The ‘Red Tape Challenge’ does Health and Social Care

Red Tape

We all knew it would come in time. This wonderful government idea to slash all that awful ‘red tape’ that stops people doing what the government otherwise would stop them doing finally arrives at Health and Social Care.

I had a brief look at some of the provisions detailed as ‘red tape’ for which the government is asking for comment and quite frankly, I am horrified.

What I might see as essential protections, they are presenting as ‘red tape’ and asking for feedback about potential abolition.

This is a consultation so it’s really important that as many people as possible to contribute and in the joyful spirit of openness, the website allows up to see the live commenting on others. I wonder how those with less technological access or knowledge are able to comment quite so openly about some of the provisions up in the air.

But openness and accessibility only seems to go so far and for the government departments responsible they seem to be after whipping up public distaste of ‘red tape’ although actually, we really do need to move from the idea that bureaucracy is necessarily bad.

There is a separate website entirely to focus on ‘ regulatory enforcement’ and where it might be unnecessary.I feel robust regulation (and thus, enforcement which has to follow as a result) is essential. The big problem with social care and health regulation since the CQC was established was the ‘light touch’ type approach which had been taken and the ‘back office’ regulation and not enough enforcement.  I really really hope that it is not cut back further. I want to see more regulation and stronger enforcement, not less of it.

But back to the ‘red tape challenge’. I want to share some of the provisions ‘up for discussion’ that the government has classed as ‘red tape’.  I’m solely concentrating on what is up under ‘Quality of Care and Mental Health Regulations’ as I felt that was the area I knew best. The numbers refer to the list of these ever so demanding provisions in the Excel list here.

39 is that oh so burdensome (!!!) regulation that requires the Care Quality Commission ‘to monitor and access for monitoring purposes, people who are deprived of their liberty’ and necessity to report this to the Department of Health.

40 is a nice one about requiring people ‘who assess Deprivation of Liberty’ to have an enhanced CRB.  – clearly unnecessary because.. er.. people who lack capacity and may potentially be subject to DoLs aren’t likely to be vulnerable, right? I think there’s an issue about effectiveness of CRBs in general but a bit worrying that that’s considered ‘red tape’.

43 is much more worrying as it is the obvious ‘red tape’ which introduced IMCAs as a safeguard for ‘those who have noone to speak on their behalf’ making them mandatory in abuse and review situations. RED TAPE??

55 is another ‘good one’ which ensures that IMHAs are ‘of an adequate standard’ because clearly, that is unnecessary (!?!)

Obviously there are many many more – I’ve just, for reasons of time, picked out a few that interest me personally but do have a look at them and COMMENT.

I’m frankly insulted that some of these provisions are even considered to be ‘red tape’  but as there’s an open consultation, it’s important that as many people as possible who know and understand the implications of removing them, to contribute.

If the government want to know what ‘red tape’ is in terms of adding unnecessary burdens, I’ll gladly explain about how useful (or not) it is to spend time recording how much time I spend on ‘smoking cessation’ work or time spent ‘clustering’ people according to diagnosis into tiny little tick boxes which are, clinically, unhelpful in order to get the ‘Payment by Results’ systems which will never work well, up and running. THAT’S red tape.

But it seems to be red tape that potentially infringes on the rights of those who might be least able to protect their own that they are classing as ‘red tape’ here.

Contribute to the consultation and let’s tell them how important some of these provisions are.

Oh, and someone should tell the Department of Health that the GSCC doesn’t exist anymore as they seem to have forgotten on their Professional Standards page (published this week!) but we know how much interest the Department of Health has in social work and social care so shouldn’t really be surprised.

Pic by Martin Deutsch@Flickr

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Making Social Work Work Better

I’ve been trying to be positive about some of the changes taking place at work recently. Being ‘in flux’ is nothing new and I have been working in the sector (and in local government) long enough to be no stranger to reconfigurations.

Being of a mind that criticism is easy but needs to be couched in ways that things can work better, I’ve been thinking about ways that my job could be better and how I could be more effective in it.

Of course, this will go nowhere,  but it’s an interesting thought experiment for me and helps me to retain hope.

There are a few themes I want to consider. It’s a bit of a fantastical ‘dream list’ of where I’d like to see social work in the future.

‘Personalisation’

‘Personalisation’  has been a massive driver but the increased workloads and paperwork have not led to better outcomes for most of the people I work with because the focus of the agenda has been on smaller specific groups of people who have fitted the model of wanting and managing well with direct payments.

There is nothing more morale sapping that completing a review for a service under so-called ‘personalisation’ agendas which have been forced onto people who don’t want them and telling them that they now have a ‘personal budget’ – not to do whatever they want with, but to have the same service provider, providing the same service at a higher cost.

It feels like a con because it is a con. This is not ‘personalisation’. This is language which has been distorted by government and policy and mashed into the conveyor belt which is the only way that local government commissioning is able to operate.

The word and the process of ‘personalisation’ has been hijacked and contaminated by providing a front for more cuts and attempts to disperse responsibilities from the state to the individual.

So how to make things better?

Let us aspire towards excellence. I said to someone earlier in the week, I don’t want to do ‘ok’ work, I want to do excellent work. I want to go home and  be proud of what I have accomplished with someone and their family.

How can this happen? By moving the personal budgets beyond direct payments or managed LA budgets. By bringing people with experience of using services and social workers who are asked to implement the systems, into discussions with commissioning teams. By breaking down block commissioning – which may be more costly. Real, true ‘co-production’ which involves discussion with all groups of users not just those who always come to the meetings. Using Individual Service Funds, using Trust Funds, using small providers, providing genuine choice and different options not just ‘choice’ within the context of what the local authority approves of – for all user groups not just the ‘easy’ ones.

Choices will need to be made in terms of funding but the cost of leaving work feeling that I could have done much better, is not something that I want to aspire to.

Advocacy

I mean by advocacy, being given – and taking where necessary – the role of speaking up more cogently for people who use the services we provide on one hand – and of our own profession on the other hand.

Social Workers have a unique position in seeing the effects of social policy experiments taken at national and local levels. We shouldn’t need to be constrained by managerial approaches which have driven us into the ground because actually, our employers are scared of some of the values we have.

I wonder sometimes if local authorities WANT social workers who are anything other than automatons. Then I think it is a necessary part of my role to be a proverbial ‘fly in the ointment’. Fortunately, I have a manager who thinks in a similar way, but we need to push this upwards to a policy-making and commissioning level.

Rather than waiting for social workers to be given a voice, we need to seize the voice. Newspapers and media companies may want personal stories but I genuinely believe there are stories we can comment on without needing to draw on the lives of those who use our services.

We have to use our voices politically and waiting around for BASW or the College of Social Work is all well and good but we need to do more.

I see a future of social work as pushing it’s own voice out whether people want to listen or not. People ARE interested in social work and what we do, they just don’t actually know what we do.

Political Developments

We are well placed to have a strong voice in political and social developments and must use that. I think it would give the profession as a whole more credence. We must remain clear about the goals of ‘social work’ and why social work is necessary.

‘Social Work’ is more than statutory social work however having social work in local government is essential too.  As skilled professionals who work on the ‘frontline’ we can’t allow our voice to be co-opted by those who claim to speak for us.

However I’d like to see a more cohesive social work voice that isn’t limited to local authority workers and embraces the voluntary sector. I see more social work taking place outside the local authority bounds but we have to use and build our professional knowledge and take responsibility for our collective professional growth and influence.

New ‘Social Work’ ways of working

We can embrace both technology and social media to promote and present different ways to provide ‘social care’ and social services. We can incorporate our professional skills in terms of active learning and reflection to use new forms of communication and collate and innovate in the field to look at the ways we build communities and relationships more broadly and what that can mean to social work as a whole.

We are able to build links more easily both across the sector, nationally and internationally, across different professions but most valuably with users of the services we provide.  Perhaps ‘virtual’ space and communities of interest rather than just location should be considered as places in which some of our expertise could gravitate. We have to take new opportunities and learn in non-linear ways.

Research into Practice

We have to build positive links with universities and organisations committed to research and encourage more practice-based research. We can’t allow the repository of knowledge of the profession to lie solely in academic institutions. Links between practice and academia have to flourish in order for the profession to flourish. Maybe there needs to be more systems of secondment. This may exist in some places already but I haven’t seen it locally.

We talk about using evidence-based and evidence-informed practice but when discussions are raised about changing things locally, we are presented with policy decisions already made. I’d like to have more autonomy personally and as a team to pursue both original research and change models of practice accordingly.

I have to think that things will get better for and in social work. We have some excellent skills that are not necessarily lauded. We are able to draw in the ways that society impacts on the individual and the ways through some of the difficulties faced. We have to shout out this unique expertise and the values that underpin it so both it is recognised as a skill and that we recognise it ourselves as skills we use.

Sometimes we get caught up in the day to day work or caught in the mire of negativity about social work to forget what a fantastic job this actually is. I desperately want it to get better. I believe it will, otherwise, I don’t think I could continue.

Broadening access to Independent Mental Health Advocates

Support each other

The statutory role of the Independent Mental Health Advocate (IMHA)  grew from the 2007 amendments of the Mental Health Act in England and Wales (with a start date of 2009).  IMHAs have particular status in terms of rights to information and access that other advocates may not have within Mental Health services.  Currently commissioned by PCTS, from 2013, Local Authorities will take over commissioning of IMHA services and the right and access to good services is intended to be a safeguard within compulsory mental health services.

Last week, Community Care reported on a study conducted at the University of Central Lancashire about the use and understanding about the use of Independent Mental Health Advocates (IMHAs)  among Mental Health Professionals in England. The study has (not, I suspect, coincidently) come at a good time for the change in commissioning arrangements and a look at where things are and where they should be going.

The article itself draws attention to the conclusions that

Some professionals saw advocacy services “as challenging, even irritating and inappropriate”, the research found. One professional told researchers advocates were “amateurs meddling” and a “bloody nuisance”. Others, particularly approved mental health professionals (AMHPs), supported advocacy “but had little or no direct experience” of service users using it.

As a Mental Health Professional (and AMHP) who has had some experience of uses and referring to IMHAs, I was disappointed by this initially. Particularly the terms with which advocates were mentioned. ‘Nuisance?’, I hope so. ‘Meddling?’ well, why on earth not? Surely being a nuisance to professionals and meddling is exactly what a decent advocate should be doing – however I would find the distinction between so-called ‘mental health professionals’ and ‘amateurs’ as advocates offensive and an indication of scant respect. Respect at every level in mental health services, social services and health services has to exist.

Community Care in a blogpost have put together some of the quotes pulled from the report by social workers and AMHPs in relation to advocates which makes interesting reading alone.

My experiences have been mixed to be brutally honest. Working predominantly with people with cognitive impairments which are significant and may not be able to instruct an advocate, I’ve found our IMHAs who have come from a mental  health advocacy background, have been less than understanding of the need for non-instructed advocacy skills. I have been told following a referral I made, that they would not work with ‘Mr Brown’ because he has an advanced dementia and they were only able to do what he asked as his advocate.

I felt some of the attitudes I’ve seen by a couple of our IMHAs towards older adults with cognitive impairments have been less than positive – and I do feel quite protective towards my client group and want to ensure equal access. If only, I have thought to myself on many occasions, our IMCAs (Independent Mental Capacity Advocates) were also our IMHAs (I can’t praise our IMCAs highly enough – even (or perhaps especially) – when we disagree!).

I am always (in a nice way, of course) a little jealous of the advocates I work with. I think their job has a lot more credence than mine in some terms because while I can advocate for my clients to a point, there’s a point at which I am a part of the oppressive systems that need to be advocated against.

I understand that and respect it. I’d certainly not see advocates as any less ‘professional’ than other members of the team I work in. There has to be a distance though – which doesn’t need to stop us being friendly, personable and pleasant to each other – but does demand that sometimes we will be coming from different angles. That’s important to protect the rights of those being advocated for.

The report itself can be read here.  It explains the context of. It explains that access to an IMHA service which should be offered to everyone who is subject to a detention over 72 hours or a Community Treatment Order/Guardianship – is sparse which particular under-representation in the following areas

There was a strong consensus that those who need the IMHA service the most,access it the least. Specific groups of people that may be under-served by IMHA
services are:
 People from BME communities
 People with learning disabilities
 Older people, with dementia
 People who are hearing impaired or deaf
 Children and young people
 People on CTOs
 People placed out of area

And the issues which have coloured my own personal experiences of using IMHAs was mentioned in the report

The development of IMHA services is based on a model of instructed advocacy provided by mainstream advocacy providers. This may inadvertently disadvantage qualifying patients who have specific needs including people from BME communities, older people, children and young people and those with sensory impairments ..

Furthermore

There was little evidence of commissioning based on needs assessment and equality impact assessment and there was evidence in the case study sites that specific needs had not been considered. In particular, gaps were evident in relation to people from BME communities, people with learning difficulties, older people, children and young people. Further, it was evident that generally service users, particularly qualifying patients, were not being directly involved in the commissioning process or in
monitoring contracts.

So it would be unfair of me to lay the blame at the lack of capabilities of particular advocates and more on the commissioning process which sees ‘Mental Health Patient’ as a block group of people with similar needs and commissions accordingly.

The report makes a number of useful recommendations and is a good read for anyone involved and engaged in the provision of mental health services in England and Wales, whether as a professional, user, advocate, carer or commissioner.

The role of the advocate was strengthened by legislation and it is important that the benefits are not lost. I have seen such incredibly useful work done by advocacy services locally that my main gripe is that there should be an equality of access and opportunity for all who are treated compulsorily by mental health services in society.

I want more ‘nuisances’. I want more ‘irritants’. I want more challenges.

That’s what an advocacy service should be about.

pic by sparkypics at Flickr

Shifts in Support Planning

Pen and Paper (1024)
Community Care alerted me to a new report developed about a great model of support planning  called ‘Empower and Enable’  that is being proposed as a way to invigorate the ‘personalisation’ agenda and move it back to the roots of putting the user at the heart of support planning and removing this from the scope of professionals.

In the process of developing and implementing care currently, after the assessment has been fed through the ‘resource allocation system’ and an indicative budget has been established – the ‘support planning’ comes in to build, yes, you guessed it, a ‘support plan’ which would be what might have been called a ‘care plan’ in the past and details how that support will be delivered for the individual to whom it relates.

Groundswell  Partnership , the ‘personalisation consultancy’  who wrote it, explain that councils should change their models of support planning and move the focus back towards the users of the services provided.

I couldn’t possibly agree more. This is what we were told when the whole personalisation agenda was moved out and I can’t honestly see what’s different apart from the lack of roll out to wider groups than those that  benefited from direct payments. This was the ethos behind rolling  ‘personalisation’ out beyond those who were receiving direct payments previously to everyone in general.

The model presented is one of ensuring that information is more freely available and that ‘professionals’ don’t need to take hold of support planning. It  talks about shedding the ‘belief’ that professional support is necessary to enable support planning. Absolutely right.   I would counter that councils have been trying to move away from professional support for support planning as it is more expensive but are too slow to change and stuck in systems of commissioning and getting services ‘approved’ to have moved quickly enough on this.

Currently, I am deeply concerned that the level of access to support and different kinds of support can be based on the particular social worker or care coordinator allocated in terms of our own knowledge of available services – particularly as regards managed personal budgets. I agree that the way around this is to make as  much information about resources and services open access – including costs and deductions and details of block contracts and how they are delivered,  so that anyone and everyone can have equal knowledge.

I love the idea that support planning should take time but there needs to be some thought to the more immediate support planning that might take place in a crisis situation and looking at how that can feed into these models and look at ways that people can – as far as possible – build in contingencies and forward planning into the current support plans.

The report also talks about building on community capacity to provide support and support planning. Wonderful. Truly wonderful but it fails to tackle those who are excluded by the communities in which they live. Working with a number of people who may lack capacity to manage their own support planning, lack informal support and are isolated or excluded by their community, I often wonder when a realistic report is going to tackle this issue properly – rather than a sentence saying ‘some people may need professional support’.  Maybe it needs it’s own report. I’d love to see that. Honestly. I want to cheer these reports as they flow out of the ‘personalisation consultancies’ and I often do but I need to see some innovative thinking that looks at the realities I face daily.

I would counter that ‘these people’ who lack capacity require independent advocacy on top of professional support. Relying on a social worker for support planning, particularly in work with older adults where the case loads and expectations regarding quantity of work undertaken is particularly high, is absolutely going to  produce a poorer quality support plan. I don’t think anyone is denying that – including the local authority employers – I suspect they would love to tender out this role however the clunky nature of contracting and commissioning makes this slow moving.

I know I put together some poor support plans myself. It doesn’t make me proud. I don’t go to work thinking to myself ‘today I’m doing to produce a poor support plan and I’m not going to ask Mrs Brown or her family about what she actually wants’. I try to consult but the time needed is squeezed. I try to engage family and friends, but you know, believe it or not, some families or friends actually don’t want to be actively involved and some people don’t have family and friends.

These reports are fantastic. We need more. We need more reports to explain why we are doing a poor job about providing support planning.

But what we also need are properly assessed and arranged targets set to local authorities that demand involvement by users in more than a peripheral box ticking way.

We need resources to provide effective and independent advocacy which will allow for equality of access to innovative support planning tools for those who are not able to independently access them for themselves.

My own dream was to break free from the LA yoke and establish some kind of local social enterprise type organisation that would be able to offer dual support planning and non-directed advocacy for those who lack capacity to produce really good support plans and support networks to fill in the gaps for those who don’t have the informal networks or whose family want to support and help but might not be able to to the extent expected sometimes.

If anyone wants to fund me or pay my salary while I do that, please do let me know.

There are better ways. I’m sure of it. While I enjoyed reading the report as it is,  my brain was buzzing about how this model could work with the people I see every day – I’m still waiting for a report to deal with that. And if noone will fund my little social enterprise project, perhaps they could commission me to write report – for myself – about ways it could work better.

But I don’t think I can promise what these reports promise – which is zero cost.

And possibly that’s the key.

World Social Work Day 2012

45/365

Today is World Social Work Day as deigned by the International Federation of Social Workers. It falls on the third Tuesday in March and is a day of recognition of the profession and particularly the international tint of social work.

The thought of having a day particularly for social work and social workers is something that I have reflected on for a while as well as the place and position of British Social Work – particularly English Social Work – amid the work done internationally.

 

Defining Social Work

The IFSW definition of Social Work is helpful as a starting point, explaining that

The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work.

It’s really important to reflect fully on this definition in our own corner of the world and remember that we are not just puppets of the statutory system but we have a professional responsibility to stand up and fight for social justice and to promote human rights.

Social Work ‘intervenes at the points where people interact with their environments’ and that happens in the political as well as social spheres. We cannot be apolitical or apathetic as social workers. We have to care.

For me, social work is about knowledge, compassion, competence, responsibility and advocacy. All those elements are necessary but the work cannot take place in a vacuum – it is about environments, remember.

So the process of embedding not only our profession but our sector into decisions made in health settings is crucial.

I see World Social Work Day 2012 as an opportunity not only to look back at how we have done things but a great chance to look forward to the future and purpose how we can do things better, differently, with more co-production, alongside those who need services and not for those who need services.

When social work is less obsessed by professional status and more in tune with behaving in responsible and professional ways, we will go some way to achieving the respect which seems to be so hard to find at times.

As for me, I don’t particularly crave respect as a social worker. I crave respect as a human being but I understand that to receive respect you have to be willing to dish it out double fold. I want no one to respect me solely on the basis of my title or my qualification but on the basis of my actions and my practice. That, I think, is something to truly strive for.

Changing Worlds

We are firmly embedded in an era where the certainties of the welfare state and the structures of the NHS are being eroded and fractured by government policies and a right-wing drift of attitudes and agendas as well as developing models of localism and post-modern fragmentation of the structures we had imagined were solid.

Some of the certainties we relied on are fast disappearing but in some areas new opportunities are growing. I have seen the shattering and deterioration of quality in adult social care in England as services have been carved up and contracted out. Not all private is bad and not all public is good but the focus on profit above quality is a theme that has driven the social care market predominantly in the last decade.

We have to shout out about this and there is a greater role for individual social workers to advocate for the services we provide and the services that are needed. We are well placed to take on this task and to feed back the impact of the cuts on those who desperately need services. We need to feed back the lack of opportunity for choice of those for whom the government drives forward in its agenda of choice at all costs.

We are able to grant ourselves a louder and more dynamic voice through different media and technology. We are able to build bridges more easily with user groups and carer groups and ally ourselves to those who are being victimised and targeted by the government and the press.

We can also build these communities of resistance internationally and promote that ideal of social justice that the government seems to have forgotten.

Messages

My final thought for World Social Work Day 2012, which falls as the NHS and Social Care Bill limps through Parliament, unloved, unwanted and ready to break the foundations of the principles of our National Health Service, are that we have to be ready to fight, to shout and to promote our profession, ourselves and those who knowingly or unknowingly may need good, strong competent social work support in the future.

Social Work is important. It is vital and it does promote positive changes. We just have to believe in it a bit more ourselves and help others believe it to.

Happy World Social Work Day!

Will Adult Social Care Reform Stall?

younger hand and older hand

The Health and Social Care Bill currently limping through Parliament is a mess. Even though I try to take an active interest in its progress, even as someone who is desperately concerned and involved (working, as I do, in an NHS team), I lose heart at trudging my way through some of the details which have been changed, adjusted and repackaged beyond the level of human (oh, ok, maybe it’s just me!) comprehension.

I was baffled though by this piece which turned up on the Guardian website yesterday.

Announcing that Lansley, having been stung and having lost credibility as his health reforms (hopefully) hit the buffers, is going to be delaying his announcement of reform in social care.
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A Dignity Code for Older People?

Old hands

The Daily Telegraph today prints a letter which sets out the need for a ‘Dignity Code’ in Health and Social Care calling on Hospitals, Care Homes and other institutions to prevent ‘issues of abuse and neglect’.

The article accompanying the letter, the Telegraph says, will encourage care workers to have this code written into their contract.
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