Exporting Care

Location, Location, Location

Yesterday I read this article in the Guardian. It reports that in Germany there is an increase in Germans being placed in residential, retirement and rehabilitation units in eastern Europe where the costs are lower.

As the article says

Germany’s chronic care crisis – the care industry suffers from lack of workers and soaring costs – has for years been mitigated by eastern Europeans migrating to Germany in growing numbers to care for the country’s elderly.

But the transfer of old people to eastern Europe is being seen as a new and desperate departure, indicating that even with imported, cheaper workers, the system is unworkable.

But before we are too quick to castigate Germany, I think it’s important that we look at what happens in this country.

Until one month ago, I was a local authority employed social worker, seconded into an NHS Trust (as I was a mental health social worker) working predominantly with older people. I made a lot of residential and nursing placements. I worked in an inner London borough.

The amount of local placements we had came nowhere near meeting the needs of the local community. Yes, there has been a push towards caring for people longer at home – perhaps it was a feature of central London, perhaps not,  but many of the people I worked with did not have family around them. The cost of housing had pretty much seen to that in terms of ripping communities apart.

Still, there are pockets of close communities even amid the high towers of the financial centres of London. Among the office blocks and fancy shopping streets, there are communities that have evolved over the decades, centuries even and those tourist spots visitors see, they are ‘home’ to many people who might not wear the smartest suits or have the fanciest accessories.

We ‘converted’ some of the residential provision locally into ‘extra care sheltered’ provision – see, that would be good, that would ‘keep people at home’ for longer.

So where are we now?

The chances of getting a placement in the local area are very slim to zero. We had waiting lists months long for some of the residential provisions in the area. The wonderful ‘extra care sheltered’ housing provision realised soon that they could not manage the needs of those who needed 24 hour residential support or maybe the criteria for residential care moved higher but they have not truly become an alternative for someone who needs a residential placement. They have become a safer environment with a constant ‘warden’ for those who may otherwise have had sheltered accommodation.

So there are fewer residential and nursing placements for people who are local to the area. If a family shouts and hollers enough they may get someone on the ‘waiting list’ for a place. Who knows when that place will come up. We don’t like saying it explicitly  but places in residential and nursing homes usually come up for one reason and that’s a death or a deterioration in physical health and noone wants to think about that.

What does a local authority do then?

It moves people out. It is more likely to move out people who have no family support and no ‘links’ to the area. You see, living somewhere for 70+ years isn’t seen as ‘link’ enough if your family and friends aren’t there. Anyway, even if they don’t want to move you out, if there are no beds, there are no beds.

So while we aren’t moving people to other countries, that’s only really by virtue of us being an island. We aren’t that much better than Germany in this respect. We are moving people to unfamiliar settings and localities on the basis of cost alone.

Commissioning Quality

How are these decisions made? Well, to absolve myself from responsibility, I’ll say it wasn’t my decision. I did and do rage against it. I raised it internally as the ways these decisions are made are purely on the basis of finances of local authorities to make placements.

Currently, in inner London we are placing frequently in outer London but soon it will be the Home Counties and further and further away from familiarity. I wonder how consistent this is with the Mental Capacity Act which demands previous preferences are taken into account. This can be ridden over roughshod if there aren’t any local placements at the right cost.

So we move to commissioning. There has been a race to the bottom in terms of providing services and placements at the lowest cost. Property is a massive cost in central London so cheaper land can push down general cost but at what price to autonomy and preference?

There has to be a way for commissioners to be accountable for the decisions they make. Families can push and make complaints on behalf of those who are not able to make decisions for themselves but there really needs to be, in my opinion, some external scrutiny of commissioning decisions made by people who really understand the social care sector. Yes, councillors can scrutinise but how many understand the needs of those who are not pounding on their doors making complaints about council services? Who understands that those who have the quietest voices or who have noone to advocate for them may be having their rights ripped away from them?

I’m not sure of the answers. All I know is that I wish the commissioners would have listened to their social workers. I wish there were a stronger, formal system of advocacy which would raise these issues with people who commission services and I wish there were an understanding in central government of the impact that geography makes on the cost of social care.

There may be cheaper and more available placements in South Yorkshire but that doesn’t mean the answer is placing Londoners there. I fear it may well be in the future.

We can’t become too complacent. Germany today may well be Britain tomorrow.

What makes residential care good?

I was asked this morning on Twitter what I felt made a ‘good care’ in a residential home. Sometimes it’s hard to elaborate in 140 characters so thought it would be useful to explain my thoughts in a little longer form.

I’ve worked in social care for a number of years, either as a care worker/support worker in a couple of residential homes (and as a ‘bank’ carer in even more) and as a social worker in adult and mental health services.

I’ve been into a lot of residential care homes and I’ve seen massively varying standards  from the home the time I left a home with such heavy concerns that I left a message for the CQC inspector on my way back to the office to the homes I would both be happy to live in myself and would be happy for any of my family members needing care to move into immediately.

So how do I judge what is ‘good’ (and these aren’t necessarily in order!) – especially in the time limited fashion that often involves me walking in and out in an afternoon.

Culture – which can be hard to quantify but you know it when you see it. From the decor and the welcome you receive when you walk in or when you call on the phone to the small interactions you might see in the lounge area and the amount and type of items you might see. Is the lounge empty except for a few paperbacks that look untouched and are mostly large saga-type romances with little variety? Are the (as there was in a home I went to earlier this week) lines of VHS videos stacked up next to the TV? (without a video recorder, incidently)? These things show care, or lack of it to the details.

Feedback – I listen to people who use the services. Communication can be at different levels and there are sometimes people in care settings who don’t want to be there but often users respond to kindness and listening to the feedback of those who use the services and family/friends who visit is vital to understanding the quality of the service. Of course, it’s useful to read the official reports but they are so rare now and often out of date – while issues around quality of care can change quickly, that we need to look in other areas and understanding how well homes respond to individuals and their needs, wishes and wants is fundamental.

Staff – How am I greeted, that’s one this but more importantly are the interactions I see between staff and residents and not necessarily the residents I’m there to visit. Is there eye contact, is there any touch involved? Are the staff sitting in the lounges responding in conversation rather than requesting things are done/not done? Is there any interaction between residents? How is this facilitated? What is the staff turnover like? I might ask the member of staff showing me round how long they have been working there, do they enjoy it? Often they’ll say yes, anyway, but sometimes you get a glimmer of something else.

Size – I have an issue with stacking up older adults in large residential homes in a way that we wouldn’t in other user groups. We have residential and nursing homes now with 50+, 90+ residents. There can be good care in these places but are they ‘homely’? Are they able to meet individual needs? Or is it a hark back to institutionalisation and long stay hospital type settings. It feels like it is about cost and age discrimination. I would be happy to care delivered in small settings. Large doesn’t necessarily mean bad and small doesn’t necessarily mean good but do we really think there is a justification for 100 bed ‘units’ in the current day. The only justifications are cost and economies of scale. I don’t think that’s good enough.

Individualised responses – are the residents individuals? Can they pursue different activities if they don’t want to sing music hall songs? What if I resident moves in who prefers Led Zeppelin to Knees up Mother Brown (real story, incidently!). What if they wanted to do things or go places that weren’t on the ‘programme’? Yes, individualisation can cost but it doesn’t need to – it can be able to things that don’t necessarily raise a charge. How is this done? I want examples in every home of how individual needs are met.

Those are some of my initial thoughts. I’d welcome thoughts from others about what and how they make judgements about what good care in a residential setting involves.

Thanks for Bill Mumford for inspiring me to write!

Is there really ‘Crisis’ in Care?

There seems to be a general understanding that the state of social care – particularly in relation to older people – is in crisis. You can look at the headline in the Independent today with their exclusive about a ‘Crisis in the care of elderly as £1 billion cuts bite’ .

I wonder about the use of the word ‘crisis’ though. There is a massive issue in relation to funding but this is not something that has been ‘magicked’ out of the air. Nor is it an issue which has suddenly arrived with this government. We have known about the needs of an ageing population for decades but each government of all parties have continued to try and ignore the fact that there will need to be a higher level of tax receipts or co-payment to meet the needs of people who require support from the state.

If it is a crisis, then it is a crisis created by lack of foresight both politically and economically – it is not a crisis created by the care sector or people who require care.

The Independent article is useful and interesting. It lists a number of cuts in services but also highlights a push into ‘reablement’ services which focus on higher intensity, shorter term care and support ‘packages’ to offset (so the idea goes) longer term care needs in the future.  It is, of course, vital to emphasis early interventions and preventative work however as the criteria for access to services initially rises, those who need care are coming to these services generally ‘later’.  It’s a useful foil to this Telegraph article a few days ago which talks of the numbers of older people who don’t have access anymore to care provided by adult services locally due to changing eligibility criteria.  It’s very important to remember that this system of reducing care to shorter visits by contracted large agencies who deliver poor support by minimum wage workers (some of whom are fantastic but not because the system does anything to actually help them) was created by the push towards contracting out and attempts by local authorities to barter for the cheapest delivery contracts without quality being considered.  This is where the NHS will go and it will be the people who are least empowered to complain who will receive the poorest service. This is not an unforeseen crisis. The roots were planted in the 1990s.

Meanwhile, remember Paul Burstow saying about there not being a crisis in care funding. The word is used to create political capital and blame. No more.

I’d argue there isn’t a crisis in care. There is a well foreseen and ignored gap in the funding and provisioning of needs in the sector. This isn’t a surprise to anyone who has an ounce of common sense. It does need action, just as it needed immediate action 5 years ago, 10 years ago and small half-hearted measures were taken without there being a fundamental reorganisation of the adult care sector.

Yes, we have had the move towards personalisation but it should have been accompanied at the time with a move towards changing in the funding systems. Having the ‘postcode lottery’ and care associated with local authority delivery in an era where people are increasingly mobile makes no sense. We are pinning an approach and delivery mechanism from a different era which should have been re-designed from bottom up to account for different needs in relation to geographical mobility and differing family dynamics.

Perhaps that chance has been lost, perhaps there will be some innovation in this field and more than tinkering around the edges and a resolution of ‘who will pay’ which seems to be the fundamental discussion at the moment.

I’d like to move the discussion further not just about how we pay but what we pay for and how these services are delivered. The ethos behind ‘personalisation’ was to transform delivery of services and it has to an extent but we need to  really embed this ethos for it to work properly and redesign the methods of assessment that feel like a ‘points for cash’ type system where people have to constantly write and discuss things they can’t do and have money and funds assigned accordingly rather than look at models that can build on strengths and abilities, which don’t discriminate on the basis of age or mental capacity or rely on family without providing safeguards where no family exists.

This isn’t a crisis in care. This is culmination of forecasts which have been long made and which have never been addressed.

Of course this needs to be tackled but lets lay the blame on those who we elect to represent us rather than those who have the needs that are no longer being met.

Will Adult Social Care Reform Stall?

younger hand and older hand

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

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

Announcing that Lansley, having been stung and having lost credibility as his health reforms (hopefully) hit the buffers, is going to be delaying his announcement of reform in social care.
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Hospitals and Respect

The Care Quality Commission has reported today on a series of unannounced inspections that it has undertaken in Hospitals over the Spring which deduced that, of the 100, 45 met the standards required for nutrition and dignity, 35 met both standards but needed to make improvements (which makes you wonder around the standards if they are not ‘absolute’) and 20 did not meet either or both of those standards.

The National Report is available from the CQC site here (PDF).

The headline reports have been covered well by the national press so I thought I’d read through the report to see what ‘dignity’ and ‘nutrition’ actually meant in terms of the inspections which were carried out.

The report explains who the survey was undertaken in that two wards in a particular hospital were chosen on one day of the year.

Regarding respect for the patients the issues most commonly found to be lacking where call bells which were either placed out of reach or not responded to, attention to language in that condescending or dismissive tones were used towards patients and attention to personal private space regarding curtains being pulled around beds, for example, was not well-respected.

Regarding nutritional intake the most common problems were that patients were not given the help needed to eat, interruptions during meals so meals could not be finished and a lack of monitoring of food intake.

The inspections were carried out by one or sometimes two CQC inspectors, a practising nurse and an Age UK ‘expert by experience’.  The inspections took place between 9am and 4pm including one mealtime.

It’s very easy to berate a lack of compassionate nursing and I have no doubt that issues such as the way that condescending language is used is a matter of staff skill and training. Unfortunately our society as a whole tends not to value the older person and the less able person.

I am shocked myself at some of the language I hear people use in reference to older people – even (perhaps this shocks me more) colleagues who work in other service areas who seem to think of ‘the elderly’ as a homogenous group of people who no longer have individual identities that we can relate to when they cease to be economically viable.

That is a matter of training, training again and instilling attitudes in a work culture. Management culture drips down to individual practitioners and staff, that’s one thing I’ve learnt from working in the care sector. You might get the odd ‘bad apple’ but if the work culture is positive, they will be routed out. If the work culture is bad, bullying will dominate and the bullying of staff invariably leads to the bullying and mistreatment of patients.

I do though think there is a fundamental ‘acceptability’ of ageism in our culture which makes these reports less surprising than they should be.  Thinking back to my own social work training, which focused heavily on children and families (it’s a generic qualification so it is important that all age groups are covered well) the amount of time we spent talking about the needs of older people was below a minimum acceptable standard (one lecture in two years and most people didn’t turn up to it as it wasn’t compulsory)  and the course itself seems to adopt an ageist approach by not covering the needs of older people to a sufficient or acceptable standard.

If that is what is happening in the universities that train our professionals then we have to work harder and improve and push respect far higher up the agenda.

The other issues relate to staffing levels and the costs of providing a well-staffed ward. While I think every professional who is registered by a body which oversees them has to remain responsible for their own actions there are systemic failures in a management culture which does not allow sufficient staffing to deliver basic respect, dignity and nutrition.

The report itself says

The key theme was around the lack of time staff had to spend with patients to attend to their individual care needs. Reference was often made to certain times of day or night when staffing was inadequate.

Equally in the section regarding nutrition it says

A lack of time to deliver care (due to short staffing, persistent high demand or excessive bureaucracy) can prevent staff from making sure that people’s needs are assessed and they are given the right support to eat.

Poor practice may also result if there is a culture in a hospital that does not place an emphasis on treating people with dignity and respect. This might explain why needs assessments do not seem to be a priority in some hospitals, and the habit of talking across (rather than to) patients by staff.

As we see from the post about the Stafford Hospital inquiry, blaming nurses is too simplistic. The management should not be able to get away with this. Why do they push these targets and maintain poor staffing levels? Because money is haemorrhaging and needs to be saved by the Trusts. The brutal truth is that the fantasy of efficiency savings remains a fantasy while people are not being fed properly in hospital and while management cultures do not focus on staff training and development but allow understaffed wards to operate.

It’s a useful, if somewhat depressing report but there have been similar reports over the years and the key thing is for the findings to be acted on and not filed away. The ‘usefulness’ of the report relates to the way it  might move beyond the news headlines and affect funding decisions and management decisions in all hospitals, not just those that weren’t forced to make changes.

It’s interesting to see the CQC be a little more proactive though, particularly around the need for unannounced inspections. Now, if it can manage it with hospitals, it should be able to manage the same with nursing and residential homes?