Eligibility Criteria – Thoughts on Draft Guidelines #swjcchat Thurs 1 August 8pm

28 07 2013

The document to discuss this week on 1/8/13 is the Draft National Minimum Eligibility Threshold for Adults.  While the government isn’t necessarily known for creating snappy titles for policy documents, eligibility criteria for access to Adult Social Care are at the heart of services and how they are and will be provided so the fundamental importance of this consultation can’t be underestimated – to those who use and work in adult social care.

Eligibility Criteria – a background

Fair Access to Care Services (FACS) were introduced in 2003 as a way of trying to ‘standardise’ and clarify decisions across local authorities in England and Wales when decisions were made as to who would receive social care services. There are four ‘bands’ of services and there are descriptions of what each ‘level’ consists of. The bands are ‘low’, ‘moderate’, ‘substantial’, ‘critical’.

Gradually as money has been squeezed, there has been a tendency for the band which is provisioned by local authorities has edged higher.  There’s a useful introduction to FACS here (PDF) which explains the system as it currently is succinctly.

Why Draft New Thresholds?

There has been much criticism of FACS and that will be an issue we can explore more as a part of the chat – why has FACS failed? I  have a lot of ideas myself. Part of the issue the government has identified to be ‘solved’ in the new Care and Support Bill is the ‘postcode lottery’ issue. Each local authority can which criteria it will provide support for. This has been seen as unsatisfactory as people in neighbouring authorities can be entitled to vastly different levels of service.

So we are looking at new national thresholds which will not be reliant on the judgement of local authorities. The idea is that this will create more clarity about who can and can’t receive services funded by local authorities. This is a crucial draft document which will have enormous repercussions.

Where will be national eligibility criteria sit?

The first chapter of the document explains the need for change. The document dwells on the inequity and lack of clarity about people knowing what they may be entitled to in terms of care services and how different this can be in different local authorities. The paper explains that from April 2015, the government is committed to introduce national eligibility criteria at least as a minimum (LAs will be free to provide more than the national minimum if they wish/are able to afford to). The ‘postcode lottery’ will not disappear.  There is a thinking that the national minimum threshold will be at the ‘substantial’ level which is currently pretty much where most local authorities have their threshold at the moment. The immediate difference might, then, be very little. But there have been difficulties in definitions through the lifespan of FACS. ‘Substantial’ to me could be interpreted differently to ‘substantial’ by another social worker in the same team as me. This is where some of the difficulties lie.

What will the new Care and Support system look like?

There’s an interesting part of the paper which pushes to how the ‘new’ support system will work and uses the lovely government language of adjusting the way that they envisage this system will be delivered. ‘Assessments’? They won’t be primarily used to gatekeep to services (or not) but will be used to ‘supporting people to identify needs’ and look at where support will come from. Well, to be honest, I don’t see how this is different from what happens now – except the language but perhaps that’s the key.

The govt do envisage people accessing assessments from local authorities ‘earlier’ when they have lower needs so that support which might take place outside that which is funded can be provided earlier. The difficulty is that there has to be support available to be signposted to and if people are not assisted with funding for low level needs, those who are able to self-fund will have an obvious advantage. Mind, money, in itself, creates advantages which may or may not be fair (not but I’m a bit of a closet socialist at times!).

What will an assessment look like?

I was interested that the paper looks at what an ‘assessment’ is and emphasises that it should not be deficit-led. This will be a real change if it is what happens but I have doubt and the reason for my doubt is that it is not the way that systems have and are built. If I look at my experiences in mental health social work over the last few years, we have been increasingly moving away from ‘needs-led’ ‘strengths-based’ models of assessment and running towards ‘deficit models’. Clustering means we are being asked to look at the greater impairments people have and not at their strength. That is what the system asks us to do. I wonder if the people writing this draft guidance are actually aware of that the move has been far and away from the strengths-based models that they claim to embrace. This is an example of the Department of Health not having a clue what is actually happening in social work currently.

The paper also looks at the need to work across health and social care for assessments. Again, I sniggered. Seriously. Do the people writing the document know what work we did with the Single Assessment Framework – trying to simplify assessments across health and social care so they could be jointly undertaken – and do they know or have they properly evaluated what happened there and why it didn’t work?

It’s easy to make broad statements of ‘assessments will take place across health and social care’ but there needs to be an understanding of all the times this has been attempted in the past and what the barriers have been because those barriers (mostly about different pots of funding) have not been removed.

Draft Regulations

The govt have presented some draft regulations to be used. They are in the paper and I won’t go into them in detail but the paper asked a few questions specifically about these draft regulations. They want feedback and I think it’s something we could have quite a focussed discussion on. The question the paper asks are

Whether the draft regulations have any holes in terms of groups who may not be covered by them?

Nothing sprang out at me specifically but thats something that might need someone with a more detailed knowledge of Community Care Law than me to establish.

Are the regulations equivalent to current ‘substantial’ threshold?

This made me chuckle because ‘substantial’ is so hard to define. The draft regulations are sufficiently woolly and unclear to ensure that interpretation will continue to be the key. That’s no shock really.

What are the practical implications for implementing the regulations?

Here the government ask about how easy they will be to implement and what statutory guidance should be included. The definitions within the regulations are vague enough to be useless but what would be better? I am going to have a ponder about whether better regulations could be written by people who actually use, know and understand the system. I’m interested that the government talk about  having focus groups with users, carers and local authorities? I’d ask how they choose the people who sit on these focus groups. I hope there are people who have cognitive impairments included and social workers who work in the teams that implement these criteria and that the representations from ‘local authorities’ are not simply at the management level (which is what I fear!).

What’s the impact of the Draft Regulations

The paper presents rough cost estimates for implementing the new draft regulations. There is a rough costs between £18-25million given. I wonder how much of this will come from central government – and these costs don’t include additional services provided to carers which increase those potential costs exponentially.

Where now?

In the discussion on Thursday I’d like to look at the following questions (and please do feel free to add your own)

Have FACS failed?

What would be the implications of new national criteria?

Is the government plan to move from defining needs to identifying support realistic?

Experiences/examples from practice?

New regulations – are they clear enough?

will they make a difference to anyone?

Can they be improved?

Is ‘substantial’ the only realistic place to draw the line?

How do you define ‘substantial’ – do these regulations make it clearer?

Anything else!

I hope at the end of the discussion we’ll have enough to submit a response to the consultation which I’ll post here if I can work out how to do that!

So join me on Thursday 1 August at 8pm to discuss the draft document about adult eligibility criteria – I know there’s no better way to spend an August evening!





Draft National Minimum Eligibility Threshold for Adult Care and Support – #swjcchat 1/8/13 8pm

20 07 2013

 

Thanks to all who joined on 18th July for the inaugural outing of the Social Work Journal Chat. I appreciate the support. I haven’t yet collated the tweets into a post but will try to over the weekend.

 

In the meantime, I had a suggestion for the next chat in two weeks time – which has the nice, snappy title of the Draft National Minimum Eligibility Threshold for Adult Care and Support (PDF) – while it isn’t a ‘journal article’ as such – it’s a policy paper that will be of use and interest to all who receive or work in adult social care services so I hope it will be useful and maybe prompt some of us who participate into collating a response.

 

Next week, I’ll write up a summary and some thoughts/questions in advance of the chat!





Personalisation Falls Short – Summary and pre-discussion thoughts (18/7/13 8pm)

18 07 2013

Before the inaugural ‘Social Work Journal Club Chat’ tonight at 8pm (BST), I’m going to run through a summary/my thoughts of the article chosen completely undemocratically by me.

Anyone who wants to suggest an open access social work/social care related article for the next chat on 1/8/13, I’d really welcome it in the comments.

Thanks

 

Personalisation Falls Short – Paul Spicker

The article starts by explaining that ‘market forces’ are increasingly ubiquitous in all aspects of our lives but there are some areas which are recognised as needing some ‘assistance’ in order for a true ‘market’ to grow.  In social care the market seamless. Some people enter social care ‘market’ through coercion (examples given are people who might be offenders) and some have less capacity to make choices about the kinds of support which they receive (people with dementia for example).  So while the ‘market’ for social care provision is not free – there are elements that could be replicated and adapted to allow for greater choice than would otherwise be the case.

Interesting that Spicker says

‘Personalised’ services, in the sense of responsive, individualised treatment, are supposed to extend to the needs of elderly people, psychiatric patients, learning disability, people with addiction, offenders, school pupils, homeless people and the unemployed’

Moving away from some of my discomfort at his differential labelling (psychiatric patients yet people with addiction and no further explanation of addictions to what – elderly people rather than older people – but maybe I’m too sensitive about this!).

I’m curious by his use of ‘supposed’ to. It, to me, gives me a glimmer of hope of a realistic appraisal of where we are now as ‘supposed’ has a lot to do with the chasm between policy and practice.

Spicker offers us definitions of ‘personalisation’ which will be a useful starting point for a further discussion of the article itself.

These definitions are

1. Personalisation as a needs-led rather than a service-led provision (professional assessment and decisions about what is ‘needed’ though)

2 Personalisation as meeting wishes rather than assessed needs of users. (choice as an alternative to ‘assessment’)

3. Personalisation where professionals facilitate and inform user choice (hybrid between 1 and 2)

First thing to consider is whether these models ‘work’ in the context of the work we do/PBs we receive?

And what IS the role of the professional? Is there a role for a professional to ‘assess’ and how does this reconcile with duties or discharge of duties under NHS and Community Care Act (1990).?

 

Spicker then looks at whether ‘personalisation’ has over-promised. Personalisation should offer people who use services a ‘stake’ in the system that they are buying into and this is the change in attitude in services as being ‘given’. Co-production is the goal to move towards and it is a key stepping stone on the way.

Fundamentally, person-centred approach (which is the heart of personalisation) should lead to better outcomes for individuals as these outcomes are based on what is highlighted by the individual as being important to them.

 

Spicker quotes a govt document (Changing Lives Service Development Group 2008) saying ‘Personalisation is about prevention, maintenance or intensive support – whatever is needed’ which is a very broad brush statement.

So is personalisation preventative? We have to look at the funding streams and FACS  and my response would be ‘unlikely’ but maybe that’s too harsh. Spicker claims that there is no reason prevention would feature more highly necessarily in a preventative agenda than in a professional-led service – which isn’t to say choice shouldn’t happen/isn’t better but that it doesn’t necessarily tackle this issue more robustly.

Then there is the issue that services delivered through personalisation can be more flexible and change more easily. Here the key difficulty, Spicker relates, is the link, in some services between accommodation and service provision, for example in supported living or residential care.

Then there is the hope that personalised services will be better ‘linked’ but while this is a hope, personalisation doesn’t inherently guarantee it.

 

FOR

Spicker moves to argue in favour of personalisation and it’s benefits.

It should be more effective, theoretically, and tailor services to individuals and put choice at the heart of the provision of services. There are different models of emphasis between professional and user but at its heart it is about shifting power and allowing more personal input and preference in delivery

Then, he says, personalisation can be more cost-effective. This is controversial. A lot of cuts came in through the personalisation agenda but in theory, the same outcomes could be achieved with less money and preferred results. I would dispute this but perhaps, its an area that can be discussed.

It can be more efficient. Assessments of need can be costly and take time. By taking into account individual needs/preferences – more dynamic choices can be made about where services can be directly. This is controversial in terms of cynical decisions about where money can best be spent.

People manage their own budgets better than the State does. Spicker comments that some of the criticism of ‘state-imposed’ systems of care as ‘one size fits all’ has been unfair in the models of care management which were more flexible and he refers to some of the services which have been provided as a ‘group’ – like day centre provision/respite provision and meals on wheels – which did limit choice but reduced costs. There may be some situations where personalised and individualised is not always the ‘answer’.

 

Markets

Spicker looks at the marketisation of social care from the roots in the Griffiths report in 1988 which looked towards the market to provide ‘answers’ however possibly the systems which grew through the 1990 NHS and Community Care Act possibly became less responsive to individuals.

Spicker challenges the ‘In Control’ claim to have ‘pioneered’ personal budgets in 2003 but by looking back at the ideas which had been in operation since the 1970s – the Family Fund and later ILF (Individual Living Fund) which pre-date direct payments.

Individual budgets, then, move in the direction of the market but it’s a wave of movement which has been happening for decades. Spicker refers to the fluidity of the market and some of the challenges that pushing social care into the market have presented. You can give someone a budget, all you like, but there have to be things – and reasonable, decent, affordable things – to spend that budget on.

The market has to deliver a range of viable options on the supply-side while on the demand-side people have to be able to decide on alternate provisions. This is not always the case and the ‘market’ is very much stunted.  This doesn’t mean some choice is better than no choice – there’s no doubt it is and can be.

Spicker notes that the principle of personalisation depends on making it possible to match provision to need.  Who makes this choice may differ from professional to user (or may not in respect to LA controlled ‘personal budgets) but there need to be a variety of options to choose from in order for that provision to be ‘person-centred’.  As he says

“There has to be enough excess provision for a choice to be possible. That rarely happens”

There is always going to have to be compromise to the ideal in terms of supply. Spicker uses the example of accommodation where there are always constraints in terms of provision.

He says

“if the problems are problems of scarcity, lack of resource and lack of choice, it is difficult to see what there is in the process of personalisation that could overcome them”

He refers to the difficulties of taking professionals wholly out of the process of choice which may mean (not necessarily and this may be an interesting point to debate) people may have less information about the options available to them.

He is very clear that “The process of personalisation was intended, at least in part, to save money and there are certainly indications that the desire to make savings has driven reforms” I think that is undeniable for anyone who has working in or has experience of using social care services.

 

Evaluations of personalised services.

Direct payments were opened up in 1997 and Spicker refers to guidance at the time

“A local authority should not make direct payments unless they are as cost-effective as the services they would otherwise arrange”

So DP (direct payments) reduced average costs.  The Audit commission confirmed in 2006 report that more effective services could be delivered at a lower cost.

Spicker raises some of the difficulties with evaluations to date and I recognise some of his criticisms

“Arksey and Kemp (2008) point to some of the difficulties of evaluation: studies do not compare alternative approaches, agencies select clients who are most likely to benefit.. “

“Pilots are often undertaken by committed professionals who are active innovators. Positive results are liable to be generated not by the character of the programme so much as the energy and enthusiasm that go into them”

This has been very much my concern so I’m glad to see it raised. A lot of effort has gone in to telling us what we know works. Spicker notes “We are liable to be offered uncritical evangelism and case studies of enthusiastic professionals doing a wonderful job – some of them difficult to relate to personalisation at all” so where does the evaluation leave us.

There is little evidence of cost-effectiveness  although it differs between user groups – particulatrly positive in mental health service users for example but is cost-effectiveness the main measure? It depends what we are looking for.

Spicker says, unsurprisingly but less helpfully for those of us looking for answers for a system which has been embedded for many years now

“It (personalisation) seems to work in some circumstances and not in others. The benefits are mixed, and contingent on application of the principles in context’ Thanks. That’s helpful”

Spicker concludes that the Dept of Health is claiming ‘personalisation’ is something new but it has its roots firmly in the processes started in the Griffiths Report.   While it is supposed to match services to needs there is little entirely unequivocal evidence of that.

He says in conclusion

“Neither the theory nor the practice offers adequate justification for developing a programme of personalisation for all groups, all of the time”

Personalisation doesn’t ‘fail’ – but it isn’t necessarily universally appropriate and there is a danger that over-reliance on a model which doesn’t match all user groups may discriminate against some  groups.

Spicker concludes that personalisation isn’t a failure but it does ‘fall short’ significantly and the model requires more critical examination.

 

So where now?

There’s the paper to discuss. Do read it and join me – I think there’s a lot to discuss about the evidence that Spicker looks at?  What the relevance is of the groups where it fails and where it succeeds and whether the market can provide an answer?

I hope users of direct payments and individual budgets will join us as the experts in this field as well but of course, anyone and everyone is welcome!

There’s a lot there and I think we can come up with a solution to government policy gaps between us – on Twitter – I’m nothing if not hopeful!

 

See you tonight at 8pm @swjcchat and hashtag #swjcchat

 

And I hope to publish a summary afterwards here – unless it is just me talking to myself!





The Cavendish Review

10 07 2013

Today the Department of Health have published the “Cavendish Review” [pdf] which was an exploration into the role and focus of Healthcare Assistants and Social Care Workers in NHS and social care settings.

Reading through it, I thought it might be useful to summarise the main points and see where the direction of travel may be heading. Firstly I should say that I was always in favour of regulation of social care workers (I had less involvement and knowledge of Health which is why I exclude it here). My understanding was the role of the GSCC (General Social Care Council) was to register beyond social work professionals but it ran out of money/political will. In my opinion that was always a gap – so that’s the direction I’m proverbially shooting from on this.

There are some interesting points to come from the review and I think it’s worth looking at in more detail than the headlines and quick newspaper articles allow. I hope the government give it time to breathe.

The preamble recognises the disparate sectors of ‘health’ and ‘social care’ with social care being forgotten amid the more high profile hospitals. Again, I have to claim some bias because I was a support worker before I was a social worker and I have worked fairly consistently in social care for most of my working life – with an off-shoot into the health service in latter years. Social care though, is where my heart is and it’s certainly the area I know best.

Cavendish makes the key point, that really doesn’t need anyone to make and the sadness is that years into the so-called ‘integration’ agenda, people still aren’t getting it.

“I have been struck by how disconnected the systems are which care for the public. The NHS operates in silos, and social care is seen as a distant land occupied by a different tribe. Yet when Mrs Jones leaves hospital for a care home, or to recuperate in her own house, she is still the same person. She wants to be treated as the same person, and to be looked after by staff with the same core knowledge and core values”

METHODOLOGY

Cavendish conducted her review by arranging focus groups of healthcare assistants, social care workers (residential care and domiciliary care), nurses and social care managers, she went to meet people working in hospitals and care homes, conducted an online survey and conducted some seminars/webinars.  The language she uses is healthcare assistant to refer to those working in health settings and support worker to refer to those in social care settings as a shorthand.

THE FRONTLINE OF CARE

Interesting word, ‘frontline’. Social workers use it. Personally I think it’s not the best word to use to describe people who work closest with those who use services. ‘Frontline’ implies a ‘battle’ or a ‘challenge’ when actually working with people who need the services we provide is a privilege and not about drawing lines or setting out ‘battle scars’ as a sign of honour. Here, though, ‘frontline’ refers to those who deliver health and social care directly. None of the ‘sitting in offices’ that social workers do. I think as a profession we need to regroup what we describe as ‘frontline’ but that’s probably a discussion for another place – back to the review..

Cavendish presents some interesting if unsurprising statistics about the predominance of women in this field (84%) and the low wages (average £13k in social care/£14-17 (band 2) in healthcare).

She presents some of the background to HCA (Health Care Assistants) and their roles in hospitals and tries to break down some of the tasks that are asked of them.  Nurses spend time on care planning, liaison and discharge while HCAs have a stronger role in building up relationships with patients.  She refers to a recent study which found

HCAs spent the majority of their time on a typical early shift carrying out direct and indirect care, whereas nurses spent the largest proportion of their time on organisational tasks such as answering the phone and handovers

Some HCAs are carrying out more complex tasks that would previously have been reserved for nurses and there is some inconsistency between Trusts – and wards – about what tasks are being done by HCAs and there is an increasing blurring of roles.  Interestingly but unsurprisingly she notes a shift of people moving from social care into health care assistant roles, possibly because pay and terms and conditions in the NHS are better than in private social care settings.

Turning to social care she makes a vital point, and one that I’ve made often and consistently

The paradox is that some of the lowest paid care workers are those who we expect to work the most independently, walking into the homes of strangers, and having to tackle what they find there, without any direct supervision. This requires a high level of maturity and resilience. Calling this “basic” care does not reflect the fact that getting it right is a deeply skilled task.

While I try not to despair at the low status of social care work, it is good that it is recognised more broadly what enormous skill is needed to do it well. The average wage in social care support work is £6.72ph. That’s ‘frontline’. Not sitting in an office writing care plans.

While status is low, the tasks demanded can be incredibly complex.

VOICE OF THE FRONTLINE

The information from this chapter of the report comes mostly from the feedback and focus groups which inputted into the review as a whole.  Cavendish reports the passion people speaking to her expressed about wanting to help and make a difference to the people they worked with and, she mentions, noone had a negative word to say about the people they provide care for – which is more than I can say for some so-called ‘professionals’ I’ve worked alongside but that’s a different matter.

In both health and social care – they feel that some of the work they do is encroaching into the ‘professional’ (far more highly paid) jobs of social worker or nurse, respectively.

Paperwork was seen as a barrier to providing care and particularly in social care settings, so was staffing levels themselves.

Many raised concerns about the level and quality of training provided to them and the lack of career progression. Personally, (and this is because it was my personal career progression so I admit bias), I’d like to see more steps being taken to allow social care workers to move into social work, if they want to, rather than focusing on ‘elites’ out of school and parachuting them into social work jobs. Another argument for another day, perhaps.

Some people felt they were unsupported by management and some that they were asked to do tasks they didn’t feel they were capable of. I think it’s something for management to reflect on but hopefully the report will provide a spur to those who want to be good employers.

THE VOICE OF USERS

I’m glad this had a discrete section as after all, it is the entire reason that health and social care exists.

Some interesting different themes are set out between health and social care here with the impression given that in some ways, health can learn from social care in terms of communication skills, dementia care and end-of-life care. Interesting with the focus on dementia nursing that skills in social care are sometimes forgotten.

Patients said they weren’t always sure what the role of healthcare assistants was and who was responsible for which part of their care, maybe making healthcare assistants more immediately recognisable as different from nurses.

There was widespread general support for the need for better training for health and social care workers and better support from management structures.  A key factor being

an environment where staff are supported and their emotional well-being is considered once they are in post is also vital in sustaining a workforce that is able to cope in times of stress.

My personal opinion is that an organisation that values it’s staff and it’s staff’s values will embed them when the same staff are delivering care. It’s not rocket science  but it needs empathy from the top down and from the bottom up.

RECRUITMENT, TRAINING AND EDUCATION

There is currently no minimum educational requirements to work as a HCA or Support Worker. Sometimes numeracy and literacy aren’t tested. There was a wide variety in the quality of training from people being given DVDs to watch at home to support workers being asked to pay for their own training. Skills for Care introduced Common Induction Standards in Social Care but these are not mandatory. Not having qualifications or educational levels doesn’t mean someone doesn’t and can’t work well but it is about facilitating someone to learn and understand about their role, their need to reflect on the actions they are taking and how they affect others and the need to allow people to develop to their strengths and support them in doing so.

Qualifications shouldn’t and can’t ‘tick a box’ because it’s about the quality of the training and the effect that the training has on the quality of care provided. That’s the key.

Sometimes training isn’t transferable from one organisation to another, sometimes it actually doesn’t have any value apart from the organisation being able to tick a box saying they have ‘trained staff’.

And sometimes ‘care’ doesn’t feel like it has a progressive career structure – unlike other professions – which may add to the low status.

The review suggests there is a more ambitious programme of training for HCAs and Support Workers, a ‘certificate in fundamental care’.

This would be published by Skills for Health and Skills for Care and would be based on National Occupational Standards.

There is a suggestion that a part of this should be common training to nursing students and HCAs to study together (which I think is an excellent idea – we need more togetherness not professional silos).  This would be the first step, with a follow up Higher Certificate of Fundamental Care attainable and there would need to be robust quality assurance of the training programmes across health and social care sectors.

MAKING CARING A CAREER

The point is made about the lack of career progression

While not many HCAs or support workers will go into nursing, therapy or social work, it is vital that the opportunity exists

As a support worker who went into social work, it’s something I feel very strongly about. I think it was a fantastic route into the profession and one reason I worry about the schemes now being devised to siphon off the ‘top quality graduates’ to go straight into social work. Nothing taught me better than having had the experience of hands-on care work. But I digress..

The report states categorically

HCAs and support workers in social care must have a clear line of sight from the most junior rungs of their careers through to jobs in nursing, social work, physiotherapy or occupational therapy, if they want to. It is vital that the move to all-degree nursing does not cut off opportunity. The Review recommends that bridging programmes proposed by the Institute of Vocational Learning should be commissioned.

I hope this is embraced by those tasked with changing social work education. Again. We don’t need to be blinded by elitism. We need good social workers. It’s not an either/or necessarily but we can’t exclude one group in favour of other groups we claim we want to see as ‘leaders’.

GETTING THE BEST OUT OF PEOPLE: SUPERVISION, LEADERSHIP AND SUPPORT

Rightly the point is raised that it isn’t enough to train people. There has to be a context in which to support people on the day to day basis.

The important point made is this

In the airline safety industry, human factors studies show that the most junior staff can be the most important links in the safety chain56. HCAs and support workers are the backbone of many parts of health and social care. So the question of how best to manage and support them, to make them the best they can possibly be, is paramount.

Let’s think about that and how we value people who do the most direct patient/user work. I have come across some very unpleasant and frankly, patronising/snobby attitudes to care workers. Of course the people talking to me now in those ways, don’t really get the fact that I used to do that job myself so am never going to collude but I fear there is a perception of low paid work as being low skilled when it’s anything but.

The review looks at the importance of team building and supportive teams existing across ‘hierarchies’. A clinical team includes health care assistants as equals not as juniors as all have important roles to play.

There is an important pivot role of the ‘frontline manager’ addressed here and how crucial they are to people’s experiences of work and support at work. The review is very clear in this recommendation – which I like and can be transferred equally into equivalent social care settings

: Trusts should empower Directors of Nursing to take greater Board level
responsibility for the recruitment, training and management of HCAs, from day one

There is a role for mentoring within organisations and for accountability to be directed at the top of organisations if they don’t nurture the culture which allows care to thrive. Good, I say.

TIME TO CARE

Interesting point about whether 12+ hour shifts are ‘conductive to compassionate care’. I think there are a few organisations that will need to think long and hard about that and what it might mean in terms of potential costs. There’s no avoiding that ‘lack of time’ is a barrier to quality care. We can think about the home care workers who are shunted between visits with barely time to catch their breath. Again, treating staff compassionately feels into better treatment for those who use the services provided.

And here the point is made

Care is increasingly being bought “by the minute”. Figure 9 shows 15 minute visits are commissioned, with the average visit lasting 30 minutes. Not surprisingly, service users report services being rushed, or lacking compassion, dignity care and respect, and little continuity of care. Elderly people with dementia are particularly upset by seeing so many different faces; and very high attrition rates place a real cost burden on employers

Everyone knows this is wrong, it’s easy to say but hard to change as LAs have been squeezed of money. We need to push responsibility back to the govt as well as the commissioners who think this is an acceptable way to provide tickbox care. Of course the effect on the user is horrific but I would wager that it’s also a pretty horrific effect on members of staff and it embeds a lack of compassion in care.

But changing that costs money. There’s a rub.

The review looks at commissioning by outcomes but this has only happened in very small NHS based pilots and has leant heavily on direct payments. We need these models to be extended to people in social care funded settings and people who may not be able to manage direct payments. But it’s a start.

The review also raises the utter immorality of care agencies not paying workers for travel time and some excessively long shifts which all have an effect on quality of work and the feeling of being valued as a member of staff. The thing is though, time costs. Are we willing to pay for it through our taxes? I know I am (although I don’t trust the govt not to spend any increased tax receipts on cutting billionaires capital gains tax).

CONCLUSION

I’ve summed up each part of the report so I won’t dwell on the conclusion. It’s an easier digestable and useful read that is necessary to challenge some perceptions of health care assistants and support workers and I’m very glad to see it.  I would wholeheartedly urge people to read through it and reflect on that way we value some of the most critical work done in the health and social care sector.





Right care, Right place, Right time – How can we improve care for vulnerable older people – a consultation

9 07 2013

As well as articles specifically to discuss, I thought it would be useful to use this space to bring in policy and consultation documents as well as journal articles which we come across which might be useful to others.

The Department of Health launched a consultation last week on ‘improving health and care for vulnerable older people’.

I’m not enamoured generally with the Dept of Health and their knowledge and understanding of social care and the feeling I get from looking at the initial consultation is that there is a lot of confusion about what exactly ‘care’ means. This is a ‘health’ consultation that doesn’t seem to have a consideration of social care or its place in the lives of ‘vulnerable older people’ but if we are, or have been, involved in or used social care, it’s important that we do contribute. Not only for ourselves but for those we have worked with who may not be able to contribute directly. The Department seem undecided on whether ‘care’ includes a broader understanding of the team but I’m going to share my consultation response in the hope it urges more people to contribute.

There are six ‘domains’ to the consultation and they seem to focus on primary care. Coming from a position of working with rather than working in health services, gives a particular perspective on how things can, should and most importantly, do work – to focus on how they can work better.

STAYING HEALTHY FOR LONGER

 

How can we strengthen the incentives or increase the flexibility for GPs to effectively manage the health of the local population?

Of course the language is one of ‘incentive’ which makes me cringe. But I accept that I don’t have a lot of experience in the health service and none at all in primary medical care. The world is oiled on incentives, apparently. Flexibility and capacity though is an issue I have come across working with a lot of GPs in the community, particularly with older people. I’ve worked with some fantastic GPs and some – less so. My concern is around GPs attached to care homes – and again, this is by no means a universal impression – but certainly there have been some who have shown a lack of care to those in the area. I’d like to see much better, embedded connections between health and social care for a start, including a stronger understanding of the way these links between community and residential care are managed.

In your experience, how can people be better supported to manage their own care?

Speaking as, very much, a layman, I’m a great fan of more information and peer support groups. Generally, there is no reason ‘vulnerable’ (I don’t like that word because it is so vague and lacks any purposeful definition) older people are any different from any other group in terms of extending self-understanding, knowledge and management of their conditions. The issues though that remain are, perhaps, increased lack of mobility.

Better uses of technologies can help people to link with others. I don’t want to see this dismissed because people are ‘old’ or ‘vulnerable’. That’s a whitewash because the potential cost could be high but if people can’t come to peer support groups, they can be linked through forums and voice conferencing. There are also more mobile tools for self-management available. We can’t assume that everyone has a carer. Again, rather dull, but I refer back to using the communities around people too – if they are involved in lunch clubs or day centres (dying out now) the tools and groups should base there. If they have formal care going in to them, use those people to share information and give information, same with district nurses. People generally want to be better.

Can you share any best practice examples of how to strengthen prevention and early diagnosis in primary and community services?

I’m going to pass on this for the moment  but I hope people take the opportunity to present back where things work although it’s important that those within the govt take account of what hasn’t worked too.

 

NAMED CLINICIAN: PROVIDING A SINGLE, NAMED CONTACT TO COORDINATE AN INDIVIDUAL’S CARE

I wonder if anyone finds it as odd as I do that Hunt has announced this as a policy aim even as its out to consultation. To me, that typifies ‘consultation’ in the NHS sense of the word. Let us tell you what we are doing. You can tell us what you think. If you like. But it won’t make a blind bit of difference. We are doing what we want anyway.

Enough of my cynicism and on to this ‘idea’.

How do you identify vulnerable older people or people most at risk in your local area?

This is a question based firmly at primary care clinicians so it seems a bit foolhardy to respond genuinely and with seriousness because I don’t actually think the DH wants my opinion but I’m going to go with it anyway. Firstly I wonder what on earth they mean by ‘vulnerable’ older people. When does an older person become ‘vulnerable’. Certainly in London, in terms of safeguarding, we have moved away from use of the word ‘vulnerable’ in consultation with service users who did not like it. However this is a different use and shows the difficulty of a Dept that doesn’t know it’s own language or definitions. Equally ‘people at risk’ doesn’t define what ‘people’ are at risk of. People at risk of deteriorating health? People at risk of being ignored by society? I’d like some better definitions to understand exactly what is being asked for.

In terms of my experiences in social care and mental health we were alerted through a number of sources, sometimes GPs, sometimes hospitals, sometimes self-referrals, friends, families, neighbours. Sometimes we’d be alerted by the police or the ambulance service. How did this information move? In the Mental Health team, as a secondary health services,  all information would be channelled through GPs. This didn’t happen as a matter of necessity in adult services. Should it? I’m not sure. What I am sure of is sharing information is better than not. Maybe we can go back to the idea of having GPs and Social Work collocated. I think there has to be a link between health and social care but with social care being ripped apart, this probably isn’t the ‘answer’ the government want.

 

Who do you feel is best placed to perform the role of named accountable clinician in primary care setting?

 

This is a bit of a leading question in my opinion as it’s assuming that this is a good idea and the focus is on the primary care setting which immediately moves us into the territory of health rather than any hope of looking at joined up health and social care coordination. I’m biased because I’ve been a care coordinator and had to work with trying to build links across health and social care and in my opinion it isn’t something that can be just tacked on. I do though, think social work is specifically well-placed to be a link between sectors however in the question asking for a ‘clinician’ (and social workers not being clinicians), it seems my answer isn’t one that the Dept of Health want – which is a shame. I am curious how this role differs from the GP role? What will this ‘named clinician’ actually do? Will they ACTUALLY coordinate between primary/secondary/social care because if they will, I think the lead needs to come from social care. If they are there just to coordinate between primary and secondary care, I have to ask, isn’t that just what GPs do now?  Then, I haven’t even mentioned community matrons. Weren’t they supposed to have a role in this? This question makes me angry by the amount of ignorance it displays of what actually happens now and the way it ignores the skills and role of social care in providing a cohesive connection with medical care. Surely this is an opportunity for more ‘integration’ if I believe (ha ha ha) what noises Lamb makes about more integration. Surely this is an opportunity for that. But no, the question asks for ‘clinician’. Hunt doesn’t remember that social care is a responsibility of his as its less interesting and needs more money but giving people lots of ‘lead people’ responsible for them – one ‘named community clinician’, one social worker, one community matron, one occupational therapist, one or two outpatient consultant – and yes, one person could ‘coordinate’ all that – but if we ignore the social care aspect then we don’t really make things less complicated.

 

Named clinician: Providing a single, named contact to coordinate an individual’s care

Aha. This is the crux. It’s a question that isn’t even a question. It’s a statement. So what is the Dept asking us for? To tell them it’s a good idea. Here’s what I’d tell the Dept. LOOK AT WHAT HAS ALREADY HAPPENED!!! Look at the Community Matron model. Look at the social care-led care coordination and management role. Look at how we tried to implement the Single Assessment Framework in adult services across health and social care and please please, learn from what has already been done, what’s worked (personally, I found collocation and working in teams with district nurses worked well) and what didn’t (trying to pretend ‘health’ and ‘social care’ can exist without each other) and they wouldn’t need yet another consultation with statements instead of questions.

 

IMPROVING ACCESS: MAKING IT EASIER TO BOOK APPOINTMENTS AND GET ADVICE

Here, the govt/dept are asking for ways that technology might be able to improve access. I’m probably far from the best person to advise on this but would encourage those with ideas to contribute.

Can you share some ideas of introducing new technologies and new ways of providing primary care services?

This is beyond my experience so I probably won’t comment extensively except to say we need to get the basics right and not all ‘innovative’ solutions need to have a technological base.

What are the barriers to introducing new technologies to improve access?

Again, I probably am not best placed to respond although interesting that the questions don’t necessarily relate to the heading about ‘booking appointments’. For me, personally, it isn’t technologies that would assist me although I do think that being able to book by email would be a nice start, it’s more about capacity of GPs and not having to wait  4 weeks for a regular appointment. Not feeling like the doctor’s surgery was doing me a favour by fitting me in sometime next month might be a start about making it easier to access appointments.

 

OUT OF HOURS: ENSURING A SAFE AND CONSISTENT SERVICE

I honestly think this discussion needs to move beyond the ‘vulnerable’ older people and towards a general understanding of what makes a good and reliable out of hours service because I’m far from convinced (I know, I’m bright like that!) convinced its where we are at the moment.

How can we ensure clear accountability for out of hours services?

Repeal the legislation that privatises anything the sector can get it’s hands on? I’m not sure that’s the answer they, in govt, want. These questions are, by the way, incredibly leading. Accountability can’t be held to companies which are run on profit, in my, very simple, brain.

What is the role of other primary health care services, for example, pharmacists, in providing safe and consistent out of hours care?

Well, clearly there is a need for all services to ‘join up’ but I’d include social care in their too although this is just focused on primary care.

Do you have any examples of good practice and innovation in out of hours provision?

I wish they would ask for examples of where things haven’t worked too – sometimes there can be as much learning in that – particular when there may have been an over-reliance on ‘technology’ and ‘innovation’.

CHOICE AND CONTROL: PROVIDING CLEAR AND ACCURATE INFORMATION TO HELP PATIENTS MAKE DECISIONS

I waver when I see ‘choice and control’ mentioned because I see how it has been done in social care and it has overpromised and under delivered. Hopefully Health can learn from Social Care – when it realises (starting with the Dept of Health) that social care exists. Cynical? Maybe just a little bit.

How do you think patient choice can be supported in out of hospital care for example, transparency, flexible provision and support for decisions?

Interesting that ‘out of hospital care’ is the term used rather than primary care. For  me this has to include social care because it’s vital that we join up the choices available both in health and social care sectors. I’m not sure that’s what the consultation is demanding but that’s what it’s getting from me.

The important thing about supporting choice is ensuring that people who may lack the capacity to make particular choices are not subject to second class services because they don’t have the voices of those who are better able to advocate for themselves. I’d suggest that there needs to be a role for independent advocacy to help people to make choices – not the named clnician – who may have a vested interest in promoting ‘cheaper’ options – especially if they are part of a CCG. We need an element of independence in providing options to people.

 

What do you think are the barriers to choice in out-of-hospital services?

Where to start..

People who lack the capacity to make decisions and who are not supported to make decisions bout choices

Lack of availability of choice or preference or quality services for that matter.

Geographical barriers – people want good services which are close. Choice is over-rated if we have consistently good quality, responsive services.

Where is the ‘control’ – this question is all about choice and not control? How and who to users who are ‘vulnerable’ older people have a stake in controlling the services that are provided to them?

I’m sure you can all think of more. Please do respond to the above question.

 

Do you have examples of patients who have been supported to make better outcomes through the use of choice and control?

I don’t because I’m not a clinician but I do think that this consultation talks about choice but says nothing whatsoever about ‘control’ so it’s interesting it asks for examples of ‘control’ being handed over without explaining it. I think that’s a fault in the consultation but I hope we will be able to flood with real life examples in the hope that someone listens.

 

JOINING UP SERVICES: SHARING UP TO DATE AND ACCURATE INFORMATION AND SUPPORTING COORDINATION OF CARE

Finally we see some mention of social care although only briefly because the consultation refers to ‘clinicians and carers’ resolutely ignoring social care! It’s funny because we’ve been trying to work on integration and seamless information sharing for, well, at least a decade and this consultation seems to lack understanding of that.

What do you see as the main barriers to achieving integrated out of hospital care and how can these be overcome?

For a start those in policy need to understand and appreciate the role of social care and not completely ignore it as seems evident in this consultation.  The main barriers are the lack of conversation between the two sectors and the lack of any incentive and time to create pathways across health and social care. The coordination is better coming from a non-clinician in a social care setting because we have experience in care coordination across health and social care sectors so it’s important that the experiences are learnt from.

Do you have any examples of integrated out of hospital care happening in your local area and having a positive impact on patient outcome?

I have some examples which I’ll share more fully as a part of the consultation but I’m not at all sure what this consultation means by ‘integrated’ – does it mean primary/secondary care? Does it mean medical/social care? I wish it was a bit clearer but I think there’s a role in feeding information back about what has worked (and not worked) in terms of ‘integration’ over the years so we don’t end up making the same mistakes two, three, four times.

 

What do you think are the barriers to data sharing between sharing between services to support patient care?

At the moment the systems that don’t allow social care systems and NHS systems to ‘talk’ to each other is a massive barrier to information sharing. We need to look at the basics before getting over-excited about the potential of data sharing. Until the basics of sharing information between local authorities and NHS is solved, anything more imaginative and innovative is impossible.

Can you highlight any examples where data sharing to support patient care is happening effectively?

Um, no – but maybe I’ve just been unlucky.

 

So that’s the consultation – although it’s based and focused on primary care with a few nods towards other areas, I think it’s important that those who have experience in social care respond to. We need to make our voices heard in order to help the Department of Health understand what life is like for practitioners rather than leaving it to people who sit in rooms deciding to be ‘experts’ on policy without any understanding of the reality of the situation as it occurs.





‘Personalisation Falls Short’ 18/7/13 (8pm BST)

7 07 2013

The first article to discuss is available free here . It is called “Personalisation Falls Short” and was published by British Journal of Social Work 2012 (1-17).

It raises some of the issues of the discrepancies between the ideal and promise of ‘personalisation’ and the practical experiences.

 

The questions that we will consider is:-

What is ‘personalisation’”? Does the definition in the article work? What would we add/take away? Can we define personalisation in 2 tweets? (there’s a challenge!)

Does this article reflect people’s experiences in practice?

How does the ‘market’ or ‘quasi-market’ affect the practice of personalisation? Do you have any examples from practice (obviously with awareness of confidentiality)?  Where has it worked? Where has it ‘not worked’?

Is Personalisation doomed in a period of cuts? Where does the hope for change lie? How can we, as social workers, affect it?

Is there anything we can do from frontline practice to make ‘things better’?

 

These are questions off the top of my head but if you have better ones or more interesting ones, add them in the comments. The week of the discussion, I’ll add some more thoughts about the article but go away and read and join me on the 18th July!





What is the Social Work Journal Club?

7 07 2013

I’ve been a social worker for well over a decade now and realise that we have to take responsibility for our own learning when we move away from the dusky, shimmering ivory towers of academia and move into practice.

Social media, and particularly, blogs and twitter offer us new opportunities to converse and discuss issues as they affect us as practising social workers and social care professionals and people who use the services we provide and care for people who use the services we provide. We have so many more opportunities to learn from each other and our different perspectives that it seems a shame not to utilise this fully.

My idea, copying hideously from other similar chats, is to find an article with a social work/social care interest – it might be in an academic journal or a news article or a policy document and to shape a ‘club’ around discussing it, initially every fortnight but that will be decided if anyone else decides to join me!

I don’t want to ‘own’ this but will run the first couple of chats and use this blog to introduce the articles and write about them. Then I hope that it can be a ‘revolving’ choice in the style of a book club. I want to aim at inclusivity and am aware that the best ideas are ‘out there’ so please let me know what you think and if you have any thoughts and ideas for how it could work.

My only ‘rule’ regarding articles discussed is that they must be open access/free to everyone – not everyone has the luxury of Athens access so that’s a really important thing for me.

So that’s what it’s about. It might work – it might not work – but it’ll be a new journey for me and I hope some of you will be able to join me!