’s Times revealed the full extent of what many businesspeople have known for a while now, that the sector offers rich pickings without having to wait an undue length of time for a return.

One of Britain’s biggest independent fostering providers, the National Fostering Agency (NFA) was bought by one such company in 2006 and sold to another for £130m, tripling the original investment. Another fund made a 500% return in six years. Profits are maximised, says the piece, by concentrating residential units in parts of the country where property is cheaper. Rochdale, the scene of the recent child exploitation scandal, is cited as one example. Children in care are not only big business, they are an international commodity. Acorn Care is an investment for the pension fund of Canadian teachers.

In January the Telegraph reported that NFA made £3.5m profit in the last financial year. The previous year, a Deloitte’s survey revealed an annual profit growth of 35% as they came in at number 56 in the 100 most profitable private equity backed companies. Ironically, the Thunderer itself named them as ‘One To Watch’.

As ever with these things, the blanket statements unjustly tarnish the many private concerns who work hard on behalf of children and young people. The Times article (sheltering behind a paywall so no links, I’m afraid) unfairly juxtaposes the private equity information with the Rochdale scandal by puting them on the same page but there’s no demonstrable casual link between the two even if the children lived in a private residential home. Also, the piece leaves the reader blinking at some of the fees (one placement comes in at a cool £378,000 pa) but some of the most damaged young people need the most intensive, expert care.

It’s captured more attention this time round partly because it is in the Times, hardly a refuge of pinko mungbean scoffing sandal- wearing social work types but mainly because it neatly fits the zeitgeist. We accept, or are resigned to,  firms making profits and the people owning those companies making a lot of money but the fallout from the banking crisis has revealed just how wide the disparities can be. Whether it be Jimmy Carr’s tax avoidance or Bob Diamond’s payoff, we know it goes on but there are limits. I’m not entirely sure where they are but with the provision of private equity backed care for children, it feels as if we’ve reached them. Dig deeper and there’s something profound going on – big firms selling to even bigger companies, pension funds in Canada getting fat on cash from hard pressed local authorities reeling from the very cuts that venture capital in part helped to create.

It is questionable whether local authorities are receiving the best value from the majority of providers. How do they know what the unit offers, how that compares with what other places offer, how it best meets the needs of the child or young person and how do they monitor the effectiveness of the placement? In my experience, the commissioning process is often trial and error based on factors related less to a thorough evaluation of the myriad of services on offer and more to what has worked for other children in the past or the small ads in Community Care.

Once in placement, some (not all) residential establishments are virtually impenetrable to the outside observer. Notwithstanding the complexity of some of the work undertaken, there are many places where it’s hard to grasp how the methodology or philosophy is translated into practice in terms of meeting the child’s needs in their day-to-day life, let alone challenge it. That’s of course assuming that the social worker makes more than a cursory visit. From personal experience of many fostering and residential providers, it’s unusual for children to have any sort of meaningful relationship with their social worker.

We live in a mixed economy of care. Private companies can produce excellent care, there’s no question. But venture capitalists are active in the sector because it makes them money. That’s what they do. Often they buy undervalued companies, strip out the profitable assets, let the rest go to ruin, maximise profit and get out.

Venture capitalists exist for profit. This comes at two points in the process, at the point of sale and the costs of providing a service. The sole income source is cash-strapped local authority budgets that are being squeezed beyond breaking point. For the moment, it’s a seller’s market. Outweighing the pressure on authorities to cut costs is the increased demand for places as admissions to care soar at a time when there is already a shortage of foster carers and the local authority residential sector is virtually non-existent.

There are also opportunities to cut costs by limiting the services that are available. Low pay for residential workers has been the norm since I started in the sector 30 years ago. Foster carers are paid an allowance, not a fee, and no placement means no allowance and no outgoings for the company. It’s the extra services that can rack up the costs and eat into margins. Foster carers all value the support they receive from their provider but here’s a way to cut costs. Foster care is a more complex task than ever before. The providers I work with who are most focussed on children have a ratio of supervising social workers to carers of between 1 in 10 to 1 in 14. This of course is not enough in itself to guarantee a good service but it forms a foundation because the staff have the time to focus on the children and their carers, bearing in mind that actually they have a responsibility to both. Some providers, including NFA, have a ratio of around 1 in 22 to 1 in 24 and their staff work from home, thus greatly reducing the fixed costs of office space.

The next thing to do is to push as many services that the child needs onto local health and local authority services. If the provision of, say, psychological services is rationed or not provided at all, children wait for already over-burdened CAMHS provision. The same also applies to more prosaic but vital services like transport to and from school or contact, which these days can be several days a week or every day in the case of a baby involved in court proceedings. Exclude that from the cost of a placement and the local authority picks up the bill. Include it at premium to meet a shortfall in local authority provision and the company can’t lose.

This is not a hypothetical situation. It happens every day. No wonder the sector looks so attractive. These companies aren’t interested in the long-term, or children growing up as I prefer to think of it.

And if things get rough in the placement, the firms can always play their joker. When the going gets tough, the best carers stay rock solid and consistent, knowing that trust is established precisely at these moments of greatest challenge. As one young man once said to me, quite cheerfully, ‘I kicked off for three years, then I knew they [his carers] would stick with me so I calmed down.’ For the venture capitalists, why bother? Why bother supporting a placement that will need extra resources like time, skill and extra input when you can end the placement and move on to something cheaper, because those resources cost and more cost means less profit. Blame the child. Too challenging, unacceptable behaviour, on reflection it wasn’t the right match, we were just responding to the carers, – you name it, I’ve heard it. And so it’s another disruption because the placement was taken without proper consultation. Get them in and get them out again if it’s all too much. Ofsted don’t pick this up. The companies have legions of back office staff making sure the boxes are being ticked, and if there’s one thing that Ofsted likes more than a box, it’s a ticked box. Many inspectors can’t see beyond them and the system no longer encourages it. Blame the child – it’s the perfect businessplan.

The article quotes Kevin Williams from children’s charity TACT. I’ll leave you with his words because they are the perfect summing up:

“There is a moral question about making large sums of money from children who’ve suffered abuse and neglect. If they do profit from such children, can they demonstrate that they’re delivering the best possible outcomes for those children and not simply making money through efficiency savings, by increasing workloads and reducing training and support? I would question whether they can.”

It’s Not News That Fostering Is Under Pressure

Al Murray’s news-based Sunday radio show on 5Live has a running gag where the panellists read out prominent items from the past week that are not surprising in the least. After each, he adopts an urgent cod-announcer style and bellows, ‘Not News!’ Katy Price might have a new relationship, Big Brother contestant seeks publicity, Camilla’s wearing a hideous hat: you get the picture. Shout out the catchphrase after every paragraph in this piece. Fostering Fortnight, the biggest event in fostering calendar, finished recently and frankly, nothing’s happened. It works for me.

Fostering Fortnight is a series of events to celebrate fostering and foster carers. It presents a positive view of being a carer with the dual aims of valuing those who have already discovered their vocation and attracting new recruits to fill the growing shortage of foster homes. It’s run by the Fostering Network, a charity representing the interests of carers all over the United Kingdom. This year they’ve done an excellent job, with relevant and well-timed research attracting the media’s attention alongside the heart-warming human interest stories beloved by daytime TV, climaxing with a glittering reception proudly showcasing the achievements of children and young people in care.

Children’s Minister Tim Loughton made the keynote speech. Whilst he covered a considerable amount of ground, a couple of weeks on there’s no evidence that anything much has happened. Those of us waiting for a significant initiative from the government or at the very least some leadership to take us forward were sorely disappointed. He made some eminently sensible suggestions about improving day to practice, the level at which much can be accomplished as any regular reader of my blogs will know. Reminding authorities that they should delegate more decision-taking responsibility to foster carers (something Loughton has enthusiastically supported) will improve the lives of children and young people in care, giving them the same social opportunities as their peers. Criticising the risk averse climate in decision-making is music to my ears. A drive for employers to provide fostering leave is an excellent idea and the Department are working to ensure the benefits system, including housing benefit, does not discriminate against carers. We also have familiar favourites, the ‘streamlining’ of the assessment process and introducing greater ‘flexibility’ into the placement process cuddling up to old friends like ‘unnecessary and harmful bureaucracy.’

As I say, much of this is valuable. However, the expected and trailed ‘big announcement’ did not materialise. Normally that wouldn’t unduly bother me -it’s what carers and practitioners do that counts – but fostering is facing perhaps its biggest ever challenge over the next few years and it needed a helping hand from government. In its absence, I’m left only with confirmation that fostering remains the poor relation of the care system.

Adoption has dominated the government’s agenda over the past year or so, which I’ve covered in previous posts. Loughton acknowledged as much in his speech but failed to redress the balance. The examples he gave like the Foster Carers Charter have been around for a long time and the earth hasn’t moved.

Fostering is about the skilled preparation of children and young people for the future. This can be a return to their birth family and fostering itself as well as adoption. Many young people may not wish to be adopted and also evidence shows fostering provides a successful alternative in offering stable permanence and improved life-chances, yet the perception remains that the government (not necessarily Loughton himself) sees fostering as a sort of holding area, the lounge where you rest after passing through security and checking your baggage before rushing onto the plane, the means of reaching your destination.

There are powerful reasons why the government must give a strong lead. This debate takes place within a context of the growing numbers of children and young people being taken into care outstripping the supply of new foster places, especially ones where the complexity of children’s issues can be fully addressed. I advocate an ongoing government advertising campaign for foster carers along the lines of the long-running and successful initiative to recruit teachers. Current means and methods are not enough.

Then we have inertia within hard-pressed cash-strapped local authorities. I have every sympathy but the means of change has been there for some time without there being sufficient action. Take delegated authority. It’s the jargon for enabling carers to take day to day decisions for children and young people like whether they can have a sleepover, go on a school trip, see certain friends or take part in activities where a consent form is required. Normal parenting in other words. Ask any young person in care and they would say the need to call the social worker each and every time is the single biggest impediment to being like their peers. Backed by legislation that came into force in April 2011, the decision-taking authority should now be delegated by agreement to carers and the FN have produced a spot-on format to enable this.

Nothing is happening. Not quite true, of course, but the risk averse culture is so embedded in senior management that many authorities seem hell-bent on retaining responsibility for these decisions, regardless of the fact that children are unhappy, carers exasperated and under-valued and already busy social workers embroiled in tasks others could and should take from them. In fact, the welcome legislation is nevertheless not a radical departure from the guidance that existed before April 2011. It wasn’t implemented then because of the risk averse culture and nothing significant has altered.

Finally, I’ve come across an increasing number of examples from several authorities where the much vaunted ‘streamlining’ means assessments are being rushed and the ‘flexibility’ over placements means foster homes are more crowded than ever as age and placement criteria are being stretched to fulfil demand. This is a natural consequence of fewer resources caused by spending cuts and growing demand as the threshold for coming into care shifts.

It’s not news, however, that this does not contribute to better childcare. Children are given what is available, not what they need. Carers are pressurised to go beyond their areas of preference and expertise. Carers are great, they don’t want to say ‘no’, they want to help, but to do so they require support from us professionals, which is not the case if we take shoddy resource-driven placement decisions. Above all, children’s needs are not being met. Far from addressing the problems, I fear we are merely storing up worse for the future.

KM v Cambridgeshire: the Supreme Court’s decision is not about assessment

“I’m just hoping that after tomorrow the link between value of cash payment and cost of meeting need is not utterly broken!”

…I tweeted yesterday, contributing to a debate about our hopes and expectations for today’s Supreme Court ruling in KM, R (on the application of) v Cambridgeshire County Council 2012] UKSC 23 (31 May 2012). This blog is about that case. I’m pleased to say that my hopes have been fulfilled. But I had set my sights low. I am utterly bemused by some of the other claims being made for this judgement.

Community Care: three key questions

Adult Community Care issues can generally be boiled down to three questions:

  • Assessment: deciding what needs should be met
  • Funding: deciding who is going to contribute what to the cost
  • Delivery: deciding how the needs are going to be met

The KM case was about direct payments, so where do direct payments fall to be considered? Answering that question is key to understanding this judgement. Although direct payments involve the flow of money between local authority and service user, they are not about how the package is funded. And although there are tools to determine how much a direct payment should be, these need have little to do with assessment of eligible need. Direct payments are, pure and simple, one of a number of ways of delivering a service.

What the Supreme Court said about assessment

To be fair, the Supreme Court said a fair bit about how to assess eligible need:

  • It set out the legal framework (paragraph 11ff);
  • It affirmed that the statutory guidance ‘Prioritising Need in the Context of Putting People First’ gets the framework right (paragraph 16);
  • It reaffirmed that once a local authority has determined eligible need, it must meet that need (paragraph 21);
  • It decided not to revisit the case of Barry, which held that resources could taken into account during the assessment process (paragraph 43);
  • It decided that the assessment of eligible need in KM’s case was not irrational (paragraph 38).

What the Supreme Court did not do is say anything new. It certainly said nothing that would turn a previously ineligible need into an eligible need. And therefore it said nothing that would turn someone who was previously ineligible into someone who is elible.

And therefore I am bemused by the Guardian headline, ‘Court ruling means thousands more disabled people could get access to care‘.

Where the RAS fits in: service delivery

Roughly, local authorities have three possible approaches to delivering the services to meet eligible need. One is to deliver it directly. One is to commission someone else to deliver it. And one is to allow the service user to commission services themselves.

It is here that the RAS fits in. Essentially, the RAS is a tool used in the process of converting eligible need into a cash value, so that the service can be delivered in cash instead of in kind.

Though this is hardly a secret, I am very cynical abut the RAS. Not only is it a tool used to convert eligible need into a cash value, but it is used to obscure the process. In theory, there is a scientific basis. The RAS uses an algorithm. According to that reputable source, Wikipedia,

“Algorithms are essential to the way computers process data. Many computer programs contain algorithms that detail the specific instructions a computer should perform (in a specific order) to carry out a specified task… Thus, an algorithm can be considered to be any sequence of operations that can be simulated by a Turing-complete system.”

Sounds scientific? But according to Luke Clements (2011) ‘A Sideways Look at Personalisation and Tightening Eligibility Criteria’ in Elder Law 1 pp47-52, along the way, “any science in the process is jettisoned in favour of witchcraft.” The computer does the sums, but what the end result has to do with the original assessment of need is anyone’s guess.

Remember, there are two other ways of delivering services. They can be delivered directly, in which case the local authority must have a fairly good idea how the service delivery meets the eligible need. Or the local authority can commission directly, in which case it will also know how much it costs to meet the eligible need.

It is ironically only when the service user is commissioning their own services that the algorithm – or witchcraft – which obscures the link between the eligible need and the cost of meeting it comes into its own.

Back to KM v Cambridgeshire

KM had his needs assessed. He was seeking direct payments to meet those needs. He has considerable disabilities. Cambridgeshire used the RAS, then another algorithm called the Upper Banding Calculator. Then it jiggled about with the figures a little bit more. Ultimately he was offered £85,000 per annum. But he thought he should get £157,000 per year.

That is a big difference. But was the dispute about what his needs were (i.e. the assessment), or was it about what it would cost to meet them (i.e. the service delivery)?

Here’s the simple answer: Cambridgeshire was so effective at obscuring its decision making process that KM couldn’t tell what the dispute was about. The Supreme Court criticizes Cambridgeshire for three things:

  • Failing to be open about its assessment of the mother’s contribution to care (paragraph 30);
  • Failing to be open about its rejection of the independent social worker’s assessment (paragraph 34); and
  • Failing to explain how it arrived at its own sum (paragraph 35)

It would be correct to characterize this case as being ultimately about transparency and not about assessment or resources.

So is the case good news for service users at all?

A brief history of transparency

Having dismissed the notion that thousands will become eligible, having highlighted that the case says nothing new about assessment, having said ultimately it was just about transparency, is it just a storm in a teacup?

No! It is well worth remembering where we were at before:

In Savva, R (on the application of) v Royal Borough of Kensington and Chelsea [2010] EWHC 414 (Admin) (11 March 2010), the high court upheld the principle of transparency:

“without being able to properly understand the use made of the RAS, the service user and anyone acting on her behalf, is left totally in the dark as to whether the monetary value… is adequate to meet the assessed need… The process of conversion made by the Panel is not explained to the service user. It should have been underpinned by an evidential base, and it was not.”

And as I commented at the time,

“What is being said is that there is a duty to give effect to the rhetoric, and actually demonstrate how the cash payment is adequate to meet assessed need. If the duty to give reasons goes that far, it may help to ensure that the cash payments actually do link to assessed need. Which in turn may undermine the approach of ‘Points mean Prizes’, and defer the day when a computer programme completely replaces the social worker.”

The judgements in KM’s case in both the High Court and the Court of Appeal below were bad news for transparency, and therefore bad news for anyone like me who wants a link between the cost of meeting need and the value of the cash payment. In KM, R (on the application of) v Cambridgeshire County Council [2010] EWHC 3065 (Admin) (26 November 2010), the Court said this:

“[The Claimant] criticises the Defendant for failing to provide an explanation setting out the services required to meet the Claimant’s needs. That appears to me to be a complete misunderstanding of the system of self-directed support. Both the RAS and the Upper Banding Calculator, compared as they were with the assessment and operated using the skill and experience of social workers, were assessment of needs and not services but the RAS was a tool for translating needs into a sum which was adequate to provide the services for those needs by reference to the average costs of the provision by the authority of meeting those needs for other disabled people.”

Upholding this decision last year, in KM, R (on the application of) v Cambridgeshire County Council [2011] EWCA Civ 682 (09 June 2011), the Court of Appeal observed that, “There does not need to be a finite absolute mathematical link” between payment and need.

In short, the history of this case is a history of judicial approval of algorithms and witchcraft, of obfuscation and lack of transparency. The beauty of today’s ruling, the reason I can consider it a victory, is that it reaffirms Savva on the need for transparency. Particularly poignant is the observation in paragraph 36:

“that a local authority’s failure to meet eligible needs may prove to be far less visible in circumstances in which it has provided the service-user with a global sum of money than in those in which it has provided him with services in kind. That point fortifies the need for close scrutiny of the lawfulness of a monetary offer.”

Or to put it another way, it is concerning that it is too easy to use direct payments to obscure potentially unlawful cuts that would be quite obvious if they were delivered or commissioned directly.

The RAS should still go!

The RAS has survived another level of challenge, see paragraph 26. But I still think it should go.

The argument in defence of the RAS in paragraph 24 of the judgement is:

“To set about costing each of the services identified in answer to the question at the [eligible need] stage upon, as it were, a blank sheet of paper would be unacceptably laborious and expensive. So a mechanism has been devised in order to give the exercise a kick-start. It is called a Resource Allocation System (a “RAS”); and many authorities, including Cambridgeshire, have developed one for their own use.”

I am resolutely unconvinced. If we can cost the services to meet the needs on a blank sheet of paper when we need to commission them, then we can cost them on a blank sheet of paper when the service user is going to commission them.

If the RAS is only “the generator of a “ball-park” figure, subject to adjustment up or down” (paragraph 26), then it is a wholly unnecessary extra step rather than a kick start to the calculation.

This is the heart of my concern. Arriving at a cash value of need by generating the starting figure by computer and the final figure by magic is not the most simple way of doing it, it is the most complicated. @TheSmallPlaces has shown in a series of blogs how local authorities actually value the complexity of the process:

In this, the Supreme Court got it wrong. It was right to approve clear and transparent reasons. It was wrong to approve the RAS as simplifying the process. The RAS is the very antithesis of clear and transparent reasons. In this case, it helped to obscure not only the reason for the sum itself, but also disputes about the assessment. It should go.

Allan Norman (@CelticKnotTweet) is a registered social worker and a solicitor at Celtic Knot – Solicitors and Social Workers.

Adoption Reform Isn’t Just Common Sense

Around 18 months ago, I offered some consultation to a small project that planned to set up activity days where children in care met prospective adopters. Last week I saw a DVD of the first event. There was no sense of the controversy that surrounds these so-called adoption parties. Children, their social workers and adopters mingled happily during the course of a day’s outdoor activity and lunchtime entertainment. The adults acknowledged some awkwardness from their respective standpoints but all agreed this was outweighed by the positive experience, not only of meeting children but also of feeling part of something larger and important.  All valued the careful preparation that had preceded the event.

Seven children were subsequently matched and two more were in the pipeline. One, a severely disabled young girl, had been waiting almost as long as the project had taken to reach fruition. On the day, some carers met her, a real person now rather than a case or a prognosis, and an emotional bond began to form. In the carer’s words, “We just clicked.”

It’s an innovative approach not without its risks and detractors and it’s not right for everyone, but it worked. Other opportunities could and should exist for finding more carers for siblings, disabled children or black children, where shortages of adopters exist. Or just for children full stop. Yet the government is not supporting such practice-based local measures in favour of grander solutions to address long-standing problems in the adoption system.

There’s no doubt that something has to be done and the government’s drive for action comes from the very top. Michael Gove has taken the lead and adoption reform is one of Cameron’s top ten priorities in the life of his term of office. Those in the profession who are involved can barely keep up with the breakneck pace of consultation meetings and unpredictably changing policy drafts.

The result – everything is going to be quicker, including the point at which children are taken into care. The headline news was one measure in particular, that culture and ethnicity is to be of secondary importance to finding a good home. The announcements were accompanied by powerful and moving testimonies from parents who had successfully adopted children from a culture different from their own. Those who have not had such a positive experience were conspicuous by their absence, although articles did emerge as the days went on.

Whatever your views, it’s disconcertingly easy for the evidence of the lasting effects of culture and background to be shunted into the sidings in favour of the ‘common sense’ conclusion that children are better off in a home than they would be in care, regardless of the consequences later in life.  The seductive comfort of common sense in adoption provides a measure of security and sanctity for almost everyone involved in the adoption process, except for the child who has to deal with this, now and for the rest of their life, and has nowhere to hide.

Many decisions about what constitutes a cultural match are absurdly arcane and are based not on a proper understanding of the child’s history and perceptions of their own identity but on a skewed, mechanistic process that equates ‘culture’ to a sum of their parents’ ancestry and distorts complex reality as much as the common sense approach. I’ve come across siblings who waited and waited because their maternal grandparents were Polish and no white family was considered unless that box was ticked, or black prospective adopters rejected because they lived in an area of London that was predominantly white.

Of course there is some truth behind the government’s apparent wish to relegate culture and background to a minor role. The remedy, however, isn’t an arbitrary shift based on ideology and expediency. Rather, it is about better practice, better assessments and a more preceptive insight into the subtleties of identity. This in turn leads to improved matching, including both an acceptance that perfection is not possible every time but also what does and does not constitute an acceptable deviation from the vital principle of a cultural match, what the evidence is for such a conclusion and how this will be handled, now and in future. None of this is encouraged by the proposals.

Which brings me on to two other problems that I have with the government’s suggested reforms. One is that it views carers as static and unchanging, rather than individuals who can learn, develop and grow into the task of being an adoptive parent. How might they develop, what is their potential and how can this be nurtured? And here’s point two, the thorny question of more post-adoption support, which adopters’ organisations will passionately say is the biggest problem we have at the moment, as opposed to dog assessments or paperwork that the government would prefer to focus on. Both these suggestions, extra training and support post-adoption, taken together require considerable extra funding, so they are not a priority.

Of more interest is the idea that children can be placed with their prospective adopters and effectively fostered until the order goes through. This could make transitions easier and create less change for children. However, it is not without its problems. As Adoption UK point out, adopters want to do just that, adopt. The fact that children may have contact with the birth family while they wait or may be removed if the order does not go through could act as a deterrent to carers coming forward.

As I have mentioned in previous posts, the proposals appear to take little account of the court process. Changes are in the pipeline but parents and members of the extended family will still have the opportunity to prove they are a worthy alternative to adoption. These issues and the time-consuming and resource draining assessments that accompany them can delay an adoptive placement extremely effectively.

I desperately want the system to make good placements for children and young people, and to make more of them. It’s needed now more than ever before. My fear is that the complexity of meeting the needs of vulnerable children hopeful for a stable future will become lost amidst the targets, league tables and rhetoric.

 

 

Care Quality?

Another day, another report. This time, Which? has done some undercover work into the quality of homecare delivered to older adults as reported by the Guardian.

The team at Which? asked 30 families to make notes and diaries over a week in January and feed back the information, some of it is horrifying but the sad thing is that it doesn’t shock or even surprise me. That’s the real shame of the system.

One elderly woman was left alone in the dark for hours unable to find food or drink. Another was left without a walking frame, leaving her unable to get to the bathroom, while one man was not given vital diabetes medication, the watchdog said.

Which? has not named the agencies which I feel is wrong. I hope they are going straight to the Care Quality Commission (CQC)  with this information because for a consumer organisation which is supposed to be behind us as consumers of care services (oh, it’s coming in health care too – just wait) I’m surprised they feel they need to protect the names of those companies involved.

The reason they do is that those companies will not be removed from their positions of providing care to those who have been subject to institutional abuse such as that meted out in the examples given, because yes, this is institutional abuse.

These companies are probably tied into long term extensive contracts with local authorities than are bound in law and allow for a certain level of ‘default’ that makes them difficult to replace.

So what should and can be done?

1) However admirable Which? is, the fact that we have to rely on  Which? and Panorama to do the job of council quality assurance teams and more importantly the Care Quality Commission is not acceptable.

2) Embedding advocacy into the system far more fully. These people monitored were the ones who had families to complete the diaries. What about those people without families particularly those who may have cognitive impairments. We have to replicate the ‘checking’ role that involved families have to those who don’t have family support and for me I see that as happening through greater advocacy.

3) Commissioning (again, apologies to Guilty Commissioner who I know does things differently). The people who buy into and commission these block contracts aren’t the people who use them. They award on the basis of cost where quality has to have a greater impact on quality of life and quality of care provision.

4) Politicians. People go to their MPs about Forests but not about social care. The people who need the changes aren’t the people who are most likely to be politically active and that’s why this area has slipped so far down the political agenda. Politicians of worth need to advocate for electors who might not be clamouring at their surgery doors. They need to think of those who may be disenfranchised and take the advocacy and representation role more seriously to affect change.

Let’s hope we stop seeing these reports soon but i remain sceptical.

Is Adult Social Care Broken? And what can and will fix it.

FIX

Over the past few weeks, oh, who am I kidding, over the past few years, I’ve been pondering the way that adult social care is structured in this country from the position of having worked in this area over a number of years. I have seen many changes but anyone who has been involved in social care for more than a year could probably say the same. If there’s one thing that is sure about statutory social work/social care, it’s that the next reconfiguration or improvement is just around the corner.

In my renewed spirit of positivity though, I thought it would be worth reflecting personally on some of the changes I have worked through and look at some of the directions we are going with a thought to what I would do if I were in a policy-making position rather than the position of a front-line practitioner.

So I entered social work in the shadow of the changes pushed through by the NHS and Community Care Act (1990). We were moving from ‘social work’ into care management and this was going to be an improvement for those who used the services as local authorities were going to be contracting out/selling off their own centrally run and ‘inflexible’ services to new, private and voluntary sector providers who would be far more flexible about meeting the needs of individuals.

When I think back to those heady days, the ideas weren’t so different to the ways that the personalisation agenda was presented. Direct Payments were just about to start but the idea was that care would be planned by a care manager to put the service user at the heart of the process and more interesting, more exciting and more specialist services would be commissioned for the same ‘pot of money’.

We were also sold talk of community involvement rather than segregration – gyms instead of day centres –  but the day centres remained and the processes weren’t flexible enough to allow the choices that should have been there.

So Direct Payments were introduced, first as an option and then as a right. They led from the ILF (Independent Living Fund) model of giving mostly younger adults (because you had to be under 65 to qualify for ILF) with physical disabilities a pot of money and a choice of employing a PA directly.

Quite rightly, this model was seen as positive and there were attempts to spread this more widely to all user groups. The take up was much higher in some user groups than others, strangely (I’m being ironic – bear with me) related to access to greater ‘pots’ of money or more informal support.

There has also been a massive push and development of carer services. It might not seem it to those who devote themselves to caring for family members or friends but there are now statutory rights to assessments and increasingly service provisions directly for carers.

And so we moved through to the Putting People First agenda of pushing the right to a personal budget for care services to everyone who uses and is eligible to support.

It is the right direction absolutely. Increasingly choice and control for social care packages is and must remain at the heart of social care provision for adults in the UK but there are genuine practical problems.

Firstly that too often councils have just shifted people who have been more difficult to engage in the process of choosing in the way the LAs want them to choose onto ‘managed’ budgets where the LA implements the care for the user and essentially makes the choices for them leaving very little different.

Secondly, the provision of 24 hour residential and nursing care has been lost in the push towards choice. It feels a lot like an poorly regulated afterthought when actually provision of residential and nursing care can be the most important decision in someone’s life and affects life quality absolutely.

Thirdly and by no means lastly, funding issues.

There is not enough money to pay for good quality care services for all who need it so the decisions are made about who will pay and how they will pay. The Dilnot report offers some potential solutions, personally, I don’t think it goes far enough.

The fact is that people don’t want to pay for care. They don’t want to pay for care related to health needs. People believe it is a right to receive care free. But that isn’t the case. Care costs and it is means-tested.

The postcode lottery comes into its own here with charging policies varying massively. On the ‘ground level’ I know people I assess and review are increasingly refusing care I feel they desperately need purely on the basis of cost. This shifts costs from self and social care onto health in the future, but at least health costs are free to the individual.

The Future

Personal budgets are not going anywhere and must be embraced and embraced positively as they are supposed to be. We must look past some of the cynical ‘target fixing’ of the local authorities who want to prove they are doing better on ‘choice’ and really adopt a strong advocacy role in using them the way they were intended to do and keep pushing and pushing until they deliver the promised change in terms of outcomes for all users of adult social care rather than relying on a few old examples. They must work but they also must work better.

Charging policies must change and this is in the offing. While I don’t agree 100% with the Dilnot recommendations, it is better than what we have. We need transparent and equitable methods to fund social care that don’t regard the sector as an afterthought.

Promotion of advocacy to all user groups who don’t have informal networks and particularly to those who may have issues with capacity is essential to back up and check on progress of professionals and local authorities who have different budgetary agendas. We have to offer support to challenge on an equitable basis.

Our systems have to be more flexible, as professionals within local authorities we have to have access to different styles of commissioning that include micro-providers. We have to have access to different communication formats and promote more interactive feedback using more technology to those who find it more useful while backing up with face to face contact, discussion and feedback for those who don’t.

Our world is becoming more fragmented as we have more access to information sources and accept that people cannot be defined merely by needs identified in traditional style assessments. We have self assessments now but they are more similar to DLA forms based on ability to wash and dress rather than building holistic pictures of who and what someone is. That is what is needed. Yes, it will be labour intensive but we need to find more value in quality and more value in the individual.

Where will be money come from to do this and to make these changes? Well, I think that better quality and treating people as human beings has so many longer term benefits regarding outcomes that it will be a saving and not   just in value but in quality of life.

Is the system broken? In parts. But the people who work in the system aren’t and nor are the people who use and need it. We need to build it back up together. Co-production has to be the answer.

These are exciting times for adult social care – lets build a positive from too many negatives and make things better.

Photo by Amanky/Flickr