NHS psychotherapy services hit by austerity

In sad but unsurprising news, a report by the UK Council for Psychotherapy and the British Psychoanalytic Council shows that psychotherapy, and in particular long-term psychotherapy, is getting more and more difficult to access on the NHS. They surveyed 2000 psychotherapists.

Continue reading

Patient Stories – Will we learn?

Today the Patients Association published a report ‘Patient Stories’ (PDF). It focuses on thirteen different stories. These are stories directly about the experiences of patients through hospital systems and discharges. Some are told by family members when the person involved and some are told directly.  Some are anonymised and one is from a doctor who received treatment herself.

The format of ‘telling stories’ is a good one because it makes for interesting reporting. It personalises tales that we know about poorly managed hospital discharges which take place before they should because we hear the voices of those directly affected and it is easy to see the lack of humanity in some of the systems that exist in acute health care.

Sometimes what is remembered is a single comment which may have been made by a busy member of staff in an offhand manner, for example, in relation to Margaret Allen, her sister writes

‘my (other) sister called the hospital to enquire after Margaret’s health before her death. The answering nurse replied that Margaret was ‘screaming away nicely’ and held the phone out for my sister to hear her cries’.

There are some shocking details in some of the stories of miscommunication, arrogance and rudeness of staff, basic care not being given but sometimes it is these snippets of language which are telling in terms of respect and attitudes of professionals towards staff.

While it may be possible to write these off as ‘individual stories’, I think that would be an massive error because there is an enormous amount of learning and themes which can be traced – not just through these stories but through the similar ones that have emerged over many years.

There is a consistent lack of flexibility and a lack of listening in these processes.

An example would be in the story of George Robertshaw who was admitted to hospital and was discharged in a way that his GP felt was ‘unsafe’ due to it being so rapid and was discharged in thin pyjamas in the winter – so that when carers did arrive to him he was cold, hungry, very thirsty and still not well.

His daughter writes

‘Following my father’s death, I again spoke to someone to inform them of my father’s demise and that I would be making a formal complaint re procedures. She told me directly that she would ask a nursing director to phone me back in a day or two, This never happened. No call, no communication, no nothing. I again rang and I was told that they had informed whoever it would be and that they would remind them. I got the impression that the relevant person was present but did not wish to speak to me and was telling the person on the phone what to say

Again, this could be claimed to be an isolated incident but as a rule of thumb and as someone who takes quite a lot of verbal complaints about the services that I provide, I tend to assume for everyone one person who complains or whose family complains, there are far more who will not have the confidence, strength or understanding to do so. It is important that systematic errors are challenged and improved but it is also important that clarity of information and respect are given to those who use services.

I wonder if that same Nursing Director would have been so slow to respond to her own manager? No? Then treat the people who use the services, particularly if they have a complaint with at least enough respect to contact them in the same time frames – even if it’s a matter of updating them with no additional information.

An organisation which is not willing to take or deal with complaints, cannot be a ‘learning organisation’ which is willing to improve.

I don’t have time to identify the issues in all the stories but it is worth reading as a snapshot of some of the care which is being given in hospitals in this country.

Of course there are good stories, and there are fantastic staff. The very first section of the report is based on positive feedback but we cannot ever become defensive about the systems as they exist and must treat each of these experiences as areas of learning. Sometimes it isn’t always about resources, it’s about respect and it’s about listening and responding.

Yes the NHS is wonderful and many of us have personal stories of gratitude, I have many myself, but if there is anything that can be done by any one of us to make things better, we absolutely must.

The main lesson I will take from these stories is to make sure that every interaction is bounded in dignity and respect. Mistakes happen but they can be resolved by listening and learning from those who experience them.

Defensive organisations that won’t encourage criticism are dangerous organisations. These lessons are just as important in all social care organisations as it is in health care.

The saddest thing about these stories is that we have heard similar before. There have been commitments between increasing ‘compassion’ in nursing and care staff but the systems need to become more compassionate too and far more responsive and flexible.

This is a series of awful stories and experiences but they must be learning experiences so that some positive may come amid the extreme pain and grief caused.

‘Reclaiming’ Care Home Fees

A deathly silence has descended upon us!  Call me sceptical but I couldn’t help noticing that it started around the 30th September 2012.  Claims companies that were once assisting the good people of this fair land to ‘claim back’ (almost as if they were referring to a benefit that had not been claimed by the masses) care home fees that they had incurred for themselves or a family member fell silent.

So why has it all gone quiet?

Until recently, individuals and family members have been able to make retrospective claims (backdate their claim) if it was identified that they or a family member were paying for all or some of their care when in fact they should have been receiving full funding to pay for it.   There then was a decision to place a deadline on retrospective claims which is why there has recently been an influx of ‘helpful’ organisations desperate to assist you.  In return for their kind assistance they would take a percentage of your successful claim.  However, one of the deadlines for making retrospective claims that could date back several years has now passed and there remains a less modest time-frame within which claims can be back-dated.

For cases during the period 1st April 2011 – 31st March 2012 the deadline for individuals or their families and representatives to notify the relevant Primary Care Trust will be 31st March 2013.

The truth of the matter is, not everyone who has paid care home fees is entitled to claim a refund.  They were of course referring to Continuing Healthcare funding which is the NHS funding stream that enables some people to have their care home fees refunded or not pay them in the first place if that person meets the eligibility criteria for Continuing Healthcare funding.  Throughout this article I am using the example of a care home but the same information applies to all care such as nursing homes, live-in carers and care agencies visiting someone in their own home.

Why do some have to pay for care home fees and others not?

Care homes charge a weekly fee to cover the cost of such expenses as accommodation and care.  This can range from a few hundred pounds to several thousands of pounds depending upon the care provider and the necessary skills required by the home and carers.  Anyone who is in need of such care is entitled to a community care assessment from the local adult social service department.  If, following this assessment the individual is eligible for help from social services they will then receive a financial assessment.  This has been common practice for a number of years and beyond the scope of this article to discuss in any depth. If an individual has assets (such as savings or a property not being lived in) just over £23000 then they will be required to pay 100% of their care (in this case the care home fees).  If they have less than this amount, they pay variable contributions towards the care home fees and the local authority pay the remainder.  Local authorities usually have funding thresholds which are a maximum they will pay for a care home so won’t automatically pay thousands of pounds each week if the same care is available within their funding limits.

Can I avoid paying care home fees?

This is where Continuing Healthcare funding comes into the equation: Continuing Healthcare or CHC as it is usually referred to is the NHS funding stream used to pay for care fees is someone’s needs are predominantly health related.  Because it is the NHS, unlike social service funding (see section above) CHC funding isn’t means tested and you don’t pay a contribution towards your care home fees.  In practical terms, receiving CHC funding rather than social services funding could be the difference between having to sell your home to pay for care home fees and keeping it!  It is worth reiterating though that not everyone in a care home is entitled for CHC funding.

How do I see if I’m eligible for CHC funding?

The CHC assessment process is detailed within 2 documents; they are national documents so it shouldn’t matter where in the country you live.  I say that with slight apprehension because in reality any assessment that involves human intervention is not always 100% objective all of the time.  If you would like more information, the documents are:

Eligibility for CHC funding starts with the completion of a checklist.  This will be considered when an individual is discharged from hospital for instance or can be requested at any time.  Professional including G.P.’s, social workers, district nurses & occupational therapists might also complete a checklist.  Individuals or family members can also ask for a checklist to be completed.  The threshold for the checklist is set lower than the eligibility threshold to ensure that everyone who may be eligible for CHC funding is considered.

If the checklist has a positive outcome (high enough scores) the full consideration for CHC funding is undertaken in the form of a decision support tool (DST).  A DST isn’t an assessment itself but a tool to help professionals collect all the relevant information such as assessments in order to reach a conclusion as to whether someone is eligible for CHC funding.

How is a decision about CHC funding made?

If someone has a rapidly deteriorating health condition, a G.P. or health professional can ‘fast-track’ a CHC application and avoid an unnecessary assessment; the funding should be agreed by the local Primary Care Trust without question and immediately. Your local Primary Care Trust or PCT is the agency responsible for administering NHS services such as CHC funding at a local level.

If a DST has been completed, the professionals involved will look at the tool and make a decision based on the following characteristics:

Nature –   This describes the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the type of those needs. It also describes the quality of care required to meet those needs.

Intensity – This relates both to the quality and severity of the need and the support required to meet them, including the need for ongoing care.

Complexity – This is concerned with how the needs present and interact to increase the skills required of the carers.

Unpredictability – This describes the degree to which needs fluctuate and thereby create challenges in managing them.

As you can see, the process isn’t an exact science and can’t be determined by a series of tick boxes.  The determining factor is whether the care required is predominantly health related than social care.  A local authority is not permitted to provide or pay for health care which is why health funding such as CHC exists.

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

Integration, Conversation and Change

Some Random Thoughts about Making Things Better

I have spent a good deal of the last week thinking about the importance of building and making links across different parts of the ‘whole’ in terms of the way services are provided by agencies to us, the public. Some of the following thoughts may seem random but I’m trying to connect them in my head! Slowly but surely..

Conferences

Last week I attended the Digital Health Conference and Hack in Leeds (which I wrote about here).  Without repeating myself too much, there was a programme around changes and new thinking in both health and social care that stretched over two days and involved a lot of conversations with people from many different areas – both in terms of place of interest and work and in terms of geographical area and level of authority.

The main theme I took from those days was around the important of connections and conversations. Ideas and innovation is not a top down, nor a bottom up flow. The channels and flows need to be horizontal – and across sector and areas of interest – as well as vertical. We need to look at ideas from outside the sector rather than only talk to ourselves and rely on well-meaning civil services to devise policies in London, particularly when ‘social care’ is often seen as an afterthought in the ‘health and social care’ agenda. When I look at models and policies developed for ‘health and social care’ and see that social care is little more than an afterthought with processes developed clearly by people who probably would find it difficult to define social care, let alone understand the messy way it is structured locally, I start to despair and then remember that if I invite myself to the table, I can make those points directly which may, possibly, make a difference.

I left Leeds with some glimmers of hope that as long as social care does continue to place itself around tables like that, we would be able to contribute and even, perhaps, influence thinking in a little way.

‘Health’ is universal, social care is not. The narrowing restrictions on access to funded social care is a massive challenge as access unfortunately can play into the government agenda of stigmatising those who need the provision of service. There isn’t yet a more general perception that social care is something for everyone and in adults services, anyway, the charging policies cause a great deal of anger and resentment when we are trying to offer them to people.

Conversation

I had another conversation earlier this week too, with Mark Brown who is the editor of One in Four (highly recommended, I’ve been a subscriber for a while).  We come from different angles but want to find answers to the same problem of how t0 provide a better service to those who need it. While we haven’t (yet) found the answer, he’s a lot further ahead of me and I highly recommend looking at the keynote speech he recently delivered in Australia about new ways of delivering and providing mental health services.

Change

In the background as well, I heard about the closing of Social Work teaching at the Institute of Psychiatry and the move towards outcome measurements based on clusters and quantifying diagnosis and recovery, I wonder if Mental Health services are moving backwards rather than forwards in terms of promoting and developing different ways of thinking about services and different ways at delivering which move away from ‘medical models’ which have not proved to be useful generally.

Integration

‘Integration’ is only integration if it actually brings people together rather than driving them apart which is what it feels is happening at the moment. The pots of money are split and the silos are created. This currently is in the interests of those who are working across the sector as they have their own fiefdoms of interest and can’t see new ways of developing practice that is based on unquantifiable aims.

So what do we need to challenge and change from within?

The current systems promote wrong thinking in a number of ways.

If we can’t measure progress, progress doesn’t exist.

We are expected to aim towards mediocrity rather than strive for excellence.

There is an emphasis of the ‘us’ and ‘them’ dichotomy of professional and user with little understanding of the user as professional nor of the professional as user.

Thinking of the tenets of personalisation and how the poor implementation has been managed in England, I can see both some rays of hope and some shadows of despair.

What was supposed to be a user focused attempt to shift power in social care services has, instead, imposed an attempt at new ways of thinking onto old models. We were told we had to ‘make things work’ but as we have seen in practice, the tools we were given were old and rusty. Local authorities were not able to shift models of commissioning nor of power structures rapidly enough to make the system a reality. We should be studying and learning from what has gone wrong with this model and pulling up the examples of poor practice to learn rather than constantly dwelling on the models of good practice.

Despite and because of the conversations I’ve had over the past week, I am learning that there isn’t enough different thinking within the systems I work in. The knowledge and desire to change is being paid lip service because there is a demand on time and money. The truth is delivering better is not only potentially further savings in the long run in terms of cash, the amount that can be saved in terms of quality of life improvements are priceless.

Social Work has the possibility to be at the heart of these conversations. We occupy the space around the ‘social’ which strides across health and social care – and across the life course.  However the profession itself doesn’t seem to welcome innovation itself and hasn’t been able to define a specific role which leads to possibilities for much confusion. The way out is for practitioners to develop a voice. Personally, I’m holding out that the College of Social Work will do a better job of it than has happened previously – but the need for innovation and fresh thinking is the only thing that will improve the outcomes for those who rely on us.

We owe it.

Carers Week – More than Words

Building Blocks of Art
‘Carers Week’ begins today. While the ‘official theme’ of the week is ‘In Sickness and In Health’ with a focus on the health of carers, I would provide my own theme from my position of having worked in social care for a fair few years as ‘more than words’.

Carers’ need more than accolades in order to feel supported and be supported properly. We need to be able to provide resources and that needs money.

Over the last 15 or so years, there have been definite changes in the status of ‘carers’ in social care organisations.  We have rolled out ‘Carers Assessments’  and have been able to provide services for carers directly as a result of new legislation. While we  assess the needs of carers – what we don’t have and where the disconnect exists – is a duty to provide services and nor national criteria about where a service should be and must be delivered.

The problem I face all too often is revolves around carrying out Carers’ Assessments (of course there is a target for these) but not being able to actually provide anything as a result of them. To which the obvious question I am asked is ‘Why do them if they only provide information to the Local Authority?’.  My local authority, fortunately and for now, at least, is fairly generous with carer support and direct services but this is by no means universal.

Mother watches over

I have been fortunate to see and provide some excellent services through direct payments made to carers and in a lot of ways, the services I have been responsible for providing as direct payments to carers have been a lot  more successful than some of my experiences with direct payments more broadly. I am able to encourage assessments with the possibility of a direct service provision as a result but I know this is by no means universal.

Assessments in themselves can be useful if they are conducted well and sensitively. Sometimes allowing a carer to have the space to discuss their own needs and explain fully the care they are and do provide and the effects that this has on their own wellbeing/goals and lives can be valuable – however there comes a point when this has to be acknowledged in a more ‘real’ (and yes, that can mean costs) way than smiling and nodding. More than words.

I’ve also seen an increase in the ‘posting a carers assessment out’ style of assessing which can lose some of the subtleties gained in a conversation and a visit. Of course, not everyone wants an assessment because the language and the questions can be formalised and particularly we get the ‘I’m not a carer, I’m a spouse/child/parent’ response but I’d counter that’s something that can be addressed by a change in the way of ‘paper assessment’ and the language and discourse models that exist around social care. Why can’t we be more flexible regarding what an assessment actually is? Do we have to ask the questions on the form?

We give, others receive but that’s a tired model – particularly in relation to carers who give us, as a service and organisation – much much more than we can ever give them.

So why is it reduced to a paper assessment logged onto a computer database? Because that allows performance indicators to be met.

My ideal service would be more flexible about the ways that assessments are compiled and would allow much more for free text and less on box ticking. Box ticking can help some clarify but it by no means captures what role caring plays in all lives. ‘Caring’ is not uniform. There are a myriad of needs and a myriad of ways to both communicate this need and for support to be delivered – or there should be. If people want boxes to tick, by all means provide them but if they want open space to discuss or write or record what and how they feel about their role and what might help, then allow that too.

We also (in social care) need to work on our assumptions a lot. Families exist in different ways and have different histories. There may be many reasons that don’t need to be disclosed about caring may be more difficult in particular situations and assumptions can be very damaging.

The new Adult Social Care White Paper is imminent, apparently. There needs to be a commitment not just to assessments of carers but of delivery of services and support to carers. More than words.

While the government talks about ‘respite’ and the need for breaks, I’d argue that is essential but while the provision of services is being cut and there are fewer, more distant places to offer respite the realities will remain as far from the government planning as they are at present. Capital investment and investment in decent staffing in homes that offer respite consistently would help. Clear explanations about entitlements and potential costs would help. Services that speak to each other would help. Pooled budgets would help but the easy words come thick and fast. The solutions can’t be found by words alone.

The current system as it exists relies on carers significantly to ease the burden of cost of the social care system. This needs to be more transparent in terms of publishing details of how indicative personal budgets are arrived at and the amount that is ‘saved’ by a carer. If some of these ‘savings’ (not even a minute proportion – but some ) is ploughed back into effective and personalised support with professionals who are able to access and feedback good, local information and provide support and training to carers where they want it the savings over the long term would be much higher.

The cost of poor support for carers is much much higher than the cost of good support – but in these times of ‘belt-tightening’ it can be forgotten while we reach the goals of short term savings.

It’s a lesson that both the NHS and social care systems would be mindful to heed.

In order to support carers ‘In Sickness and In Health’ the government, the organisations such as the NHS and local authorities, employers and communities needs to provide ‘more than words’.

Images by W4nd3rl0st at Flickr and Sapphiren at Flickr

Regional pay cuts for NHS staff (Except if you’re a top exec on a commissioning body)

Sometimes I think Andrew Lansley exists purely to make me angry. I’m sure one day I’ll wake up to find him vomiting in my shoes. This morning, however, what I woke up to find was that he’s backing regional pay cuts.

Andrew Lansley, the health secretary, is threatening another controversial revolution in the NHS by proposing that its staff be paid less if they work in poorer parts of the country.

The cabinet minister is backing a plan for regional pay, which would mean that nurses, midwives, hospital porters, cleaners and paramedics would earn less if they work in the north or the Midlands rather than in the south of England.

Yep, we’re going to follow the private sector in a race to the bottom, and helping to further entrench the North-South Divide while we’re at it?

But what if it creates skills shortages? Surely there’ll need to be exemptions to make sure clinically-vital posts get filled?

Official documents reveal that the only backed by the Department of Health would be for highly paid managers working in new bodies established to deliver Lansley’s controversial NHS reform programme, widely criticised as a privatisation of the health service.

The department, according to a submission to the NHS pay review body, believes special arrangements would be necessary for this new cohort of executives to “attract and retain high-calibre leaders and staff responsible for transforming delivery”

So, the only posts for which we need to “attract and retain high-calibre leaders and staff” are for the commissioning bodies that nobody wanted in the first place?

I’ve said before and I’ll say it again. What a complete and utter Lansley.