Care White Paper – pre-publication thoughts and hopes

Cash

Finally the Adult Social Care White Paper will be published today. There have been a number of ‘leaks’ and there is a fair bit of information we know already. I wanted to collate what I know is coming with some hopes about what is contained.

Funding

We’ve known since the weekend and suspected for far longer that the bulk of the Dilnot recommendations will be shelved. The government while supporting the idea of a cap have been unable to find the money ‘in the pot’ for it and so any significant changes to the funding systems are going to be put on hold until the next Spending Review which conveniently will make it too late for anything to be done in the Parliament.

Care Home Fees

Oh look. The Government have worked out this REALLY CLEVER plan to allow people to pay for their care home fees after their death. Oh, so that would be completely different from the system already in place that allow people to pay.. um.. care home fees after their death.

Well done, clever little government, you’ve managed to bring out as a headline something that is already fairly standard practice across local authorities in England. Oh wait, you are now allowing the local authorities to charge interest.

I don’t understand how selling a home after death is better than selling it during a lifetime if it is still being ‘lost’ to potential inheritors. Remember, the value and asset of the home is discounted if there is a spouse or dependent still living in it. Making the process all about the inheritance is disingenuous at best.

Reducing ‘adult social care’ to ‘residential care’ is also enormously deceptive. There’s a lot happening to and with people who don’t own properties.

Carers

There is expected to be a broadening and firming up of rights of carers and duties of local authorities to provide support. I will be very glad to see this. There are enormous complexities in the systems that we are often not very good at explaining to people who are unfamiliar with the jargon. While ‘powers’ to provide support are all well and good, ‘duties’ are better and can be challenged.

Personalisation

We’ve heard Burstow make noises about increasing choice and moving away from minute by minute commissioning. I am really excited to see what will be proposed to avoid this and particularly seeing the focus more heavily fall on the commissioning by local authorities which favours block contracts with large companies. In fact, oddly for me, this is the area which I hold out the most hope for in terms of the content of the White Paper – with a look at the way the processes of commissioning can bring in more local organisations to provide more interesting/creative and most importantly – individually tailored support.  I expect a lot in this and I hope for a lot too.

Safeguarding

This is another area I think will be shored up. The current processes of adult safeguarding can be frustratingly flimsy at times and it is very hard to bring some prosecutions or to take speedy action as would be the case if the age of those who are being abused were under 18. I think we need to look at streamline the procedures and pathways in terms of safeguarding so it doesn’t become meaningless in terms of a process – and we need teeth that can bite in terms of protection of adults who may potentially be abused.

It’s can be a difficult balance often but it’s really important to be able to get this right and can be improved considerably.

Access to Support

I don’t expect many significant changes to the eligibility frameworks although I can’t help hoping for it. I do expect to see more entitlements to support/information/advice to those who fund their own care and are not reliant on local authority to pay some or all of the costs. I will be very glad to see this. It is an enormously complex system to navigate and everyone is entitled to help to access and understand it, regardless of income/assets.

Legislative Frameworks

We know the legislative framework is going to be ‘tidied up’ so we aren’t needing to hark back to legislation from the 40s (National Assistance Act (1948) I’m looking at YOU). I expect the new composite Adult Social Care Bill will encompass previous legislation. It will be interesting to see the specified roles around assessment/entitlements to services and how they are updated in the context of ‘self-assessments’ and ‘call centre assessments’. I hope they are.

Final Thoughts

While reading and thinking about the White Paper,. I’m going to conclude with five key points to remember.

Adult Social Care is not just about older people.

Adult Social Care is not just for ‘other people’

Adult Social Care is not just about funding possible residential care.

Anywhere ‘choice’ is mentioned I want to see how it will be extended to all, even those who may not be able to engage with decision-making processes individually.

Adult Social Care isn’t free. You don’t get it paid for if you ‘pay into the system all your life’. The funding stream doesn’t work like that. The funding stream needs to change and the governments and parties (all of them) need to bang their heads together in order to improve the quality of life for some of the citizens who rely most on the state to provide support/guidance/assistance and quality of care.

I’ve said it before but I want to work in a system which offers quality and excellence in terms of support – not the minimum amount at the minimum cost.

I’ll read the White Paper with interest and am sure I’ll be back tomorrow to comment on it.

picture by Bashed at Flickr

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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.

Bye Bye Bower

Yesterday Cynthia Bower resigned at the Chief Executive of the Care Quality Commission. I remain amazed that she was ever seen as competent to run it in the first place but it’s easy to be wise in hindsight. Her departure is no surprise as the organisation has consistently been shown to be ineffective and unable to effectively or safely keep within its remit as the regulator of health and adult social care services in England.

As the Guardian states, at the time of Bower’s appointment by the Labour Government

Andrew Lansley, the then shadow health secretary, said at the time: “We have to ask whether it is right that the person in charge of the West Midlands strategic health authority at the time, Cynthia Bower, is now to be put in charge of the national regulator which heads up these investigations and which will be responsible for ensuring that this never happens again in Mid Staffordshire or elsewhere.”

Lucy at The Small Places refers to some of the closing statements at the Mid Staffordshire Inquiry which shine a light on the actions in the CQC at the time. She quotes Dame Barbara Young’s evidence – who had resigned as CEO of the CQC and was asked why – saying

I really believed strongly that we could only do a good job if we were on the ground locally inspecting with rigour and understanding what was happening locally in health core systems and in hospitals that were delivering services. And I knew that we were finding it quite difficult to ensure that that was the case with the resource we had. And I could see further restrictions in resources on the horizon, because by then it was clear that the service was going to share in cuts. And I could also see that that was going to happen at a time when the quality of care was going to be even more at risk than usual as a result of health core cuts in services.

So you’d be a regulator in a very difficult position, with government, accountable to government, but responsible really to the public, with less resource to regulate effectively, and services being more at risk And it just felt to me that that was not a job that my skills were best suited for.

Lucy, in her excellent post, points out, quite rightly that it was the Labour Government that was responsible for establishing the CQC in its current form. This goes beyond the party political. It is about creating a system which has allowed a more rigorous inspection regime to lapse faced with cost and faced with the potential to cause a political ‘stink’ when hospitals in particular might be found to be ‘failing’.

And where now for the CQC? Bower leaving was necessary but it looks as if the problems that run through the organisation are far more endemic than a change at the top. There needs to be trust restored in an organisation which is supposed to regulate services that we all depend on wholly.

My experience is more in the social care side than health and I see the dilution of regulation has happened over the years with poorer services, fewer inspections and inspectors with more experience in auditing paper records than inspecting care homes thoroughly ‘on the ground’.

Meanwhile, Paul Burstow calls for Dignity Codes for older people – who will be responsible for ensuring these ‘codes’ that apparently he wants care workers to sign up to are upheld? and his now cancelled so-called ‘excellence’ schemes which was unravelled and ratings sites – they all seem to be attempts to cover up the need for strong regulation and inspection because that would cost more money.

So Bower’s leaving is just an admission of failure and acceptance that she should never have been in that post to start with. She has barely displaying competence in ‘leadership’ but leadership is not just about one person and while the systems remain in place, we wait to be see if there will be any really useful changes in a regulatory body which has had such a difficult birthing experience.

A Dignity Code for Older People?

Old hands

The Daily Telegraph today prints a letter which sets out the need for a ‘Dignity Code’ in Health and Social Care calling on Hospitals, Care Homes and other institutions to prevent ‘issues of abuse and neglect’.

The article accompanying the letter, the Telegraph says, will encourage care workers to have this code written into their contract.
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Burstow’s Bluster

I, like many others in the sector, no doubt, were perplexed by the headline as I read it yesterday on the Guardian website that Paul Burstow, the Minister of State for Care Services, claimed there was ‘no funding crisis in social care’.

Although I follow Burstow fairly regularly and have a good idea of his rhetoric, I thought it was worth checking to see if a quotation or ‘soundbite’ had been taken out of context.

Indeed, he concedes that there needs to be a push of money from the private sector into the care sector – I’m not sure how exactly he intends for this to happen because unlike in the health sector, there’s not much left to privatise in adult social care.
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CareAdvisor

Yesterday, it was announced that the government was going to set up a website, the details of which would be unveiled  in the Spring White Paper on Adult Social Care which could bring a kind of ‘Trip Advisor’ model of rating and commenting to providers of care homes and nursing homes.

Sounds good so far. I certainly welcome more open and accessible information for those who are choosing care homes but there are some real and obvious differences that need to be highlighted between the choices that are available to those who are picking hotels in New York City and those who are choosing care homes for Granny in Wallsend.

On a positive note, Burstow claims that these plans came from user-led discussion groups which shows that he is listening but there are some important points that have to be taken into consideration, lest this is seen as a way of trying to provide regulation on-the-cheap because the actual regulatory body – the CQC – is unable to carry out its function.
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