RiPfA and Social Work Value

Research in Practice for Adults (RiPfA) will shortly be launching a manifesto for adult social work. They were asking on Twitter for people to feedback using the #socialworkvalue hashtag to explain in 140 characters or less the value of social work.

Being verbose, I couldn’t restrict myself to 140 characters. They are kindly hosting my thoughts here.

It’s an interesting debate to be had so join in by leaving comments on that post or on Twitter by following @ripfa and/or using the #socialworkvalue tag with your thoughts.

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The Costs of Home Care

Today, the Guardian published an article about the inequitable costs of home care services throughout England and the shrinking of access to council-paid support for care in the home.

The article refers to a survey and report comprised of a number of Freedom of Information requests. It says

The survey, seen by the Guardian, shows the average charge for an hour of home care has risen by 10% in the past two years – from £12.29 to £13.61.

Also stating

…there are wide disparities in the price people pay for care depending on their location. Home care, for example, is free in Tower Hamlets but costs £21.50 an hour in Brighton and Hove.

The data show that fewer older people – in excess of 7,000 – had their care services fully paid for by a local authority in 2011 a reduction of 11% compared to 2009.

This certainly reflects my experience in practice. There are a number of concerns that result from this report which merely confirms what everyone in the sector knows.

Eligibility criteria are moving upwards.

If we look at the Fair Access to Care Services which are the supposed ‘standardised’ entry point to ‘care provision’ in local authorities – the lower ‘access’ point has moved higher. From moderate needs being ‘covered’ more local authorities are moving to only allowing ‘substantial’ or ‘critical’ needs to be covered. This moves a lot of the preventative work away from local authority provision.

This has a significant impact on the manner which personal budgets are implemented. A lot of the leisure type activities we see as examples are being pushed out in favour of budgets which are strictly intended to meet immediate personal care needs. Options for choice are much more limited in this context, particularly if a person does not have support around them.

More people refusing care on the basis of cost

This is something I’m seeing much more as my own council has increased the costs of care. More people whom I assess as needing care are refusing it or refusing discharge from hospital solely on the issue of cost of care. There may be an assumption that ‘working hard all my life’ means that social care provision will be free in the future but it’s very hard to argue the value of a personal budget at (for example) £10 per hour when the charge will be £10 per hour. It is counter-intuitive and yet by bypassing the local authority ‘processes’ there is potential support that can be lost in terms of assistance in recruitment of staff/tax related issues. We are forcing more ‘cash in hand’ work sourced via Gumtree or notes in the newsagent windows.

Longer term costs as people supported at home less

This also means that people remain at home without the support if they do not wish to pay for it and the potential for much higher costs will come at a later point. Either through preventable or delayable hospital admissions or by admission to residential care sooner than might have otherwise been necessary.  Seems obvious but I see it happening every day. We can’t ‘force’ care on anyone (putting the capacity issue aside for one moment) and if someone is adamant they don’t wish to pay for care which is assessed as being needed, we just sit on our collective hands and wait for things to deteriorate –by which case, it may be too late.

Personal budgets and the ‘personalisation’ agenda.

I’ve mentioned some of the counterintuitive ways that services can cost as much as they are charged for – that’s particularly evident if we are considering a direct payment. There’s another problem with the implementation of the systems of ‘personalisation’ as they exist in reality. We were told initially it was intended to be a shift in ‘power’ from professional to user – which is fantastic – however the reality is often far from that. Assessment forms look similar (and ask similar questions in similar formats) to DLA application forms and focus heavily on physical rather than mental health needs.

The RAS (resource allocation system) pushes these assessments through an accountancy system which is non-transparent and spits out an ‘indicative budget’ based on a number of often unknown factors. So you get more money according to lack of ability to do things which perpetuates a top down model which doesn’t build on strengths of what someone CAN do – rather what they CAN’T do.

This process is convoluted and opaque. However well explained, sometimes people want good services delivered. Choice is only choice when it’s actually offers options. Seems obvious but it isn’t the reality.

Commissioning decisions

I am sad to say when I arrange support via a managed personal budget, I can’t necessarily guarantee quality of care to the user. We use agencies that have won their tenders for the contracts with the council purely on the basis of cost rather than quality. There may be carers rushing in and out on minimum wage without being paid travel time, between 30 min visits in disparate geographical locations. Is it any wonder that people are refusing these kinds of services when we can’t guarantee consistency or quality of support. There are some fantastic care workers. Really, they are gems but it can be hit and miss because the way that costs are being driven down mean the agencies cut costs at every moment. We aren’t delivering value for money.

This shrinking of provisioned support for older adults and people with disabilities will lead to much higher long term care costs both with costs shifting to health care services as people are admitted sooner into hospitals and care costs as residential care becomes an option sooner. In some ways, more importantly, it will and does lead to a reduction in independence and quality of life which is much more important and can’t have a price put on it.

Is Adult Social Care Broken? And what can and will fix it.

FIX

Over the past few weeks, oh, who am I kidding, over the past few years, I’ve been pondering the way that adult social care is structured in this country from the position of having worked in this area over a number of years. I have seen many changes but anyone who has been involved in social care for more than a year could probably say the same. If there’s one thing that is sure about statutory social work/social care, it’s that the next reconfiguration or improvement is just around the corner.

In my renewed spirit of positivity though, I thought it would be worth reflecting personally on some of the changes I have worked through and look at some of the directions we are going with a thought to what I would do if I were in a policy-making position rather than the position of a front-line practitioner.

So I entered social work in the shadow of the changes pushed through by the NHS and Community Care Act (1990). We were moving from ‘social work’ into care management and this was going to be an improvement for those who used the services as local authorities were going to be contracting out/selling off their own centrally run and ‘inflexible’ services to new, private and voluntary sector providers who would be far more flexible about meeting the needs of individuals.

When I think back to those heady days, the ideas weren’t so different to the ways that the personalisation agenda was presented. Direct Payments were just about to start but the idea was that care would be planned by a care manager to put the service user at the heart of the process and more interesting, more exciting and more specialist services would be commissioned for the same ‘pot of money’.

We were also sold talk of community involvement rather than segregration – gyms instead of day centres –  but the day centres remained and the processes weren’t flexible enough to allow the choices that should have been there.

So Direct Payments were introduced, first as an option and then as a right. They led from the ILF (Independent Living Fund) model of giving mostly younger adults (because you had to be under 65 to qualify for ILF) with physical disabilities a pot of money and a choice of employing a PA directly.

Quite rightly, this model was seen as positive and there were attempts to spread this more widely to all user groups. The take up was much higher in some user groups than others, strangely (I’m being ironic – bear with me) related to access to greater ‘pots’ of money or more informal support.

There has also been a massive push and development of carer services. It might not seem it to those who devote themselves to caring for family members or friends but there are now statutory rights to assessments and increasingly service provisions directly for carers.

And so we moved through to the Putting People First agenda of pushing the right to a personal budget for care services to everyone who uses and is eligible to support.

It is the right direction absolutely. Increasingly choice and control for social care packages is and must remain at the heart of social care provision for adults in the UK but there are genuine practical problems.

Firstly that too often councils have just shifted people who have been more difficult to engage in the process of choosing in the way the LAs want them to choose onto ‘managed’ budgets where the LA implements the care for the user and essentially makes the choices for them leaving very little different.

Secondly, the provision of 24 hour residential and nursing care has been lost in the push towards choice. It feels a lot like an poorly regulated afterthought when actually provision of residential and nursing care can be the most important decision in someone’s life and affects life quality absolutely.

Thirdly and by no means lastly, funding issues.

There is not enough money to pay for good quality care services for all who need it so the decisions are made about who will pay and how they will pay. The Dilnot report offers some potential solutions, personally, I don’t think it goes far enough.

The fact is that people don’t want to pay for care. They don’t want to pay for care related to health needs. People believe it is a right to receive care free. But that isn’t the case. Care costs and it is means-tested.

The postcode lottery comes into its own here with charging policies varying massively. On the ‘ground level’ I know people I assess and review are increasingly refusing care I feel they desperately need purely on the basis of cost. This shifts costs from self and social care onto health in the future, but at least health costs are free to the individual.

The Future

Personal budgets are not going anywhere and must be embraced and embraced positively as they are supposed to be. We must look past some of the cynical ‘target fixing’ of the local authorities who want to prove they are doing better on ‘choice’ and really adopt a strong advocacy role in using them the way they were intended to do and keep pushing and pushing until they deliver the promised change in terms of outcomes for all users of adult social care rather than relying on a few old examples. They must work but they also must work better.

Charging policies must change and this is in the offing. While I don’t agree 100% with the Dilnot recommendations, it is better than what we have. We need transparent and equitable methods to fund social care that don’t regard the sector as an afterthought.

Promotion of advocacy to all user groups who don’t have informal networks and particularly to those who may have issues with capacity is essential to back up and check on progress of professionals and local authorities who have different budgetary agendas. We have to offer support to challenge on an equitable basis.

Our systems have to be more flexible, as professionals within local authorities we have to have access to different styles of commissioning that include micro-providers. We have to have access to different communication formats and promote more interactive feedback using more technology to those who find it more useful while backing up with face to face contact, discussion and feedback for those who don’t.

Our world is becoming more fragmented as we have more access to information sources and accept that people cannot be defined merely by needs identified in traditional style assessments. We have self assessments now but they are more similar to DLA forms based on ability to wash and dress rather than building holistic pictures of who and what someone is. That is what is needed. Yes, it will be labour intensive but we need to find more value in quality and more value in the individual.

Where will be money come from to do this and to make these changes? Well, I think that better quality and treating people as human beings has so many longer term benefits regarding outcomes that it will be a saving and not   just in value but in quality of life.

Is the system broken? In parts. But the people who work in the system aren’t and nor are the people who use and need it. We need to build it back up together. Co-production has to be the answer.

These are exciting times for adult social care – lets build a positive from too many negatives and make things better.

Photo by Amanky/Flickr