How not to do heroin harm reduction

There’s an argument that any references to heroin use in culture inevitably glamourises it. I recall there being a lot of debate about this around the time that Trainspotting was released in the cinemas.

My own view, and this might be coloured by my anti-censorship inclinations, is that while there may have been a bit of glamourisation, the film did also show the harrowing nature of heroin addiction. Overdoses, withdrawal symptoms, HIV transmission – they were all dealt with in gruesome detail. After watching Trainspotting, only a jaw-dropping imbecile would conclude that getting hooked on smack was in any way desirable.

Now let’s take a look at Vice – the magazine for jaw-dropping imbeciles.

We all know that pumping heroin into your veins turns you into a phenomenal artist. Basquiat? Cobain? Burroughs? Have you seen the shit they were putting out before they started using? Of course you have, because it was put on your high school syllabus to teach you that you’ll never be able to create real art without a smack habit. But one group of artists your school books might not have mentioned are the dealers who use their own graphics to beautify their heroin baggies. Kind of like acid tab art, I guess, only more sinister and likely to kill you.

Yes, this is indeed an article on “The Art of Heroin Bags”. No, I’m not kidding, I just wish I was.
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Not Working Together Any More In The Name of Less Bureaucracy

Regular readers of my efforts in NSBS may have discerned an emerging pattern, the theme that simple solutions to problems in social care will not work because reality is complicated and perverse. That certainly wasn’t my intention when starting out. I’ve merely been reacting to some of the major news items in child care social work, specifically the government’s proposed changes to the process of assessing adopters and foster carers. Banging on about the same thing is tiresome for me as a writer, let alone the poor reader.

But here I am again, putting fingertip to keyboard in response to Community Care’s exclusive that “ministers are planning to ‘slaughter’ key child safeguarding guidance as part of measures to tackle bureaucracy in children’s services.” Apparently on the instructions of Michael Gove, Working Together is to be reduced from 300 pages to 60 or even 10. In welcoming the Munro Report on child protection work, many of us wondered exactly how the recommendation that has been embraced most wholeheartedly by the government, a decrease in bureaucracy, would be put into practice whilst maintaining quality standards and the absolute necessity of keeping good records. Now we know – by dismantling wholesale an intricate but solid structure of multi-disciplinary procedures created in response to a failing system that left vulnerable children unprotected and replacing it with a few sides of A4. It’s an absurd response to the complexities of safeguarding, almost as baffling as the concept that I have regular readers.
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The Court of Appeal ruled yesterday on the scope for adult safeguarding

The Court of Appeal ruled yesterday (DL v A Local Authority & Ors [2012] EWCA Civ 253 (28 March 2012)) on the possible scope of adult safeguarding. An elderly couple had chosen not to take steps to protect themselves from their potentially violent and aggressive son. Could the local authority safeguard them?

Here is the ruling in a nutshell: local authorities can intervene to protect people who have mental capacity to decide for themselves and choose not to be safeguarded, but only if they lack capacity to decide for themselves in some other way.

Commentary

In one sense the Court has said nothing new; but in another it has said something controversial.

Nothing new, because it upheld judgements made below (i.e. by the High Court) and therefore doesn’t change anything, even though the judgement is a welcome expansion and elucidation of the law in this area. Something controversial because as the President of the Family Division said at an earlier stage in this litigation,

I am of the view that the present case involves an extension of the inherent jurisdiction… [paragraph 20]

What’s it all about?

Can we intervene to protect an adult who chooses not to protect themselves from their grown up child, because they want to protect their relationship with their child?
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Paying for Care and Generating Blame

Sold - Day 67 of Project 365

I read Liz Kendall’s article on the Guardian website a couple of days ago and while I haven’t been able to respond fully until today, I did want to.

Kendall is the shadow minister for care and older people a particular remit (as far as having a specific spokesperson for older people) that doesn’t exist in government.

Generally, I’ve found her input to be helpful. There were a number of issues raised in this article though that concerned me.

Kendall is right to draw attention to the issues that present themselves in relation to care and quality of care in this country and focused on the inequity of payments in the care system which she is right to identify as a key area that needs to be reformed and hopefully will be shortly.

The current charging policies are all over the place and there is no consistency between local authorities however for me, I see the issue of quality of care and equity of provision of high and trustworthy standards of care to be, if anything, more of a crisis.
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Adult safeguarding – introducing the concept of insignificant harm

The proposal is that the threshold for adult safeguarding should be “significant harm”, rather than the lower “harm” threshold recommended by the Law Commission. Mithran Samuel at Community Care (@mithransamuel, @ComCareAdults) debates the wisdom of this (‘Will safeguarding threshold leave adults at risk?‘) with reference to arguments aired at their Adult Protection Conference, and I note reference to the Department of Health favouring the same threshold as for children.

Good for them! I hope it was more than a quest for neatness and simplicity. I venture to suggest a parallel with the children’s significant harm threshold is legally and morally right.

I fear being torn off my high horse whenever I write favouring less intervention. Many can understand that our human rights, forged in the aftermath of a long and bloody fight against totalitarianism, are largely rights to be left alone by the State. But I write from within a profession that epitomises State intervention in private life; and many are comfortable with that and uncomfortable with anything that might limit their right to intervene.
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It’s all about the training! CQC and Deprivation of Liberty Safeguards

Inveraray Jail

Today, as Community Care reports, the CQC has published its annual report into the operation of ‘Deprivation of Liberty’ safeguards for 2010/11.

Deprivation of Liberty safeguards are a particular part of the Mental Capacity Act which allows a legal process of authorisation where there is felt to be a ‘deprivation of liberty’ in a care home or hospital related to someone who lacks the capacity to make a decision about whether they remain there or not. The process of decision-making relating to whether a Deprivation of Liberty is authorised revolves around the managing authority (the organisation which is potentially depriving the person of their liberty) and the supervisory body (the local authority or PCT (or whatever they are called now) where the person is or who is responsible for the care of that person (if, for example, they have been placed out of the local area the responsibility remains with the placing authority).  The decision is made on the basis of a number of assessments (six actually) which are undertaken by at least two people, one of whom must be a doctor and one of whom must be a ‘Best Interests Assessor’ (who can be a social worker, nurse, occupational therapist or psychologist).  The Best Interests Assessor, unsurprisingly, makes a recommendation not only on whether the deprivation is in the person’s best interest,  but whether the framework and care plan constitutes a deprivation of liberty at all.

So that’s DoLs in a nutshell. What have the CQC got to do with it? Well, amongst other things, monitoring these Deprivation of Liberty authorisations is another part of their work.
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NHS #RiskRegister Leaked

So, the much-debated Risk Register for the NHS reforms has been leaked onto the Internet.

Personally, I’m still trying to interpret and digest its contents, and therefore my immediate thoughts aren’t more cogent than, “Wow, that’s a lot of stuff marked red!”

Some areas marked as red (i.e likely to happen, and would have a high impact) include, to take a couple of random examples:

By dismantling the current management structures and
controls, more failures, including financial, eg GP consortia
go bust or have to cut services, and credibility of the system
declines as a result.

 

Risk that transition is managed by people who are
themselves at risk, eg in organisations such as SHAs, PCTS,
may not be effectively managed, with risk of delays,
performance dips and key staff lost as a consequence.

 

There is a lack of clarity during the transition in terms of
accountability e.g. between board, PCTs, and Consortia
during the transition years and the first year of the new
system. This leads to delays and increased costs and poor
BAU performance.

Okay, I know that the point of this risk register is to identify such risks and therefore work to eliminate them, but there really do seem to be a lot of them.

 

Researching and Improving Dementia Services

Memory

Today the government has announced an increase in funding for dementia research, indeed, the figures given by the BBC talks about raising the money put into dementia research from £26.6m to £66.6m by 2015.

Great news, really it is. I think it’s essential that there is a focus on dementia and what can prevent and assist those who suffer from and potentially suffer from dementia in the future.

As well as research though there were other strands to the government’s announcements about dementia.

Mr Cameron will set out plans to step up research into cures and treatments and to ensure that the health and social care systems are equipped to deal with the problem.

The highlighted part is the area that sticks a little in my throat as I read it. I do wonder how much the government and ministers are aware of the services that have been decimated (probably more than decimated if we are going to be talking literally) over the last couple of years and the disinterest shown by the general public in terms of improving both health and social care outcomes for those who have dementias.

Money into research and cure is a hopeful statement  – it looks forward and it helps us who are the electors of today have more hope for our future with the fear of losing cognitive functioning in our later (or not so later) years.

Money into equipping health and social care systems to ‘deal with the problem’ of dementia are altogether something else because it isn’t ‘us’ who will benefit – we, todays electors, are the ones who will pay and experience (or at least, the lack of political will on all sides)  shows that no-one wants to pay for the true costs of providing good quality care for older people with dementia in real terms.

I’ve seen a lot of simplistic talk about dementia over the past weeks, months, years. It is not a single diagnosis and it does not affect people in a single way. People with dementia walk and function among us and they are not all older people sitting alone in bungalows waiting for pity – although it’s important to remember that some do live alone without sufficient support or interaction. They are not all people who want or need pity – there is hope for positive life experiences even when ones cognitive functioning is impaired.  We infantilise the process of ageing and those who merely have a diagnosis of dementia and it says far more about those who are speaking and talking in those terms that those who may be bearing the progress of their diagnoses in as many different ways as there are people.

However one thing does need to be addressed and I hope it is addressed by the government today – with money. That is the issue of treatment and assumptions made about people with dementias in institutional care settings. We have had talk about ‘dignity in care’  – particularly in hospital and residential care. This must be approached and tackled in the ways I have previously discussed by putting more people on the ground in terms of nurses in hospitals and increasing staffing levels in residential and nursing homes. We need to back up a determination to provide better care for some of those people who won’t be ‘shouting loudly’ or have families to ‘shout’ for them by placing independent visitors and advocates in these institutional settings and improving regulation and quality control for those who need these services.

As for changes in home care – we need to embrace truly personalised care and the ‘personalisation’ agenda beyond managed budgets of block contract agencies providing 15 min ‘spot checks’ to put a microwave meal in the oven for older adults with dementia in their home. This is not dignified and it is not cost effective. Over time, putting more good quality and accessible care into people’s homes will keep people out of residential and hospital settings over the longer term but it will cost.

So I hope these announcements the government makes will look at quality of care and will look at funding of care over the long term for people with dementias who live both in the community and in residential settings.

I hope to see, alongside better funding for research

1) Better support for family/friends as carers

2) Proposals to make personal budgets work well and for different support to be used for those who are not able to engage in the process of choice themselves either because they don’t wish to or don’t have the mental capacity (or family) to do so.

3) More thought put into the funding mechanisms of care for people with dementia both at home and in residential settings. Dilnot or not Dilnot. I’m not in agreement with all the tenets of Dilnot (I’d favour the so-called ‘death tax’ to be honest) but its better than that awful hotch-potch that we have now and what we can’t afford is to allow things to continue and to leave matters up to different local authorities to manage in their own different ways and at different levels.

4) Better non-directed advocacy with muscle for those who don’t have family/friends/community around them (by non-directed advocacy, I mean advocates who specialise and are trained in working with people who may lack mental capacity to ‘direct’ or instruct their advocates)

5) Robust regulation of dementia nursing and residential homes and wards in hospital with random spot checks and high standards.

I’ll be back tomorrow and see how the government does on this announcement.

One day though, I’d like to see a government of any political flavour that truly does look at national interest and not political expediency in terms of policy making.

The triumph of hope over experience.

photo by Ruth Flickr

The case for health and care privatisation

Yesterday, the Health and Social Care Bill finished its passage through Parliament. Today is the budget speech.

Saturday’s Guardian had a piece entitled ‘What will the 2012 Budget mean for you?‘. It was not about the NHS, nor privatisation, just about how the budget affects the lives of ordinary people. But one of the ordinary people – acknowledgedly ‘the high earner’ – caught my attention, because he works in the field of social care. His name is Tony Stein.

According to the article,

Tony Stein is founder and director of Canterbury Care, which operates 11 care homes across the UK. Last year his earnings “just about touched” the £150,000 level…

Although Tony signed a letter in the Telegraph last month arguing that the 50p tax rate “puts wealth creators like us in an awkward position”, he is an ordinary guy:

It’s not as if I’m earning millions. Actually, what has me shouting at the telly is the executives of big banks who earn millions but aren’t putting their own money at risk.

Is Tony making out a persuasive case for private enterprise running social care, the case for privatisation? Let me make clear, I don’t know him personally, nor do I have any dealings with his company. Nor, frankly, have I done much by way of research, though I have done a little digging.

A little digging revealed that Canterbury Care is headquartered in Worcestershire, where a local Green Party member in 2010 criticized the Council’s Chief Executive for not taking a pay cut:

Mrs Haines is contracted on a salary band ranging from £167,977 to £183,725 a year.

Worcestershire County Council’s accounts suggest it is rather a larger affair than Canterbury Care with its 11 care homes; its Chief Executive gets paid more, but hardly in proportion to the size of the enterprise. Among the information I extracted from Worcestershire’s balance sheet are that it has long term assets of £1.695 billion and long term liabilities of £1.056 billion. I went looking for that figure to compare it with Tony Stein who says Canterbury Care has “£14 million in borrowing”.

I venture to suggest it is pretty plain that Tony Stein has a salary chasing that of the Council’s Chief Executive, for a far smaller venture. Measured by debt, the Council’s financial headache seems to be about seventy five times the size.

At this point, I start to speculate that it might be 75 times cheaper to have debt presided over by a local authority than a private enterprise, and that Tony Stein really hasn’t made out a persuasive case for privatisation of social care.

But, to be fair, it isn’t just the size of the financial headache that Tony relies on to convince us. It’s the fact that

…We employ 455 people, but we have £14m in borrowing, and a big mortgage on my home. At the end of the day I have my neck on the line. Yes, I earn £150,000 or so, but it’s me who has sleepless nights over the borrowings and operations of the business, and it’s me who works all weekend.

So he can shout at the bankers on the telly like the rest of us, because of the fact that his pay is justified because his own money is at risk in his enterprise. And he works all weekend – though I am presuming his residential care homes are staffed all weekend also.

I’m sorry, Mr Stein, but I’m afraid you have actually made out a case to be relieved of that risk and that income. I’m just not getting what is the benefit to the public of the liabilities and risks being borne by wealth creators like you instead of the taxpayer. If residential care were run by local authorities, no individual would have to have sleepless nights because of their personal investment and risk. No individual would therefore need to be paid £150,000 to preside over just 11 residential care homes. The tax payer wouldn’t need to worry about where the money came from and whether there might be a Southern Cross-like disaster. The case for privatisation is not made out.

And I haven’t even begun to explore the market arguments about quality, efficiency, competition and the like. This commentary is just about the apparently extraordinary cost of privatising capital and investment risk.

Did I mention, yesterday the Health and Social Care Bill cleared its passage through Parliament?

Allan Norman (@CelticKnotTweet) is a registered social worker and a solicitor at Celtic Knot – Solicitors and Social Workers.

Adoption Reform Isn’t Just Common Sense

Around 18 months ago, I offered some consultation to a small project that planned to set up activity days where children in care met prospective adopters. Last week I saw a DVD of the first event. There was no sense of the controversy that surrounds these so-called adoption parties. Children, their social workers and adopters mingled happily during the course of a day’s outdoor activity and lunchtime entertainment. The adults acknowledged some awkwardness from their respective standpoints but all agreed this was outweighed by the positive experience, not only of meeting children but also of feeling part of something larger and important.  All valued the careful preparation that had preceded the event.

Seven children were subsequently matched and two more were in the pipeline. One, a severely disabled young girl, had been waiting almost as long as the project had taken to reach fruition. On the day, some carers met her, a real person now rather than a case or a prognosis, and an emotional bond began to form. In the carer’s words, “We just clicked.”

It’s an innovative approach not without its risks and detractors and it’s not right for everyone, but it worked. Other opportunities could and should exist for finding more carers for siblings, disabled children or black children, where shortages of adopters exist. Or just for children full stop. Yet the government is not supporting such practice-based local measures in favour of grander solutions to address long-standing problems in the adoption system.

There’s no doubt that something has to be done and the government’s drive for action comes from the very top. Michael Gove has taken the lead and adoption reform is one of Cameron’s top ten priorities in the life of his term of office. Those in the profession who are involved can barely keep up with the breakneck pace of consultation meetings and unpredictably changing policy drafts.

The result – everything is going to be quicker, including the point at which children are taken into care. The headline news was one measure in particular, that culture and ethnicity is to be of secondary importance to finding a good home. The announcements were accompanied by powerful and moving testimonies from parents who had successfully adopted children from a culture different from their own. Those who have not had such a positive experience were conspicuous by their absence, although articles did emerge as the days went on.

Whatever your views, it’s disconcertingly easy for the evidence of the lasting effects of culture and background to be shunted into the sidings in favour of the ‘common sense’ conclusion that children are better off in a home than they would be in care, regardless of the consequences later in life.  The seductive comfort of common sense in adoption provides a measure of security and sanctity for almost everyone involved in the adoption process, except for the child who has to deal with this, now and for the rest of their life, and has nowhere to hide.

Many decisions about what constitutes a cultural match are absurdly arcane and are based not on a proper understanding of the child’s history and perceptions of their own identity but on a skewed, mechanistic process that equates ‘culture’ to a sum of their parents’ ancestry and distorts complex reality as much as the common sense approach. I’ve come across siblings who waited and waited because their maternal grandparents were Polish and no white family was considered unless that box was ticked, or black prospective adopters rejected because they lived in an area of London that was predominantly white.

Of course there is some truth behind the government’s apparent wish to relegate culture and background to a minor role. The remedy, however, isn’t an arbitrary shift based on ideology and expediency. Rather, it is about better practice, better assessments and a more preceptive insight into the subtleties of identity. This in turn leads to improved matching, including both an acceptance that perfection is not possible every time but also what does and does not constitute an acceptable deviation from the vital principle of a cultural match, what the evidence is for such a conclusion and how this will be handled, now and in future. None of this is encouraged by the proposals.

Which brings me on to two other problems that I have with the government’s suggested reforms. One is that it views carers as static and unchanging, rather than individuals who can learn, develop and grow into the task of being an adoptive parent. How might they develop, what is their potential and how can this be nurtured? And here’s point two, the thorny question of more post-adoption support, which adopters’ organisations will passionately say is the biggest problem we have at the moment, as opposed to dog assessments or paperwork that the government would prefer to focus on. Both these suggestions, extra training and support post-adoption, taken together require considerable extra funding, so they are not a priority.

Of more interest is the idea that children can be placed with their prospective adopters and effectively fostered until the order goes through. This could make transitions easier and create less change for children. However, it is not without its problems. As Adoption UK point out, adopters want to do just that, adopt. The fact that children may have contact with the birth family while they wait or may be removed if the order does not go through could act as a deterrent to carers coming forward.

As I have mentioned in previous posts, the proposals appear to take little account of the court process. Changes are in the pipeline but parents and members of the extended family will still have the opportunity to prove they are a worthy alternative to adoption. These issues and the time-consuming and resource draining assessments that accompany them can delay an adoptive placement extremely effectively.

I desperately want the system to make good placements for children and young people, and to make more of them. It’s needed now more than ever before. My fear is that the complexity of meeting the needs of vulnerable children hopeful for a stable future will become lost amidst the targets, league tables and rhetoric.