That Old Chestnut

[Guest post by Sharon Levisohn]

Mother came home from hospital on Friday, having been in over Christmas and New Year. She has advanced COPD (emphysema) and had a respiratory virus that resulted in pneumonia.

However, her lengthy stay was not due to her illness – a week of steroids and antibiotics settled that insofar as it could be – but the inability to plan a discharge to meet her ongoing needs. The hospital wanted to send her home with three (local authority funded) home care visits plus daily district nurse calls. The social worker could not authorise the home care package without it “going to panel” and of course there would be no more panel meetings until January 7th. Then the hospital suggested a nursing home placement but, despite full-time oxygen dependency and limited mobility, my mother did not meet the criteria for a funded admission. Next they suggested a short admission to a cottage hospital. That was rejected as they thought, frankly, that the journey would kill her. Plan D was to be discharged home with the support of the (health-funded) Re-enablement Team; however, she was not open to this as her condition was too far progressed for rehabilitation. All this time, Mother was in an acute bed – one of those infamous bed-blockers – on a ward with confirmed Norovirus, while the family and I rode the Waltzer of uncertainty and conflicting updates, always aware that she might just give up the long battle with COPD.

What is the point of this personal anecdote of woe over the festive period? I suppose it is not a unique case; even on the ward there were several other patients unwillingly playing the Cherchez La Femme game of discharge co-ordination. How many patients and families in how many hospitals were going through similar experiences? What vexed me – and as a former nurse I am not criticising the frontline ward staff – was that the hospital did not seem to know what qualifying factors were applied to the various options – one might have assumed that they had confirmed Mother’s eligibility before informing her and the family only to dash their hopes. The other bugbear is the responsibility for funding. Surely, if a risk assessment has shown that a frail elderly terminally ill patient has been assessed as needing input from various agencies in order to be at home with the people and dogs and personal touches she loves, which give her a little quality of life, and if we believe that it is better for the elderly to live at home so far as is possible, surely then the funding needs to be provided? Or shall we simply abandon that principle as practically unviable?

Familiarity Breeds Contempt

Over the course of the past months, who could help but feel a plethora of emotion as the horrors of Winterbourne View have unfolded before our very eyes: Absolute disgust that an organisation could get to the point where such blatant institutional abuse becomes a part of daily life, anger at the systems in which we work as they are revealed as insufficient to protect the most vulnerable in our society or perhaps a heart-wrenching empathy towards the vulnerable and a passion that things have to change and something done… but what?

It will hopefully have challenged us all as a professionals.  Is it just possible that as we go about our business there is a very real danger of becoming complecent unless we keep on out toes and remain true to our professional standards and ethical practices?  I’ve been reminded how very important the role of those who commission services and the need for greater accountability when choosing services for individuals who can’t choose for themselves.   Are we pressured into choosing the cheaper option even when we know in our heart that it isn’t the most suitable?  Do we sigh a sigh of relief and accept without question when we find a service that will accommodate the individual with particularly challenging behaviour knowing that the option will be limited? Do unrealistic case-load sizes prevent us from spending time to think outside of the box and identify the very best service and then think how it might be achieved? Do we have a professional relationship with providers when a less formal relationship can be so much easier? If we become too familiar those so important boundaries can become distorted and increase the risk of poor practice or even abuse going unnoticed or being excused.

I started my social care career working in a residential home for children with autism and it must be said that in my experience the majority of carers are decent caring people who go the extra mile.  Most don’t get paid heaps, have to work shifts but still turn up at work asking how they can make the next 8 hours the best they possibly can for those they have come to work for.  However, there are some for whom that isn’t the case and over the past couple of weeks we have seen 11 photos that will probably remain imprinted on our minds long after the media frenzy has died down.

I’d really like to hear how recent events have perhaps challenged you as a health or social care worker as you strive to help deliver the very best services to those who need them. I also look forwards to hearing how the Department of Health is going to drive service commissioning, delivery and safeguarding forwards.  What is agreed upon is that there needs to be a radical overhaul of social care; what doesn’t see so clear is what that will look like.

 

It’s all about the training! CQC and Deprivation of Liberty Safeguards

Inveraray Jail

Today, as Community Care reports, the CQC has published its annual report into the operation of ‘Deprivation of Liberty’ safeguards for 2010/11.

Deprivation of Liberty safeguards are a particular part of the Mental Capacity Act which allows a legal process of authorisation where there is felt to be a ‘deprivation of liberty’ in a care home or hospital related to someone who lacks the capacity to make a decision about whether they remain there or not. The process of decision-making relating to whether a Deprivation of Liberty is authorised revolves around the managing authority (the organisation which is potentially depriving the person of their liberty) and the supervisory body (the local authority or PCT (or whatever they are called now) where the person is or who is responsible for the care of that person (if, for example, they have been placed out of the local area the responsibility remains with the placing authority).  The decision is made on the basis of a number of assessments (six actually) which are undertaken by at least two people, one of whom must be a doctor and one of whom must be a ‘Best Interests Assessor’ (who can be a social worker, nurse, occupational therapist or psychologist).  The Best Interests Assessor, unsurprisingly, makes a recommendation not only on whether the deprivation is in the person’s best interest,  but whether the framework and care plan constitutes a deprivation of liberty at all.

So that’s DoLs in a nutshell. What have the CQC got to do with it? Well, amongst other things, monitoring these Deprivation of Liberty authorisations is another part of their work.
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Resource Allocation Systems on Trial

How are direct payments, personal budgets and resources allocated in adult social care? I’ve been working in this field for many years at the front line and couldn’t tell you. Fortunately, the courts are shedding some light, albeit foggy, on the matter.

This morning I came across this blogpost on the Guardian website. It mentions the case of R(KM) v Cambridgeshire County Council which will be heard by the Supreme Court on appeal next week.

I read through the previous judgement which is being appealed and would recommend it to anyone involved in adult social care in England.

While the previous judgement found that according to the Kensington and Gloucestershire rulings, local authorities could take resources into account when extending services to those in need without their bounds and remain within the National Assistance Act (1948), the Chronically Sick and Disabled Persons Act (1970) and the NHS and Community Care Act (1990) to assess and provide services, the method of developing non-transparent ‘resource allocation systems’ (AKA RAS) was criticised heavily. Continue reading

Rethinking Personal Budgets in Social Care

Reading Community Care, I saw that NLGN (New Local Government Network) have published a report stating that the ‘rush towards personal budgets’ must be slowed down.

I’ve tried unsuccessfully to find this report on the NLGN website but haven’t been able to do so am reliant on the third party reports from Community Care but I thought it raised a number of issues that are worth pondering.

The author of the report, Daria Kutsnetsova says in the article

.. in a lot of cases, personal budgets do not mean choice and control for service users because people are not given the choice of direct payments. Their budgets are handled by a care manager, which can be a choice in the personal budgets system, but in many cases it is not a choice and people are receiving the same care they were always receiving, she said.

It’s just called a ‘personal budget’ to push this government target,” she added.  (my emphasis)

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