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

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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

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What is Choice?

Lansley and Burstow and those in the Department of Health have extolled choice as an aim to strive towards in both health and social care. ‘Choice and Control’ was used as the key phrase as the agenda moved in Adult Social Care and it has been picked up as the NHS and Social Care Bill made it’s way through Parliament. After all, who doesn’t want choice? Who doesn’t want control? The answer is that not everyone is has the capacity or desire to make a number of choices in critical situations . It worked to an extent in social care in so far as those who are able and willing to choose or those who are well equipped with better funding and family advocates are able to choose.  However we have also seen the policy struggle behind in promoting true choice or in fact, any choice to those who are not as able to pick up the mantle themselves nor who have informal social networks to assist in this respect.

Does having ‘choice’ mean seizing control? Are choice and control two parts of the same coin? Does one lead to the other? Perhaps. My concern is with those who are either unable through issues of capacity or illness or unwilling (because – you know – sometimes that’s a real choice to be made too) to actively ‘choose’ the type of care they receive or the way the care is divided into a support plan.

Where we see the ‘managed’ local authority support plans, we see little ‘choice’ and no control. We see the same large agencies with block contracts tied into providing the same packages of care on the same terms that they always did. The promises of more flexibility have evaporated into the ether of local government spending cuts.

I’m not against ‘choice’  but I’m completely against false choice. I’m against the meaning of the word ‘choice’ being warped into something that makes good political capital for the government with no meaning when ‘choice’ has not been extended in any real terms. I’m against lazy use of the word ‘choice’. The government (and that’s the last government as much as this one) seem remarkably fond of it. Funny, that.

I urge anyone who hasn’t read Max Pemberton’s piece in the Telegraph a couple of days ago to take some time to read it. He writes about contract won by Virgin Healthcare to run services in Surrey.  He explains this notion of ‘choice’

. The emphasis on choice was something that was repeated ad nauseam by ministers in an attempt to sugar the bitterest aspects of the Bill. The legislation would provide choice, we were assured. Everyone likes choice, don’t they? And we all nodded in innocent agreement.

I have argued before that in a healthcare setting, choice is a misnomer: all hospitals should provide an excellent level of care because so many people – the old, the infirm – are unable to exercise choice because of geographical or physical limitations. But only now that we can see the shape of the NHS Bill can we truly assess what choice actually means.

And this is the reality as it exists more starkly in health care than in social care.

I chose my local hospital for treatment because it was the only one I could reach within an hour by public transport. The people who live where I live will be making similar ‘choices’. Those with access to cars may make other choices and go to ‘better’ hospitals further away (although I have to emphasis my treatment was great at the local hospital even though it’s ‘ratings’ and ‘feedback’ are poor!). Those who can only access public transport will have less choice.

Similarly, my GP is on the same road as me. I have had gripes. Do I go to another? No, because when I’m sick, I want the nearest surgery. I don’t have time to research the different specialisms and natures of the GPs around me. This would be even more notable if I were in a rural area.

So who is this ‘choice’ for? For the class of people that the politicians pander to. Those who have the means and ability to choose? How can we truly make choice genuine and meaningful in systems which inherently try to blind themselves to the different cultures. attitudes and natures which do discriminate in the way access to choice is made.

Perhaps this is a way to increase equitable services and access to services across health and social care. I have long believed that advocacy may be a solution. Sometimes I walk away from work and realise that the people that I spend time with on a day to day basis are not the people that politicians either speak for or to. That’s why, as a social worker, it’s important for me to remind and nip away at these groups of people who won’t be clamouring for their pens (real or virtual) to engage elected members.

We have left behind a whole swathe of people who have not been able to ‘choose’ are a part of the personalisation agenda. We must push on and the voices will grow louder as others see this happening in healthcare.

Choice is a luxury of the more able. Good universal services for everyone must be the essential bedrock.

The NHS and Social Care Act has passed, but the voices must increase. We who can choose much speak for those who cannot.

From Clicktivism to Activism

Reflections on Bevan’s Run

Yesterday, I went to the Department of Health to watch the end of Bevan’s Run. If you haven’t come across ‘Bevan’s Run’ it involved two hospital consultants, Clive Peedell and David Wilson – both cancer specialists in Middlesborough, running from Aneurin Bevan’s statue in Cardiff to the Department of Health based at Richmond House in London – 160 miles in six days. They did this to raise awareness of public (and professional) opposition to the Health and Social Care Bill.

My reasons for going to meet the runners (with a few hundred others) in London was to express my support for what they had done and my agreement in the agenda which they were promoting – namely that there is no mandate for this coalition government to dismantle and privatise the NHS – because that is what they are doing.

While I was there, I both chatted and listened to chatter of those around me – many with much more experience than me in the sector (there seemed to be a lot of doctors milling around) about the wish to demonstrate opposition again and again. The phrase ‘lions led by donkeys’ raised its heads in reference to professional leadership which had not (with some notable exceptions) provided  much leadership in opposing and disseminating the government’s plans.

Continue reading

Creating a Two Tier NHS

Reports trickled through yesterday that Lansley has slipped a sneaky potential amendment through in the pre-Christmas rush that allows NHS Foundation Trusts to increase potential provisions for private patients from a current average of  2%  to a maximum 49%.  This post on Though Cowards Flinch sharply points out the this is a total income rather than based on the number of beds which is an important distinction.

The details are explained well in this post at NHS Vault which I recommend highly because there is a lot more detail than I’ve garnered. My response is a undoubtably less erudite than both the previous posts but based unapologetically on my gut instincts and experiences of working in and around the NHS. Continue reading

Unannounced Inspections

I can spend a fair amount of time in residential and nursing homes because a part of my role is about both making placements in them and reviewing ongoing placements in them.

Over the years, I’ve seen many different types and different quality care homes and there are a couple of observations I can make very broadly.

Firstly that the quality of the inspection reports (as well as the frequency of inspections) has nosedived over the last few years. This isn’t all down to the death of CSCI and the arrival of the CQC as it was a pattern that was already happening but it does seem to have got worse progressively and unsurprisingly, this is linked to job losses and a reduction of resources allocated to the CQC. The reports seem to speak their own jargon-like language and sometimes looking at one it is hard to know (unless it is incredibly good or bad) what the issues actually are.

Secondly, there are many perceptions that people have of residential and nursing homes – not helped by media (don’t get me wrong though, I think the programmes that unearth poor and abusive practice have been very helpful to the sector) – that poor care abounds. While there is much more poor practice than there should be, there are also some gems which exist out there and provide very high quality and ‘caring’ care although the impression I get is that it is sometimes in spite of, rather than because of the way that care is organised.

Often the best care is down to individual home managers, individual care staff who have a particular approach rather than large, imposed management styles.

Yesterday, Lansley announced that there would be a rise in unannounced inspections in care homes. It’s important to note that the amount of inspections carried out will not increase but the amount of unannounced as opposed to planned inspections will.

Does regulation improve an industry and a culture? Well, not necessarily. I think there is something more deep-seated in the way that the care sector has been turned into profit-making businesses where individualised care is more expensive than warehousing of older adults in particular in very large institutions but that’s another story for another day.

Regulation can at least help to monitor some of the issues that may arise and while it is far from a panacea to cure all ills, I think that better and more frequent (unannounced) inspections are better than fewer, announced inspections as long as the inspectors are both knowledgeable about the legal aspects of the requirements of the home (I’m particularly thinking about the Mental Capacity Act and Deprivation of Liberty Safeguards here where I’ve found very little attention/knowledge from the CQC reports) and the inspectors aren’t afraid of pressure from providers.

It’s a step of course and while I can think of niggles/problems/answers – most of them involve more resources but the current situation where inspections are so rare as to be happening once every two years or less in some circumstances, does not provide a level of regulation that should be expected in such an important area.

I’ll certainly be keeping my eyes peeled for the results of these changes and I hope they will make things better.

Glossary

CQC  – Care Quality Commission

CSCI – Commission for Social Care Inspection (predates the CQC which took over in 2009)

Deprivation of Liberty Safeguards – particular legal tenets relating to adults without capacity who are detained and deprived of their liberty in care homes or hospitals.

Choice, the NHS and Social Care Bill and the Lords

It’s likely that the NHS and Social Care Bill will be voted on today in the House of Lords and the supreme irony remains that this unelected ‘Upper’ chamber may get the chance to carry the will of the people (and involved professionals) in the face of the lilly livered House of Commons.

Lansley’s Bill is pushing choice. Oh, you see, how wonderful it will be, he claims, when we will be able to choose which hospital we want to be treated in? Yes, that works great for routine surgery but there’s not much choice involved after a proverbial car crash. Choice is all well and good but it is a luxury of those who are able to express it.

I’m not knocking it – well, ok, I am a bit – but I have seen how the word itself has been warped in the field of social care and has been used to promote discriminatory practices which bypass those who are not able to make choices.

Those who can, choose. Those who can’t, are given the poorest services and it is those who are not able to exercise choice that often need much more support.

The voiceless will become ever more voiceless. That is my fear. The ‘Southern Cross’ situation was bubbling under the surface for a couple of years before the company, which gambled for profit on the homes of residents who were mostly older people, went bust. Where is the choice of those who live in those homes whose ownership has just changed with the signing of the cheque?

Think forward to an NHS with this abundance of competition and choice. I will choose the hospital in which I receive treatment. I can’t imagine I’d choose anything other than my most local hospital with good transport links (I don’t drive so that further would limit my choice more than someone who had access to a car, for example) – and why will I go with whatever consultant is allocated to me? Because I tend to trust doctors who are employed and practice in the NHS know what they are doing.

I don’t want to have to research and grade doctors. I want a doctor who will treat me well.

But choice is nice. I’m not anti-choice. I am anti a system which does not build in safeguards for the rights of those who are not able to make choices. My local hospital, as it happens, has a poor reputation (I’ve not, fortunately, sought treatment there often but every time I have been there for myself or to visit others, I have never had any reason to be concerned and indeed, have come across some of the most thoughtful and kindest staff possible – see what a reputation does?). It will probably be one that is mostly used by people who live locally, like me, actually, who don’t want to be travelling miles to get to the next closest hospital. Is that the choice I have?

Or maybe it’s about choosing a named consultant? I wonder what vested interests my GP would have in linking in with particular hospitals/consortiums to commission services with specific consultants. Is it my choice or my GPs choice? How linked is my GPs decision to money and profit? I hope it isn’t at all, but you see what changes in thinking this bill is leading me to.

I attend a multi-doctor, city practice. I don’t know my GP. My GP doesn’t know me. Cameron lives in a fantasy rural idyll where we all know and trust our ‘family doctors’. Sure, I trust my doctor but I wouldn’t recognise them if I walked past them in the street. Each time I’ve been to the GP (fortunately not often), I’ve been seen by different locums. I don’t mind this but I do mind the automatic assumption that I have built up a specific relationship with the practice. I doubt it will be my GP making commissioning choices anyway. Chances are the surgery will ‘buy in’ to an external commissioning company that will provide tidy, juicy profits to shareholders.

Yesterday Lord Owen and Lord Hennessey tabled an amendment which calls for greater scrutiny of the Bill.

Earl Howe wrote a letter to the Peers demonstrating an edge of fear in the government warning about

“The potential for slippage in the timetable carries grave implications for the government’s ability to achieve royal assent for the bill by the end of the session.

“The house must have proper time to examine the bill, but the proposal put forward by Lord Owen could result in delay which could well prove fatal to it. This is not a risk that I believe this house should take.”

Shaky ground when the House whose role remains to scrutinise legislation is asked not to.

As for me, I find it ironic that the will of the people – because there is no doubt that this is a hugely unpopular bill without public support – let alone professional support (all the medical Royal Colleges have expressed opposition to this Bill) – is in the hands of the unelected Peers.

I’ll be following with interest and hoping that the Lords are able to represent us in a way our elected politicians have been unable to.