Personalisation , Personal Budgets and Demos

I have a lot of thoughts on the push towards the personalisation agenda in general, unsurprisingly as care and support planning plays a large role in my job.

Over the last week, a variety of meetings that have taken place which have pushed this issue to the forefront of my mind locally and have given me time to pause and think, not only about the focus of the agenda and where we are along the path but also where we are going.

It has been frustrating. As I noticed in a Twitter-related conversation yesterday, the language almost seems to have a form of it’s own. I start mentioning PBs, IBs, SDS, RAS, ISF, SSAQ, DP (see Glossary below)  assuming the person beyond knows exactly what I mean in each of those circumstances and you realise how over-complicated what should be a fundamental principal about putting the keys to the power dynamic into the hands of those who use the services.

Rumbling in the background is the government agenda to push personal budgets (PB) as a way to deliver ‘personalised’ care and a push into ‘health budgets’. I think there have been a number of issues that have either not been addressed or pushed under the proverbial carpet in the meantime.

I have tried to express some of my frustrations internally but often came up against the ‘you are either for us or against us’ mentality to those promoting the push towards personal budgets for all at any cost – so by raising criticisms and concerns, that automatically seemed to push me into the ‘controlling professional’ category who obviously just didn’t want to relinquish what I saw as my ‘right’ to dictate forms of care to service users and carers. I dispute that of course. I was one of the few care managers who actively moved many people onto direct payments historically. I am very well aware of the benefits of direct payments but the move towards direct payments for all I felt, was pushed by a few particular groups of people and I was concerned that it was moving the universality of self-directed support away from a large group of people I work with who do not want direct payments regardless of how much support is offered.

I was delighted to read over the past day or so, a report by Claudia Wood called Tailor Made – it’s a long document and my reading has so far been on a superficial level (warning – um. if you are going to print it out  be aware that it’s.. er.. well over 200 pages.. )

It is a document that almost made me cry with joy because it addresses in a more coherent and less histrionic way than I have, exactly my concerns about the way the personalisation agenda has been couched while remaining (as I am) absolutely positive about the process and idea.

We have been too fixated (and Paul Burstow is guiltiest of this) of pushing personal budgets delivered through direct payments as the ‘gold standard’ option of providing self-directed support.

As Wood says in the executive summary

‘The emphasis placed on direct payments as a primary form of personal budget is too restrictive and risks excluding large numbers of people who do not have the capacity or desire to use a direct payment. No one should be excluded from having a personal budget if they wish , but to make personal budgets as accessible as possible for all groups and in all care contexts, we need to think beyond direct payments as the only, or even the preferred, form of personal budget’

For me, Wood expresses clearly my own thinking on this matter. So much energy has nationally focussed solely on direct payments as a delivery mechanism (which is fantastic for some) that local authority managed budgets have become a second-best, second-class service and ‘transferring’ support from standard support to a ‘so-called’ personal budget managed by the local authority has been a fallacy and a lesson in tick box culture at its worst. The issue is that it is  social workers, yes, like me, who have been complicit in this deception. I tick a few boxes and automatically Mr Smith has a personal budget managed by the LA where previously he had a directly provided care package. The delivery is the same service, by the same people in the same way,  but now, after these boxes have been ticked (because he expressly does not want a direct payment) – he is suddenly on the local authority ‘figures’ as having a managed personal budget.

Whereas Mr Brown next door, who has a service of the same cost but a direct payment, is able to access a personally chosen personal assistant and goes to a sports centre instead of a day centre etc etc.

This seems inherently wrong but it is merely because the managed support is so poorly serving Mr Smith. The answer isn’t to give Mr Smith a direct payment because – and this is the issue that Burstow seems to ignore – he doesn’t actually want it.

Wood writes

‘Local authority commissioners… must.. scrutinise their ‘managed budgets’ processes, to ensure they deliver choice and control and are not part of a tick box exercise’

Finally, it feels that someone ‘out there’ is listening to our worries and genuine concerns about a system that seems to have been designed to deliver inequity.

She goes on to say

‘An inclusive personal budget strategy is… one where more innovative uses of personal budgets are developed’

And that, I think is the key. We have had direct payments for a long, long term. Where the real innovation is needed is on pushing out new ways of delivering personalised care within the context of managed budgets.

Wood helpfully specifies the different ways that personal budgets can be used saying

‘There are six forms of personal budget used in social care in England

– a direct payment (held by individual)

– an indirect payment (held by a trusted other – eg a friend of family)

– a trust fund (held by a trust of people)

– a brokered fund (held by a professional broker)

– an individual service fund (held by a provider)

– a care managed fund (held by local commissioners) ‘

and then goes on to say

‘There is a danger.. that as the Scottish and English governments focus on direct payments as the default and preferred modus operandi for personal budgets (in social care at least), people may assume these other forms of personal budget are not capable of ‘real’ personalisation.

This can become a self-fulfilling prophecy, with providers spending less time developing their systems for these other forms of personal budget and them becoming tokenistic forms of personal budget, which do not offer real control’

If Claudia Wood were in the same room as me, I would applaud her. THAT for me is the crucial point in all of this. I want to deliver more personalised services but the only tools I have been given within my local authority are direct payments (or indirect payments)  or care managed fund. All these other options have been theoretical and none have developed any flexibility.

I want to see as much effort nationally in developing new ways of delivering services through all these methods and I want Burstow to at least read this report to have an understanding about why he seems to be fixated on the ‘direct payment or bust’ preferred model.

Of course, when it works, it is fantastic but we need more work on the other models too to ensure an equitable system for all needing care.

As for the report, there is so  much more in it than I’ve touched on about personalisation in residential care particularly. If you have any interest in the subject read it.


PB – Personal Budget (delivered by social care – (or health in the future)

IB – Individual Budget (envisaged to include different income streams eg health + social care budget)

SDS – Self Directed Support

RAS – Resource Allocation System (‘points’ that are translated into cash to make an ‘indicative budget’ after an assessment)

ISF – Individual Service Fund where a provider holds the budget on behalf of a service user

SSAQ – Supported Self Assessment Questionnaire – the way that needs are often assessed initially.

DP – Direct Payment

Support or Social Control?

Communities Secretary Eric Pickles’ announcement that he’s going to focus on ‘troubled families’ had a slightly familiar ring to it. It smacks of an attempt to co-opt health and social care agencies into getting those who are a nuisance to behave themselves.

In Child and Adolescent Mental Health Services (CAMHS) we’ve been here before. Pickles’ ‘troubled families unit’ reminds me of the recent fad for anger management classes.

You all know the scene. The violent husband is confronted on the TV chat show. The audience boos. The host gives him a long spiel about how he needs to change. The wife nods patiently. Then the host offers him the chance to save his marriage by signing up for anger management with the show’s in-house psychologist. The husband gratefully agrees, the audience cheers and the credits roll.

What happens next? Quite possibly he goes along to six sessions of anger management, dutifully completes them…and then goes back to merrily knocking seven bells out of his wife.

In CAMHS we keep getting requests for anger management from parents, GPs, teachers and social workers, because a child “has an anger problem”. Anger management came into vogue a few years ago, and I can see why it’s attractive – especially to policymakers. Disruption in the classroom? Youth offending? Antisocial behaviour? Not to worry, it can all be therapied away in 6 sessions. I’ve no doubt that if I spent a while on Google Scholar I could come up with a few research papers to say that anger management is an effective, evidence-based intervention for children.

But here’s the problem. Of all the kids I’ve seen who’ve been sent for anger management, I’ve been struck by how many of them have actually benefited from it.

None of them.

A lot of anger management classes are, quite frankly, a bit dire. They talk about the causes of anger, the fight-or-flight response, about breathing techniques and distraction. All too often, what they don’t ask is, “Why is this child angry?”

Children usually don’t become automatically angry. More likely, something has made them angry. Abuse, trauma, neglect, being in an environment where anger is a default way of expressing emotion. Labelling the child as having “an anger problem” ignores the wider context.

Worse, it can reinforce child-blaming. Sending the child for anger management can give out the message from services, “Yes, we agree. The child is the problem. He’s the bad one, it’s his fault and he needs to go away and sort out the problem.” I’ve seen kids attend an anger management class, and then be handed back to their parents, who start bellowing and swearing at him before they’ve even left the reception. Those parents are the first to us that we’re rubbish, because we still haven’t sorted out their kids “anger problem”. Often they tell us this while going into a long, loud tirade about what a terrible kid he is, while jabbing an accusing finger in his direction.

Anger management not only ignores the wider context, it also focuses on one particular emotion at the expense of others. An angry child is usually a distressed child. Anger just happens to be the problem that others (parents, teachers etc) want dealt with, because they want the child to behave. Others may say that the kid has an anger problem. The kid might just feel he has a problem. Or indeed, a world of problems.

No doubt the ‘troubled families’ that Pickles wants to target will also have a world of problems. He’s even kind enough to list them.

A family with multiple problems has been defined by the cabinet office as “no parent in the family is in work; the family lives in poor quality or overcrowded housing; no parent has any qualifications; the mother has mental health problems; at least one parent has a long-standing limiting illness, disability or infirmity; the family has low income (below 60% of the median); or the family cannot afford a number of food and clothing items”.

So, does Pickles envisage these families getting a comprehensive package of support, or some politically-attractive non-solution like anger management? Here’s a clue.

Pickles revealed a single problem, or troubled, family can cost the state up to £300,000 a year and predicted this figure can be cut by £70,000 annually simply by reducing the number of agencies involved.

Some of these families can be involved with the local authority, schools bodies, drug and alcohol services, the police and an array of social service departments. Pickles claimed less than 1% of the population can cost the economy over £8m a year.

Well, I’ve certainly come across cases of “agency overload” where too many professionals have become involved with a family, but are we supposed to say that if a child goes to CAMHS they can’t also go to, say, a young carer service? If not, what on earth is multi-agency working for?

So, to summarise, the message from Pickles is, “We’re cutting back the support you guys offer. Oh, and at the same time, we also expect you to sort out the stuff that gets voters irate.”

Pickles and ‘Troubled Families’

An article that appeared in the Guardian on Monday has been playing on my mind for a couple of days. Eric Pickles the Secretary of State for Communities and Local Government (who incidentally seems dead set on destroying both) wants to tackle what he calls ‘troubled families’ or more importantly perhaps, he wants to streamline the amount they ‘cost’ the state.

Louise Casey has been appointed as a ‘Tsar’ to oversee a ‘troubled families’ unit which sounds like some kind of Stalinist initiative.

Not that I don’t want people who need help to get help in the most cost effective and streamlined way but there are a few issues on which I would challenge Pickles and the government. Firstly the direct correlation that they seem to draw between the riots in the summer and particular familial issues.

The government really need to make their mind up about what they perceive to be the reasons for the riots. Personally I think they are oversimplifying to the nth degree and trying to ostracise and target particular social groups. Yes, gangs may have been an element but the reasons the riots spread has to be taken much more broadly than that. The subsequent arrests show the age ranges were not necessarily concentrated around ‘youth’ and the class base of those pillaging the country is much broader than these ‘troubled’ families if you include the political classes who continue to twist rules (re: Liam Fox) and virtually ravage public services (NHS) just as those on the street looted the electronics stores.

There are broader issues which have created a ‘must have’ society and it is not only the so-called ‘troubled families’ and ‘gangs’ that need to be tackled but the corruptions at the heart of the political elite that create an ‘us versus them’ attitude to rule and one which is not helped by highlighting those who are ‘troubled’ and targetting them.

Back to Pickles though, the article quotes him as saying

“the common refrain was where are the parents? Why aren’t they keeping their kids indoors? Why weren’t they with them in court? The whole country got a sudden, unwelcome insight into our problem families. The ones that make misery in their communities and cause misery to themselves.”

What Pickles fails to appreciate is that ‘the country’ got in welcome insight in the summer to far more than these ‘problem families’. We got an insight into the way that our society has developed a materialistic and opportunist streak that is by no means confined to the ‘less than 1% of the population’.

Indeed, it was the willingness of those who are  not in this particular group of ‘troubled families’ to join the general lawlessness and looting that was the real social issue evidence in the aftermath of the rioting.

So what is a ‘troubled family’?

A family with multiple problems has been defined by the cabinet office as “no parent in the family is in work; the family lives in poor quality or overcrowded housing; no parent has any qualifications; the mother has mental health problems; at least one parent has a long-standing limiting illness, disability or infirmity; the family has low income (below 60% of the median); or the family cannot afford a number of food and clothing items”.

Let’s see. Unemployment, poor housing, poor education.. oh look, mental health has been thrown in there too to add to the stigma as well as disability and low income. Hmm. That is a ‘problem’ family. Well, has it ever occured to the government that removing access to a comprehensive and supportive benefit system and social housing and decent education might actually cause some of these compounded ‘troubles’  rather than tackling the so-called ‘troubled’ families that arise from these social and financial circumstances.

Surely the proverbial ‘prevention is better than cure’ maxim applies? In which case, why doesn’t the government tackle the issues behind poverty rather than exacerbating them and marginalising and stigmatising poverty and the effects of poverty by dismissing families who grow up with these issues as ‘troubled’.

Labelling hurts. Labelling by a government is pure discrimination and playing politics with peoples’ lives is worse yet.

Troubled maybe, but troubled to whom?

I don’t say these families should not receive further help. Of course they should but they should on the basis of the poor housing, low incomes and ill-health rather than because they are ‘problems’.

Who created these problems and how can they be solved? That should be what the government is asking. How can we build a society with a sufficient and appropriate safety net than creates real community and doesn’t destroy localities and local services. The government cannot absolve itself from all social projects and social services by laying the blame on the ‘troubled families’ line without accepting responsibility.

Or maybe they can but we shouldn’t allow their narrative to become the predominant one.

Not Being Richard Littlejohn Therapy

A few days ago I read this deeply skeptical article about dolphin therapy.

I’ve lost track how many times my disabled daughter has been offered a swim with a dolphin. While disabled people struggle to get a hoist or a few hours’ home help, numerous charities will fly them to Florida to experience the miraculous feeling of frolicking in the water with a friend of Flipper. According to organisations that sell such snake oil, “dolphin therapy” alleviates a wide range of disabilities, from increasing the attention span of a child with attention deficit disorder to curing paralysis.

I must admit swimming with a dolphin sounds like fun, though conservationists point out that it can be less fun for the actual dolphin. Even so, the idea that it can cure your ADHD sounds a little dubious.

“Therapy” is quite a nebulous word that can mean anything and nothing. You can be a beauty therapist, an occupational therapist, a drama therapist…apparently even a dolphin therapist. Even something more formal-sounding like “psychotherapist” can mean anything from a highly skilled professional who’s completed a long, arduous postgraduate training down to some utter woo-peddler with a crystal pyramid. As I’ve previously pointed out the government is currently watering down plans to regulate psychotherapists in the same way as doctors, nurses and social workers. Instead they’re going for “assured voluntary regulation” which will at least give some form of quality kitemark, but will allow the quacks and charlatans to carry on practising.

But, you know what? If you can’t beat ’em, join ’em. I’m fed up with banging the drum for proper therapy regulation. There’s a recession on and I need some ready cash. So, here’s my very own therapy, for which I’ll be promoting a book and a lecture tour. Some impressive-looking research papers will be doodled out, showing an improvement in psychological and social functioning based on an assessment scale that I scribbled on my lunch break.

I hereby announce the launch of At Least You’re Not Him Therapy.

Clients will be taken through a series of activities to enter into the psyche of Richard Littlejohn. They’ll be asked to read through his regular Daily Mail columns. There’ll be readings from his magnum opus To Hell in a Handcart. The client is then taken through a guided visualisation, where they are asked to imagine walking down a street convinced of being surrounded by communists, “pooves”, liberals and immigrants – all of them intent on destroying everything that is decent and wholesome. Finally, they’ll be brought back to their own world with a nice soothing mug of lorazepam, and gently reassured that, whatever their current difficulties and failings, they are at least Not Richard Littlejohn.

“Wow, that put it all into perspective for me! Now that I’ve realised I don’t live in a mindset based purely on malice and fear of the other, I feel so much better about having been done for fiddling my expenses!”
– Some Celebrity You Haven’t Cared A Monkeys About Since 1997

A sequel to the book will follow at a later date. Possibly when sales of the first book are dwindling. For clients with deep-rooted, intractable problems, there will be supplementary modules in Not Being Robert Kilroy-Silk, Not Being Nadine Dorries MP and Not Being George Galloway.


Self Portrait As A Stressed-Out Bride To Be

As a student nurse we are classed as supernumerary – at least that’s what the NMC says – and what this means is we shouldn’t be counted in the numbers; nurses or support workers. We’re meant to be able to access learning opportunities as they present themselves, and seek them out ourselves.

That’s the theory anyway.

In reality, from what I’ve experienced a lot of places can run short staffed for whatever reason, be it illness or an oversight on the off duty rota. Now the standard procedure is to call in bank staff, off duty regular staff or as a last resort call agency staff. Fair one, you’ve got to cover the shift for safety’s sake and the smooth running of the environment.

Again, that’s the theory. Most places would rather go short staffed than pay for agency. So that begs the question, what do you do? The frequent answer is to use (and abuse) students, get them do direct patient care.

Now I have no objection to putting on some gloves and giving direct patient care, my background of almost a decade as a healthcare assistant means I’m pretty well versed in the methods involved in ridding an anal sphincter of faeces. I do have a most vociferous objection to students like myself being used to make up the numbers of support workers when an area is short staffed, especially when I’m already quite busy chasing up various drugs from the pharmacy, scripts from the various GPs in the area and trying to get them to work together.

I find it especially annoying when, the very next day,without a hint of irony my mentor said to a colleague “I’m not on the floor, I’m supernumerary”

I understand that this is common practice amongst placements, and not restricted just to my own personal experience.

On Anger and Occupations

On Saturday my Twitter feed was buzzing with reports from some of my Twitter chums (Twums?) about the Occupy the London Stock Exchange protests. I must confess I didn’t go myself. Not because I have any objection to their aims, but because I don’t live anywhere near London and would have looked a bit forlorn occupying my local Tesco Express.

It remains to be seen whether this new protest will grow like the Occupy Wall Street movement that inspired it. Even so, OccupyLSX got me thinking about popular anger and protest movements.

Lord knows, there’s enough reasons to be angry at the financial sector right now. They created an unsustainable bubble, and we’re all now paying the price. Public services being flushed down the toilet, a whole generation of young people unable to find work…and the Hooray Henries in the Square Mile just carry on giving themselves pay rises. And don’t even think you’ll be able to join the moneyfight yourself. Not unless you’ve got parents willing to support you through a series of unpaid internships, effectively creating a new aristocracy in all but name.

The behaviour of some of those in the City hasn’t exactly assuaged our anger either. I’m not just referring to Fred Goodwin. This Comment is Free article, by a City trader arguing that the 50p top rate of income tax would result in all the financial whizkids leaving Britain for overseas, is glorious not so much for the article itself as for the stream of comments that were left in response. People didn’t become any more sympathetic when they realised he was the author of a book called – I kid you not – How I Caused the Credit Crunch.

(Incidentally, I was so intrigued by the book title that I actually bought a copy. Second-hand, naturally. I didn’t want him to have any of my money.)

All in all, the surprise isn’t that people are angry, more that people aren’t knocking together a guillotine on Paternoster Square.

But can that anger actually translate into meaningful change? There’s the question.

Like many people who are vaguely liberal but not given to waving a placard, my first time on a protest rally was at the giant anti-war march in London on Feb 15th 2003. Depending on whose figures you believe, anywhere between 500,000 and 2 million people stomped (and at times, shuffled, it really did get crowded) their way to Hyde Park, demanding that we don’t invade Iraq. It felt like some epochal moment in history had just taken place. Until the following month, of course, when we invaded Iraq.

I actually stuck around with the anti-war movement until a few weeks after the initial invasion, when the US troops were nearly at Baghdad. God, it was depressing, watching the Stop the War Coalition shrivel quickly from a brief period as a mass movement that genuinely represented public opinion, down to a narrow locus of the usual far-left suspects.

Before Saddam’s statue had even started to topple, I felt that the Stop the War Coalition no longer was something I could be a part of, and quietly departed. It was becoming something of a strain. Have you ever tried to hold a conversation with a member of the Socialist Workers Party while simultaneously trying not to look sarcastic? It’s really hard.

If the OccupyLSX movement is to genuinely represent the anger that people feel about the chaos we’ve been plunged into, then it will need to expand into something more than those usual suspects from the SWP et al. I suspect that may not be easy. Sunny Hundal over at Red Hot Liberal-On-Liberal Action seems to be having similar thoughts.

The problem, as anyone vaguely involved with UK left-activism will know, is that many hardcore left-activists will rather swallow a cyanide pill than work with people who are slightly less radical than them. They will spend their entire time actively trying to wreck pluralistic coalitions.

It happened during the anti-cuts protests and it will happen again. Some have even gone as far as trying to wreck UKuncut (one called UKuncut a ‘populist group no different to the EDL’). These people would much rather pretend they represent the 99% than ever come into contact with the varied opinions of that 99%.

That said, I do wish the Occupiers well, and may yet attend one of their events – because real change does need to happen. When we finally emerge from the ashes of the present crisis, it mustn’t be so that we can just go back to building the next bubble.

Retreat into the Medical Model

Like just about everywhere else in the public sector, Child and Adolscent Mental Health Services (CAMHS) are feeling the effects of the cuts. As in so many other areas right now, jobs are having a nasty habit of not getting re-advertised when people leave. We haven’t yet had actual redundancies in our neck of the woods, but the whispers are in the wind.

Particularly vulnerable to the cuts are the psychotherapists – psychodynamic therapists, family therapists, art therapists, play therapists. There aren’t many of them employed in CAMHS, but their influence extends beyond their numbers. I’ve had some fascinating conversations with our psychodynamic therapist who keeps “accidentally” leaving papers on attachment theory on my desk. The opportunity to co-work with systemic and family therapists has genuinely transformed the way I conduct my clinical practice. They don’t just change kids and families. They change their colleagues too.

We get a complex mix of cases coming through our doors. Kids with neurological disorders such as ADHD and autism. Kids who have been abused, neglected or traumatised. Young carers to physically or mentally ill parents. Families under enormous strain, or with tortuous family dynamics. Educational issues. Child in need/child protection issues. It can be a bewildering variety of problems. To navigate it requires an eclectic mix of clinical models in your toolbox – medical, psychosocial, cognitive-behavioural, systemic, psychodynamic.

In hard times, it seems to be the psychotherapists – with their specialist outlooks and long, arduous training – who are most likely to be for the chop. My worry is that as we retreat to a core of doctors, nurses, psychologists and social workers, we’ll also retreat into a more narrow view of what CAMHS is for and what it does. Possibly diminishing into simply a medication and CBT service.

Don’t get me wrong, I’m not anti-medical model. I’ve worked with plenty of kids who’ve genuinely benefited from a bit of methylphenidate or fluoxetine. I’m not anti-CBT either, though I don’t think it’s the panacea cure-all it’s sometimes touted as. But one of the reasons I chose to work in CAMHS is because of its wide mix of models to suit the equally wide mix of problems that we deal with. Seeing our toolbox get smaller before my eyes is something that worries me.

Hospitals and Respect

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

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

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

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

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

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

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

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

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

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

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

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

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

The report itself says

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

Equally in the section regarding nutrition it says

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

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

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

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

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

Choice, the NHS and Social Care Bill and the Lords

It’s likely that the NHS and Social Care Bill will be voted on today in the House of Lords and the supreme irony remains that this unelected ‘Upper’ chamber may get the chance to carry the will of the people (and involved professionals) in the face of the lilly livered House of Commons.

Lansley’s Bill is pushing choice. Oh, you see, how wonderful it will be, he claims, when we will be able to choose which hospital we want to be treated in? Yes, that works great for routine surgery but there’s not much choice involved after a proverbial car crash. Choice is all well and good but it is a luxury of those who are able to express it.

I’m not knocking it – well, ok, I am a bit – but I have seen how the word itself has been warped in the field of social care and has been used to promote discriminatory practices which bypass those who are not able to make choices.

Those who can, choose. Those who can’t, are given the poorest services and it is those who are not able to exercise choice that often need much more support.

The voiceless will become ever more voiceless. That is my fear. The ‘Southern Cross’ situation was bubbling under the surface for a couple of years before the company, which gambled for profit on the homes of residents who were mostly older people, went bust. Where is the choice of those who live in those homes whose ownership has just changed with the signing of the cheque?

Think forward to an NHS with this abundance of competition and choice. I will choose the hospital in which I receive treatment. I can’t imagine I’d choose anything other than my most local hospital with good transport links (I don’t drive so that further would limit my choice more than someone who had access to a car, for example) – and why will I go with whatever consultant is allocated to me? Because I tend to trust doctors who are employed and practice in the NHS know what they are doing.

I don’t want to have to research and grade doctors. I want a doctor who will treat me well.

But choice is nice. I’m not anti-choice. I am anti a system which does not build in safeguards for the rights of those who are not able to make choices. My local hospital, as it happens, has a poor reputation (I’ve not, fortunately, sought treatment there often but every time I have been there for myself or to visit others, I have never had any reason to be concerned and indeed, have come across some of the most thoughtful and kindest staff possible – see what a reputation does?). It will probably be one that is mostly used by people who live locally, like me, actually, who don’t want to be travelling miles to get to the next closest hospital. Is that the choice I have?

Or maybe it’s about choosing a named consultant? I wonder what vested interests my GP would have in linking in with particular hospitals/consortiums to commission services with specific consultants. Is it my choice or my GPs choice? How linked is my GPs decision to money and profit? I hope it isn’t at all, but you see what changes in thinking this bill is leading me to.

I attend a multi-doctor, city practice. I don’t know my GP. My GP doesn’t know me. Cameron lives in a fantasy rural idyll where we all know and trust our ‘family doctors’. Sure, I trust my doctor but I wouldn’t recognise them if I walked past them in the street. Each time I’ve been to the GP (fortunately not often), I’ve been seen by different locums. I don’t mind this but I do mind the automatic assumption that I have built up a specific relationship with the practice. I doubt it will be my GP making commissioning choices anyway. Chances are the surgery will ‘buy in’ to an external commissioning company that will provide tidy, juicy profits to shareholders.

Yesterday Lord Owen and Lord Hennessey tabled an amendment which calls for greater scrutiny of the Bill.

Earl Howe wrote a letter to the Peers demonstrating an edge of fear in the government warning about

“The potential for slippage in the timetable carries grave implications for the government’s ability to achieve royal assent for the bill by the end of the session.

“The house must have proper time to examine the bill, but the proposal put forward by Lord Owen could result in delay which could well prove fatal to it. This is not a risk that I believe this house should take.”

Shaky ground when the House whose role remains to scrutinise legislation is asked not to.

As for me, I find it ironic that the will of the people – because there is no doubt that this is a hugely unpopular bill without public support – let alone professional support (all the medical Royal Colleges have expressed opposition to this Bill) – is in the hands of the unelected Peers.

I’ll be following with interest and hoping that the Lords are able to represent us in a way our elected politicians have been unable to.

The More Acceptable Kind of Stigma

Today is World Mental Health Day. Among the various excellent articles I’ve read to mark the occasion, the one that stuck out the most for me was on the F-Word blog.

I’ve taken psychiatric medications for 17 years, and that’s unlikely to change any time soon. I’m not overjoyed at the sheer range of pharmaceuticals I swallow every morning and evening, but it is far from the most significant aspect of my mental distress. So why do so many people focus on the pills as the problem?

The author points to articles raising concerns over the rise in antidepressant use. She responds that, while it’s true that medications shouldn’t be a replacement for psychological therapies where required, we also shouldn’t criticise people who genuinely need those medications. She quite reasonably concludes.

Antidepressants are not the enemy. I agree that appropriate psychological support should be more widely offered, and that medications should be reviewed regularly. However the problem is not with the pills. The problem is the world we live in that makes so many of us despair enough to seek medical help to manage it. It’s with the levels of rape, domestic violence, female genital mutilation and sexual abuse that can make live unbearable for so many. World Mental Health Day should not be ‘celebrated’ by stigmatising us for coping in whatever ways we can.

I couldn’t agree more. When I tell people I work in mental health, I regularly get asked whether I “believe in therapy or medication”. I always think that’s a really weird question. It’s not as if car mechanics get asked if they “believe in” spanners or screwdrivers. If somebody did, then that mechanic would respond that some problems need a spanner, some need a screwdriver, and he needs a variety of different types of each.

Likewise, some people need a certain type of meds, some people need a certain type of therapy. Some people need both. I really don’t get why that’s so difficult to understand.

But some people do seem to have a problem understanding it. There’s pretty much an industry in chin-stroking broadsheet articles decrying the evils of psychiatric medications – the Guardian seems to average one every couple of weeks at the moment. They have a habit of coming out with slightly crass remarks like this.

But doctors could recommend group running for depression, proved to have far better effects than SSRIs. Reading groups, too, offer a definite lift.

Depressed? Join a reading group! Well, that’s fine until you remember that as people get more depressed their concentration and short-term memory gets worse and worse. I’m sure a reading group would get somebody out of a bit of a rut, but a deep depression? They’d probably smack you in the mouth for suggesting it, if only they had the energy.

I really am tired of this tedious meds-versus-therapy false dichotomy, as though offering one prevents us from offering the other. I’m not saying everybody should take a pill, but there are a lot of people who can cope with life when they use psychiatric medications and can’t when they don’t. Those people shouldn’t be criticised or patronised for it.