The Human Cost of Cuts in Social Care

Yesterday I was sent a link to this blogpost by Lucy at The Small Places. I highly recommend everyone involved in social care read this post. It is written by someone who uses and needs support that is provided by the local authority, however their services have been, are being cut significantly.

The narrowing of the eligibility criteria isn’t a ‘paper cut’ made in an office within accounting departments of local authorities, it has a harsh and detrimental effect on the day to day quality of life of another human being who is dependent on the way that provisions are allocated. These are the choices that have been and are being made in the context of cuts and these are the people, actually, we are all the people that Burstow has to justify himself to when he talks about no money being taken out of social care budgets.

The author of the blogpost explains

Yesterday, my care plan was reviewed, and despite the social worker agreeing that I have substantial ‘needs’, to every question that I answered regarding what my carers do for me, the reply was: ‘we don’t fund that any more’. So from now on, no one is allowed to do: laundry, from putting into the washer, putting on a ceiling clothes rail, ironing and putting away…

no shopping allowed or putting it away; paying bills or doing any post office visits; carers aren’t allowed to accompany you out any more either socially, or to hospital/doctors/dentist/opticians or other practical appointments where you need someone to propel your wheelchair; they can’t put the bins out; can’t stack or empty the dishwasher or do any kind of clearing up whatsoever: the list goes on and on. All of the things that I cannot do for myself.Just about anything you can think of that a healthy person would do in the home or outside the home on a day-to-day/week-to-week basis is no longer allowed.

I recognise this. From the ‘other side’ so to speak. I have been, I am, that social worker (well, not in literal terms) but I have to explain that we no longer provide hot meals delivery, we can’t count time for someone to be taken to medical appointments, we deprive people of assistance for some of the tasks we, ourselves, take for granted.

There has always been an issue of resourcing with some user groups benefiting more than others. In older adults services, for example, it was always rare to allow carers time to accompany service users to go to the shops – however, wasn’t the new and wonderful era of personalisation and choice supposed to change this?

We are now able to offer the choice between the hours (and money) spent on someone helping with a bath and use it instead to go out for an hour to the shops. Not necessarily a palatable choice we would expect for ourselves, is it?

The author of the post goes on

I am supposed to have everything delivered now, but they don’t understand the costs of that. Fresh food (and I say that in the loosest sense since they mostly send you stuff that’s about to go out of date), in terms of fruit for example does not last a whole week; you’re lucky if it’s a few days. I can’t eat processed food because I also have IBS. So I’ll have to do an internet shop twice a week which will cost £8 delivery and I will also have to spend a minimum of £25 per shop, that means my four weekly food bill would be £240: I cannot possibly afford that. And since no one is allowed to put it away, what do I do with it when it arrives?

Cost transfers from local authority to user and is the ‘personal budget’ supposed to allow for this? You’d think so.  This was one of the more baffling parts of the post

Ah, now the very helpful social worker had a suggestion for all of this: I can use my D.L.A. to employ someone to do all of the other things now and pay for any transport needs! That’s what D.L.A. is for isn’t it? As I replied however, I pay ALL of the care element and part of my severe disability element back to the local authority for my care, so how can I use that?

Well, exactly. Disability Living Allowance (or Attendance Allowance for over 65s) is non-means tested however it is counted in terms of assessments for charges so there is an expectation in the finance departments within Local Authorities.  This allowance is seen by the local authority as a legitimate  target for charges to be recouped back to the Local Authority for the costs of care – and to be honest, I can see the point. These benefits (at least, the care component) are paid because there are care needs specifically. However for the social worker to lack this information is no doubt rubbing salt into the wound of cuts.  The social worker sounds to have been put in a difficult position and I know the feeling. We are tasked to pass the news of cuts to those who can least afford it and who rely most heavily on the provision of services – but it’s a duty to give fair and honest advice at this point.

It does make it clear though that ‘better information’ and shiny web sites providing directories of services or new ‘Trip Advisor’ type sites rating services are all very well and good but the real thing that social care needs is funds to meet basic needs. The focus needs to be on quality of life not ‘how much can we slice off budgets’. There no easy answer but being disingenuous about the nature of ‘choice’ available and being honest about the realities of decisions being made is significant.

This post speaks the truth of many others who cannot speak up – and this is someone who has been able to use a direct payment positively. There are many many more who haven’t.

As a social worker this post spoke the realities I see every day and highlights the benefits of social media to improve my personal practice – it shows me how social workers are perceived with an honesty I rarely get in terms of feedback on a day to day basis due to the power differentials which exist.  I hope I don’t respond to people in the way that social worker did but I will be more aware of my responses and how they are interpreted when I am in people’s homes.

And I will continue to fight against the cuts agenda all the harder. We have a powerful collective voice as social workers and we have to use it to tell the stories that we say, to not passively accept some of the hardships and injustices we see on a daily basis.

We can and must do so much better.

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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.

Personalisation , Personal Budgets and Demos

I have a lot of thoughts on the push towards the personalisation agenda in general, unsurprisingly as care and support planning plays a large role in my job.

Over the last week, a variety of meetings that have taken place which have pushed this issue to the forefront of my mind locally and have given me time to pause and think, not only about the focus of the agenda and where we are along the path but also where we are going.

It has been frustrating. As I noticed in a Twitter-related conversation yesterday, the language almost seems to have a form of it’s own. I start mentioning PBs, IBs, SDS, RAS, ISF, SSAQ, DP (see Glossary below)  assuming the person beyond knows exactly what I mean in each of those circumstances and you realise how over-complicated what should be a fundamental principal about putting the keys to the power dynamic into the hands of those who use the services.

Rumbling in the background is the government agenda to push personal budgets (PB) as a way to deliver ‘personalised’ care and a push into ‘health budgets’. I think there have been a number of issues that have either not been addressed or pushed under the proverbial carpet in the meantime.

I have tried to express some of my frustrations internally but often came up against the ‘you are either for us or against us’ mentality to those promoting the push towards personal budgets for all at any cost – so by raising criticisms and concerns, that automatically seemed to push me into the ‘controlling professional’ category who obviously just didn’t want to relinquish what I saw as my ‘right’ to dictate forms of care to service users and carers. I dispute that of course. I was one of the few care managers who actively moved many people onto direct payments historically. I am very well aware of the benefits of direct payments but the move towards direct payments for all I felt, was pushed by a few particular groups of people and I was concerned that it was moving the universality of self-directed support away from a large group of people I work with who do not want direct payments regardless of how much support is offered.

I was delighted to read over the past day or so, a report by Claudia Wood called Tailor Made – it’s a long document and my reading has so far been on a superficial level (warning – um. if you are going to print it out  be aware that it’s.. er.. well over 200 pages.. )

It is a document that almost made me cry with joy because it addresses in a more coherent and less histrionic way than I have, exactly my concerns about the way the personalisation agenda has been couched while remaining (as I am) absolutely positive about the process and idea.

We have been too fixated (and Paul Burstow is guiltiest of this) of pushing personal budgets delivered through direct payments as the ‘gold standard’ option of providing self-directed support.

As Wood says in the executive summary

‘The emphasis placed on direct payments as a primary form of personal budget is too restrictive and risks excluding large numbers of people who do not have the capacity or desire to use a direct payment. No one should be excluded from having a personal budget if they wish , but to make personal budgets as accessible as possible for all groups and in all care contexts, we need to think beyond direct payments as the only, or even the preferred, form of personal budget’

For me, Wood expresses clearly my own thinking on this matter. So much energy has nationally focussed solely on direct payments as a delivery mechanism (which is fantastic for some) that local authority managed budgets have become a second-best, second-class service and ‘transferring’ support from standard support to a ‘so-called’ personal budget managed by the local authority has been a fallacy and a lesson in tick box culture at its worst. The issue is that it is  social workers, yes, like me, who have been complicit in this deception. I tick a few boxes and automatically Mr Smith has a personal budget managed by the LA where previously he had a directly provided care package. The delivery is the same service, by the same people in the same way,  but now, after these boxes have been ticked (because he expressly does not want a direct payment) – he is suddenly on the local authority ‘figures’ as having a managed personal budget.

Whereas Mr Brown next door, who has a service of the same cost but a direct payment, is able to access a personally chosen personal assistant and goes to a sports centre instead of a day centre etc etc.

This seems inherently wrong but it is merely because the managed support is so poorly serving Mr Smith. The answer isn’t to give Mr Smith a direct payment because – and this is the issue that Burstow seems to ignore – he doesn’t actually want it.

Wood writes

‘Local authority commissioners… must.. scrutinise their ‘managed budgets’ processes, to ensure they deliver choice and control and are not part of a tick box exercise’

Finally, it feels that someone ‘out there’ is listening to our worries and genuine concerns about a system that seems to have been designed to deliver inequity.

She goes on to say

‘An inclusive personal budget strategy is… one where more innovative uses of personal budgets are developed’

And that, I think is the key. We have had direct payments for a long, long term. Where the real innovation is needed is on pushing out new ways of delivering personalised care within the context of managed budgets.

Wood helpfully specifies the different ways that personal budgets can be used saying

‘There are six forms of personal budget used in social care in England

– a direct payment (held by individual)

– an indirect payment (held by a trusted other – eg a friend of family)

– a trust fund (held by a trust of people)

– a brokered fund (held by a professional broker)

– an individual service fund (held by a provider)

– a care managed fund (held by local commissioners) ‘

and then goes on to say

‘There is a danger.. that as the Scottish and English governments focus on direct payments as the default and preferred modus operandi for personal budgets (in social care at least), people may assume these other forms of personal budget are not capable of ‘real’ personalisation.

This can become a self-fulfilling prophecy, with providers spending less time developing their systems for these other forms of personal budget and them becoming tokenistic forms of personal budget, which do not offer real control’

If Claudia Wood were in the same room as me, I would applaud her. THAT for me is the crucial point in all of this. I want to deliver more personalised services but the only tools I have been given within my local authority are direct payments (or indirect payments)  or care managed fund. All these other options have been theoretical and none have developed any flexibility.

I want to see as much effort nationally in developing new ways of delivering services through all these methods and I want Burstow to at least read this report to have an understanding about why he seems to be fixated on the ‘direct payment or bust’ preferred model.

Of course, when it works, it is fantastic but we need more work on the other models too to ensure an equitable system for all needing care.

As for the report, there is so  much more in it than I’ve touched on about personalisation in residential care particularly. If you have any interest in the subject read it.

GLOSSARY

PB – Personal Budget (delivered by social care – (or health in the future)

IB – Individual Budget (envisaged to include different income streams eg health + social care budget)

SDS – Self Directed Support

RAS – Resource Allocation System (‘points’ that are translated into cash to make an ‘indicative budget’ after an assessment)

ISF – Individual Service Fund where a provider holds the budget on behalf of a service user

SSAQ – Supported Self Assessment Questionnaire – the way that needs are often assessed initially.

DP – Direct Payment