Where are the DoLs?

25 08 2013

The annual report – Mental Capacity Act (2005) Deprivation of Liberty Safeguards Assessments (England) Annual Report 2012/13 was published earlier this week and I couldn’t let it pass without comment.  Community Care have written a good summary here which highlight some of the headline figures.

My own interest is slightly different in that I was a Best Interests Assessor up until last November and still have a very active interest in the implementation of the Mental Capacity Act in detail and the Deprivation of Liberty Safeguards in particular.

There are a few things before I look at some of the figures, which I want to comment on. I’ve seen very poor understanding of the Deprivation of Liberty Safeguards reported. There are a few things it’s important to remember for anyone looking into them and researching these figures.

Deprivation of Liberty Safeguards applications and orders do not ‘mean’ that people are being tied up more or subject to worse restrictions than they were last year – despite the increase in applications and orders made. What is means, in my opinion, is that the care is the same (as restrictive as ever) as it was before  but the SAFEGUARDS have actually been triggered. While there is a lot of criticism (often quite rightly) around the process of the Deprivation of Liberty Safeguards – it’s important to remember that they are the SAFEGUARDS. In themselves, they are not ‘bad’. They are actually beneficial when used properly as they ensure there is a process to involve family and advocates and multi-disciplinary teams to make decisions in the best interests of people who lack capacity to make decisions about care for themselves.

Secondly, I wish that care providers, local authorities, social workers, doctors, everyone really would stop rolling their eyes and saying they are ‘too complicated’ to understand. Just stop it. They aren’t. Just because there isn’t a list of things that count as a ‘deprivation of liberty’ in the DoLS Code of Practice doesn’t mean  it’s ‘complicated’. The ONLY person in the process who has to make a decision about whether there is a deprivation or not is the Best Interests Assessor – the care home owner/hospital etc only need to decide if an assessment is necessary and I’d favour a low bar on that – so I’d expect a lot more applications but we’ll get on to that when we look at the figures. The important thing, in my view, in the Code of Practice is that a deprivation is ‘complete and effective control’ over someone’s life. Is that happening? Or might it be? Refer it for an assessment and let the BIA made the judgement.  As a former BIA, the case law about the definitions of ‘deprivation v restriction’ was fluid but it was my job to keep up to date with that and understand it. I’d rather have more referrals and refusals than applications not made when they should have been.


So back to the report. The real surprise is in the massive variation in requests for assessments and applications made through different local authorities through the country.  Regarding the language I’ll use in the following post, two things to point out.

Managing authority = care home or hospital that is potentially ‘depriving’ someone of their liberty who make the application to the LA. Important to note that the initial request to assess and make an application comes from them.

Supervisory body = Now the local authority (previously – well, up until April PCT or LA) who receives the application and arranges the assessments and makes a decision to authorise or not the deprivation of liberty.  It is the LA where the person is funded/is ordinarily resident that authorised (or not) the deprivation of liberty – not the place the care is being carried out so that may affect the figures.



The most shocking data for me was the massive discrepancies between the figures across England.  Why would Kingston Upon Hull – a city of more than 1/2 million people, only have three applications made in a year – none of which were authorised while Sheffield, which has a very similar population had 108 applications made in the same period with 64 granted.  Hertfordshire made 78 applications with 36 granted while Buckinghamshire made 365 applications with 102 granted. There are lots of examples of massive unexplained discrepancies and I haven’t got the space (or energy) to go through them all but it gives a picture of very erratic use of Deprivation of Liberty safeguards throughout England.

I’d much rather see a high application rate, even if they don’t transfer into authorisations granted than very low application rate, by the way. Sometimes situations change between the application and assessment – sometimes the application isn’t appropriate, sometimes changes in care can take place which mean the person involved is no longer being deprived of their liberty but at least it means someone is looking at the situation of that individual person and making a decision about what is best for them. My worry is that where the rates are particularly low, there are people who are being detained without authorisation. I’ve got no evidence for this except gut instinct and having been to a lot of care homes who wouldn’t know what making a request for an deprivation of liberty authorisation was if it came and hit them over the head.

I’d always feel far more secure and comfortable with a care home that knew and understood when they needed to make an application than one who said (yes, I’ve heard this) we don’t do that (deprivation) here. Hmm. Maybe, just maybe you do and you don’t recognise it.

I also worry about how these systems are operated between local authorities. Do some DoLs leads ‘discourage’ or ‘pre-vet’ applications for authorisations – because they really aren’t supposed to.. at least let people have assessments.


I’m veering away from the document and data and making my own conclusions here so apologies in advance but if anyone has any other ideas, please do leave comments below.

1) People (managing authorities and supervisory bodies alike) REALLY don’t understand DoLs and think they are somehow ‘bad’ so they want to avoid making applications so they don’t look bad – failing to get the fact that depriving someone of their liberty without authorisation is much much worse (unlawful).

2) Everyone who goes into a residential care home and a hospital (social workers attending reviews, community nurses, GPs,  CQC/Mental Health Act Commissioners)  needs to understand DoLs. Not ‘recognise in great detail if someone is being deprived of their liberty’ but aware enough to alert the management if an application should be made as unfortunately, the management can’t be relied on to make the applications themselves.

3) Some local authorities really need to get their thumbs out on this. They need to provide support and training to all managing authorities and check up on them.


If I could make one change to the law, incidently, I’d remove the need for the managing authority to make the application as they are clearly (at least in some areas) proving completely incapable of doing so.


So a slightly different post but I hope you’ll forgive me as it’s a topic close to my heart.


Does Telecare Work? – a randomised control trial

23 08 2013


It’s a slightly misleading title for this post which I only partially apologise for but I wanted to look at an article I found from ‘Age and Ageing’ (Vol 42 No 4 Feb 2013) called “Effect of telecare on the use of health and social care services : Findings from the Whole Systems Demonstrator cluster randomised trial”.

The project was undertaken to ascertain whether the provision of ‘telecare’ had any significant difference to people in terms of hospital admissions/use of social care (namely admissions or care in residential settings, contacts with GPs or practice nurses and weeks of domiciliary home care provided.

The trial involved a group of 2600 people from 217 GP surgeries who already had identified social care needs and resident in three areas within England (Cornwall, Kent and Newham).

I’ve been involved, personally, in a number of ‘telecare’ trials (not this one!) over the years as I’ve seen the technology change over the years I’ve been working in adult social care. From the simple, button alarm call type system which has been around for a long time – to increasingly sophisticated electronic monitoring devices which were able to monitor if someone has moved (or not moved) for certain periods, if someone has fallen and which rooms they would be going into and when. Monitors for gas, fire, smoke, CO2, floods – they are all common now. Increasingly, we are moving to more motion sensor type telecare and remote monitoring – most recently we used a system which can allow families (um, and social workers) to access a remote website to get an idea of where someone is in their property – this can sound a bit ‘big brother’ – and it is – and has to be carefully risk-assessed vis a vis the potential wrench of residential care but it has also put long distance families’ minds at rest.

Anyway, so telecare is constantly evolving and while I don’t think there’s any doubt that it can be useful all round, the argument for cost reduction by limiting reliance on social care services, that’s less clear in  my mind – I see it as an addition rather than a replacement but here’s a study so let’s turn back to that.

The study says

The three sites were left to design and procure their own telecare systems but all intervention participants were given a Tunstall Lifeline Connect or Connect+ base unit together with a pendant alarm and up to 27 peripheral devices, assigned by local teams. These covered [9]:

  • Functional monitoring, including the ‘Lifeline’ base units and pendants, bed and chair occupancy sensors, enuresis sensors, epilepsy sensors, fall detectors and medication dispensers.
  • Security monitoring, including bogus caller buttons, infrared movement sensors and property exit sensors.
  • Environmental monitoring, including gas, monoxide and smoke detectors, heat sensors, temperature extremes sensors and flood detectors.
  • Standalone devices not linked to a monitoring centre, such as big button phones, key safes for carers and memo minders.

Data from the peripheral devices were sent to a monitoring centre via a telephone line and alerts were monitored continuously.

My local authority used the Tunstall systems so I’m fairly familiar with the systems that were available. The study ran over 12 months.  People were excluded from the trial if they were already receiving telecare services (apart from a pendant alarm/smoke alarm).  The main goal of the study was to see if there was any change between the control group and the group with the provision of extensive telecare services in the hospital admission rates over the year but other factors were monitored such as inpatient days, admission to residential or nursing care, domiciliary care provided, visits to GPs and nurses.

There were 1324 ‘control group’ participants and 1276 ‘intervention group’ participants across the GP practices which were involved in the study. It took place between 2008 and 2009 (which, in itself, shows one of the problems with assessing ‘telecare’ because things have moved on in terms of provision enormously since 2009).

While there’s a lot of statistical analysis in the original paper – much of it which is beyond me as a fluffy humanities/social science graduate (!) – there were no significant differences in the areas being compared between the two groups on any of the levels measured. In terms of hospital admissions, 46.8% of the intervention group were admitted to hospital as opposed to 49.2% of the control group. There were no significant differences in access to health and social care services between the two groups and no differences in mortality rates. The usage of GPs was higher in the intervention group but when this had been adjusted on the basis of prior use, it levelled out.

As the paper says

No impacts were indicated in rates of hospital use, length of inpatient hospital stay or admissions to residential or nursing care. Higher levels of general practitioner contacts were detected among intervention than control participants, but differences appeared to exist before the trial and adjusting for prior use removed the significance of results.

So does this mean that telecare doesn’t ‘make a difference’?

The study was the first large scale randomised trial of telecare interventions – however, the authors say that ‘making a difference’ is relative. This, very  much, relied on quantitive data which is easy to analyse.

There are gains, certainly, (well, this is where I veer into the anecdote but bear with me) in terms of peace of mind, particularly for family carers and for ‘services’ which can sometimes be too risk averse. My own experiences of using telecare is that they could augment rather than replace traditional services and could act to minimise risk levels rather than eliminate them. Someone may be able to stay at home for a few more months, but a monitor can’t stop someone falling. It can make the service more aware when they do though.

It’s useful to see some data about the use of telecare as often it is seen as a cheaper ‘cure-all’ and this study allows greater perspective on that. It can’t replace but it can augment – that would be what I would take from this.

It all comes back to what does ‘work’ mean? Does it mean reducing costs to a stretched health and social care system? Or does it mean improving the quality of life of people and their families who need social care and want to add additional factors which can help ease some of the worry and strain that is otherwise present in these situations.

Telecare, quite rightly, isn’t going away, but its useful that we don’t perceive of it as a replacement and rationalise – with the evidence – some of the perceptions that technology alone can be a cure-all.

Winterbourne – The Legacy

16 08 2013

The Journal of Adult Protection has a special issue on Winterbourne View published (volume 15 issue 4). As it’s so key to safeguarding adults – and the contents have been opened up free. I want to read through a few of the papers over the next week or so and comment on them.

I’m going to start with the paper by Margaret Flynn and Vic Citarella – who wrote the Serious Case Review into Winterbourne View. I’d recommend reading that too, incidently,  it carries a lot of learning.

My initial ‘review’ of the Panorama programme is here. I wrote it the day after it was on television. Obviously, there has been a lot of information and change that we know since then but useful for the context of the time.

Winterbourne View Hospital – A glimpse into the legacy – Flynn and Citarella

The paper starts with some background and explanation of the context of the BBC Panorama Winterbourne View TV programme. We are reminded of the main issues which were raised at the time. Flynn and Citarella raise five points initially

a) Viewing the merciless abuse of power

b) The experiences of the undercover journalist who got a job at Winterbourne

c) The lack of response by Castlebeck and CQC to the whistleblower, Terry Bryan.

d) Staff, including more senior staff, who ignored the culture of violence, abuse and degradation of residents

e) The responses by senior management in Castlebeck and CQC to their lack of action.

The authors give some background into both Winterbourne View and Castlebeck as a provider.

Winterbourne View was a private hospital in South Gloucestershire run by Castlebeck. Before the broadcast of the programme, the BBC, the authors explain, were sent a letter (via a local councillor) which detailed the “systematic mistreatment of patients by staff” The letter also raised the issues which had been brought up by the whistleblower, with the acting manager, on 11/10/10. The same issues brought up by the whistleblower had been forwarded to the local council in Oct 2010 and the council had sent it through to CQC in November 2010.

Winterbourne View closed in June 2011. Nine support workers and two nurses were convicted of mistreatment under the Mental Health Act (1983).

After the programme, CQC inspected other Castlebeck provisions. It closed on Arden Vale – another setting in the Midlands and Castlebeck themselves closed Rose Villa in Bristol.

As the article says

Thus a hospital which undertook to provide a high-quality specialist healthcare service including assessment, treatment and support services to adults with learning disabilities and autism, through the application of the key principles of Valuing People: rights, independence, choice and inclusion was exposed as negligent and cruel.

The paper points to the follow up programme in October 2012 by Panorama which showed a ‘turned around’ Castlebeck apparently yet still evidenced some of the same issues of power and cruelty of language and behaviour that resonated.  The continuing use of illegal and dangerous restraint was not a lesson Castlebeck had, apparently, learnt – despite the flowery language. Words are cheap but changing attitudes, particularly in settings which are not often exposed, is more costly and more difficult.

This is particularly telling

In the Serious Case Review we came across no examples of physical restraint being the intervention of last resort. The practice of wrestling patients to the floor and lying across them occurred on a daily and routine basis and yet was not identified as constituting abuse by any professional

For me, this is crucial. Where restraint becomes routine we are on extremely dangerous and cruel ground. Restraint is not a management method, it is a last resort only if absolutely necessary with checks in place. That was not what was happening in Castlebeck settings.

The paper goes on to explain how few rights the people at Winterbourne had in the face of assault carried out by members of staff. The  comment from the Public Prosecution Unit investigator was

restraint is usually carried out by two or more people so any allegation of improper or criminal conduct is countered by two people’s word against the victim – the victim always unlikely to make a good witness in a criminal prosecution

Now I could divert to a rant about the lack of teeth of adult safeguarding legislation and the difficulties of securing prosecutions but that’s probably best for another day. The prosecution was secured by the BBC camera footage  but it’s a pretty shameful situation when that’s the best that people with learning disabilities and mental health difficulties can rely on for justice against abuse and assault from members of staff in settings where they are supposed to be cared for.

In March 2013 Castlebeck went into administration.

The article goes on to talk about the programmes of action which kicked into place after the transmission of the programme.

There were three questions asked, they say

a) Why did it need an undercover reporter to find this level of abuse?

b) Why were there hospitals for people with learning disabilities and autism still around?

c) With Castlebeck funded by international equity firms – how does this match up with the so-called much trumpeted ‘personalisation’ agenda that we hear about – or is it one service for those with voices and another, poorer, possibly cruel one, for those without?

I’ve asked myself these questions – well, not the second so much but that’s only because, having worked in this area, I knew there were these facilities around so it didn’t come as a surprise to me. Of course the level of embedded cruelty and lack of oversight was a shock. I’ve come across a lot of abuse – unfortunately – in my time in adult social care and mental health – but this embedded level is something I had fortunately not seen and I hope never to again.

A variety of reviews have been undertaken and I won’t list them all but we reach a point where Castlebeck built a 24 bedded hospital in a business park and commissioners paid for it because they needed the service.  Long stay hospitals were closed and commissioning bodies needed somewhere for people in crisis but they didn’t spend a great deal of time considering what the best provision was and where it would be and who would provide it. These beds are expensive but they were there. They were easy to commission  but they were not meant to fall off the radar of those who were paying for the services – nor those who were regulating the services.

CQC had moved to a system of ‘light touch’ regulation which relied on self-reporting from provider organisations. I wrote about this back in 2011.  Commissioners showed little oversight. Cultures of abuse were allowed to develop. Few people knew these services existed. There were many blind spots in the ‘system’ and no one to shine a torch on them. Except there was. There was a whistleblower. And that’s another failing of the system.

Now the Department of Health plans to reduce the numbers of people in long stay institutions ‘like Winterbourne’ but it’s important to remember that Winterbourne wasn’t intended to be a long stay institution. It became one because there were no alternative (or no cost-effective alternative) provisions available to either provide significantly more support at home or to provider support in smaller settings – with better care.

The article looks at the disjointed roles of the CQC and the oversight of the Mental Health Act Commissioner whose report didn’t really ‘go’ anywhere. I hope this is something that will be changing with the movement within the CQC but it’s worth keeping an eye on. An understanding of restrictive practices in care settings is a skilled role to understand and to appreciate and it needs inspectors on the ground who have a good understanding – not just of the Mental Health Act but of the Mental Capacity Act too.

The article picks up on the conclusion that most of the recommendations from the Serious Case Review were accepted but that Castlebeck did not respond to the suggestion that therapeutic support be provided on the basis of people who might be subject to distress exacerbated by their institutionalisation. That sometimes the ‘treatment’ has a cost in terms of mental health (I’d say ‘sometimes’ is being very generous here).

Another recommendation which was not taken up was the banning of restraint in settings like Winterbourne and instead more ways to record and monitor restraint solely as a last resort. My concern – and question – would be who is doing the monitoring to ensure that that’s the case? If it’s the same people who were monitoring Winterbourne, we can retain some concerns.

The authors conclude

The Serious Case Review’s findings buttress a growing concern that adults with learning disabilities and autism have been disproportionately disadvantaged in assessment and treatment settings where they may be subject to violence on an unknown scale. Winterbourne View Hospital has taught us about the arbitrariness of cruelty under the guise of restraint and the lamentable lack of interest of all professionals, most particularly Castlebeck Care (Teeside) Ltd and the NHS commissioners of this service, in ensuring that patients were physically well, protected and safe. Had it not been for the undercover-mediated revelations of the BBC Panorama, then needless human suffering in an unnoticing hospital would have continued.

I’d add a further conclusion which is the first thought I had pretty much – why did it need a TV camera to find this? This is the importance of regulation and monitoring. Internal – by the companies providing the services, local in terms of commissioners and also in terms of regulation.

The other concern I have is that while Winterbourne was a particular situation (although we don’t know how common it is/was), it is not a situation which is exclusive to private care providers or services which provide care to people with learning disabilities.

When the conclusions look at how services are provided to people with learning disabilities, I hope they’ll be future learning to transfer to other sectors which also don’t get much light shined in – like older people with dementia in some of the large residential and nursing settings. When we talk about ‘deinstitutionalisation’ we need to look at the sizes of some of the nursing and residential facilities that exist now and wonder if we meant ‘deinstitutionalisation’ for all –or just for younger people.

As for the article, it’s useful and I’ll try to cover some of the other ones. We all have a lot to learn and we all need to look better.

The Berwick Report – What can Social Care take from it?

7 08 2013

I read through the Berwick Report “A promise to learn – A commitment to to act” which was published yesterday. While I have experience working in both health and social care settings over the years, I read it very much with my ‘social care’ hat on. The lessons are geared towards health settings. I wondered and still do whether they can be transferred into a social care specific setting – accepting (and I understand this better than ever) that while ‘health’ and ‘social care’ aren’t isolated entities – there are different pressures and cultures that exist although there is a lot that is transferable. In a sense, the sadness is that some of the most fundamental recommendations needed to be told.

Berwick identifies seven ‘problems’ and ten ‘recommendations”.

The problems he identifies are

1. Patient safety problems exist throughout the NHS

While Berwick highlights poor care evidenced in Mid-Staffordshire, there are many other ones we can all recall in the public consciousness. Similarly with social care there is no room for complacency. Winterbourne View was very much a hospital but it shows where the boundaries between health and social care blur. We have seen Panorama programmes which specify poor care in particular care homes or home care agencies. I’ve possibly seen more than most due to my work in safeguarding adults over the years but the important lesson is not that abuse goes on in services that should be providing care – unfortunately – but that no service can afford complacency.  While we don’t talk of ‘patient safety’ in social care – we can look at a basic expectation of care provision which provides the basics to people.

2. NHS staff are not to blame

Berwick is big on looking at systemic rather than individual failings. Social care is far more fragmented than health – although the NHS is going the same way. There is so many different models/structures/sizes involved. I’m not sure I’d necessarily go with the ‘no blame’ approach  but I’m not as fine a person as Berwick. I think accountability for decisions and actions taken needs to remain. However, most people want to do a good job and that has to be a starting point.

3. Incorrect priorities do damage

Targets. Oh, targets. I think this is definitely transferable. I’m not inherently against targets but targets are gamed and twisted until the outcomes are meaningless to the people whom we are supposed to be serving – just look at the way local authorities have warped personalisation from positive progress towards people getting more choice to a tick box exercise which favours those who are most able to manage their own budgets but ignores the needs of those on ‘council-managed personal budgets’ (which are EXACTLY the same as they were before but allow councils to tick the ‘done’ box and give no incentive to do anything differently – with the collusion of central government who just want to prove they have ‘done’ something).

4, Warning signals abounded which weren’t heeded

Perhaps this is where we diverge – the health and social care agendas. While I can tell many anecdotal tales of the changes in quality of provision since the onward march of the purchaser/provider split after the 1990 NHS and Community Care Act, we don’t have the same data tools (or I’m not aware of them – which may actually well be the case!) to evidence falling quality in social care provision. I’d like to think the warning signs have been evident though – thought more qualitative research and reports. It’s just harder to pin down.

5. Responsibility is diffused and not owned.

I can definitely relate to this. We have a myriad of small providers in social care from single operations – but then we have the large organisations like the Castlebeck/Southern Crosses. There are public sector commissioners from local authorities and CCGs and there are individuals who do not qualify for funding purchasing care individually. Where is the responsibility for quality? Well, with the providers but commissioners (and regulators) have a role. With more people buying their own care, the commissioner role becomes more removed and where is the responsibility or accountability? It’s not the same as NHS responsibility but it echoes.

6. Improvement requires a system of support

Berwick emphasises the importance of building a learning organisation which constantly learns. In social care we are left with building strings of systems in organisations both public, private, third sector – all and nothing – so where does that support and what is that ‘system’. I suspect this might be the biggest challenge in social care.

7, Fear is toxic to both safety and improvement

Without any doubt this is something the social care sector has to embrace. We have to recognise our failures and faults and drop any hint of defensiveness.


So looking at Berwick’s recommendations through the same social-care tinted spectacles, I wonder where we can find the improvements to the ‘system’.

His first recommendation is

1. The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning

While Berwick focuses on patient safety as the goal – we can’t detach social care from quality of life questions which are beyond ‘safety’ alone. We have to continually strive for the best care than can be delivered. He does mention the balance between minimising harm and allocation of resources and that’s always going to be the key. We can look at the care homes that are presented in the Guardian in brochure-like appeal (where prices are FROM £1200 per week) but that’s not where we need to start. We need to start at the minimum wage, zero hour contracted home care workers going into people’s homes for 15 min ‘visits’. How do we improve quality and assure standards without impacting resources? We do need a change in culture, understanding and appreciation of social care and the skills needed to do the job well.

Meanwhile, Norman Lamb suggested Neighbourhood Watch can provide personal care – we are not providing the same amount of respect for social care work that Berwick clearly expresses towards NHS staff.  ‘The ethic of learning’ is important too – but not in the same way. Organisations need to learn – providers and commissioners. They need to be unafraid of criticism but there’s too much money in the ‘business’ for improvement to be pushed for its own benefit alone. Am I too cynical? I hope so. I’d like to see this transfer to the social care sector.

2.  All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.

Now let’s replace ‘NHS healthcare’ with ‘social care’ and it’s even more depressing to read because we are so far away from having cohesive and strong social care leadership. We see many faces who talk to each other and pat each other on the back – but I see little inspiration to those who are doing the job every day directly with people who use social care services.  I’m thinking of the Department of Health too – while Berwick says

“Leaders need first-hand knowledge of the reality of the system at the
front line, and they need to learn directly from and remain connected with those for whom they are responsible. “ We have a ‘Director-General of Social Care who doesn’t have previous experience in social care and the Department of Health seem to think this is acceptable as leadership for the sector – oh, he’s local government, that’s good enough – seems to be the thinking. Berwick says ‘first-hand knowledge’. Hmm.

Ministers seem to think it’s fine to denigrate social care because it isn’t as ‘political’ as healthcare and make statements about any neighbourhood watch volunteer being able to do it. Is that political leadership?

Social care has a long way to go on this. I hope that the new Chief Social Worker can pick up on this a little bit but social care is so disparate – we can have many leaders but they need to lead more. They need to lead people who are doing the job at the grassroots – rather than existing in self-referential circles which seems to be the case at the moment.

3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.

In some ways I think social care may well be ahead of healthcare in terms of user participation but there is no space for any complacency. We have to involve more people better – not just the same people who put themselves forward. We need to think about how we can gather the voices that are quieter as well as those most likely to step forward first. We have to invest in involvement. Pay people proper and respectful wages – equally with ‘professionals’ and not as a token.  We have to make meetings/consultations accessible and invest in that including investment in advocacy where necessary.

4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well supported.

This could relate within residential settings as a responsibility however it already existed – less clear in home care settings but we do need to ensure that community teams are well-resourced – however that costs money – something that everyone seems to want to avoid admitting.

5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals including managers and executives.
6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS

These come together in the report as a part of learning as individuals and as organisations. Personally, I’ve found that the NHS has been better at promoting learning than the local authority I worked for but that doesn’t mean there’s no room for improvement in both.

Social care needs to appreciate the value of learning and training. That doesn’t mean giving care staff 10 e-learning modules on everything from health and safety to safeguarding to do at home in their own (unpaid) time. I think we need to focus on learning across the levels of people who deliver social care. I’m less concerned about the ‘managers and executives’ than Berwick as they are paid good money and have power.  I think we need to look at the support for training and career progression for people who are care workers and often working with low pay and low status.

As for organisations learning, it’s absolutely the way to go. We need to actively welcome complaints as a positive opportunity for learning and not as a personal attack to be swept under the carpet. I think that may take a while.

7. Transparency should be complete, timely and unequivocal. All non-personal data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.
8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.

I’m a great believer in transparency as is Berwick. There are different challenges within social care as there are so many different organisations collecting different information in different ways but there may be ways for local authorities to share information between them and most importantly with us, the local residents, to understand more about the quality of social care provisions locally.

As for seeking the patient and carer voice in monitoring quality of care, I hope we will see an increasingly substantial place for Healthwatch in this process. I’d like to see users and carers involved more in local authority monitoring and commissioning decisions. These are all ways that progress can be made. We need to know how commissioning happens in a much more open way. I’d love to see a council explain what, how and why they make the decisions they do about choosing providers and being held to account for it.

9. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.

The regulatory model is currently similar across health and social care with the CQC taking charge of both. Hopefully the current changes which are in progress will point towards ‘simple and clear’ in social care as well as in health systems.

10. We support responsive regulation of organisations, with a hierarchy of responses. recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment

Personally, if I were rewriting regulation, I’d come down a lot harder on social care providers who do practice wilful or reckless neglect or mistreatment. I think we are not strong enough on that as things stand. I don’t see why this cannot be transferred wholly into the social care regulation system


Where next?

The report was written for the NHS and for patient safety. I’m supposing that some of the tenets would be transferable but I’m not convinced (unfortunately) it’s possible. I wish we could see similar interest in the social care system and its failings as we see in health though but in the absence of that, we take and adapt what we can.

I hope we can see some movement in some of these areas in social care as well as health though because it’s equally important and equally needed.

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”


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.


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.


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.


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.


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.


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’.


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.


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).


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.