Privatising or Pioneering Social Work Practices

Yesterday, I came across this article on the Community Care website about new pilot ‘independent social work practice’ set up as a social enterprise. It made me pause for thought and ponder a number of things about where social work is going and what social work is.

The article extols the wonder of the ‘Topaz’ team in Lambeth which is described as

One of the six independent social work practice pilots for adult services, it has £91,300 start-up funding from the Department of Health until August 2012.

and explains

The team has three core aims: early intervention, preventive work, and promoting people’s independence and wellbeing in the community. To keep funding next year, it has to show that this is keeping people at home for longer, which saves the council money in care home and nursing fees.

Working with local health services, voluntary, faith and community groups, the idea is to create more resilient communities and raise awareness of services within Lambeth.

People who were assessed in the previous year and deemed ineligible for services are contacted to review whether there has been a change in circumstances.

It sounds wonderful. Really it does. So this team looks at people who might be at the lower end of the ‘needs’ spectrum and works towards ways to prevent a future dependence. It sounds a little like some of the work some voluntary sector organisations like Age UK might have scope to do but the council have gone a different route through this social enterprise model.

Topaz, according to it’s websitealso provides support and guidance to those who are ‘self-funding’.

So why do I have to rain on this parade of wonder and innovation?

Firstly, it’s about my discomfort about the talk about ‘getting back to ‘real’ social work’. What does that mean? Is that disparaging to the current social workers in a statutory setting who don’t get have the same role regarding ‘cherry picking’ those who need to use the services. Or is community social work (which no doubt is very valuable) the only ‘real’ social work that goes on. There’s a little hint of superiority in that attitude that I find discomforting and disconcerting.

The Team Manager says

It’s about improving the image of social work, telling people what we do, how we can help, that we are not agents of control who take children away

Which is great, but you know, sometimes we are ‘agents of control who take children away’.

As I said, I think it sounds like a fantastic project but it employs social workers and pushing them out of local authority ‘bounds’ – it seems very benign and creative – but – I see it as the start of a slope to eventually push statutory functions outside the local authority control and most importantly, beyond the local authority democratic mandate. While that’s fine as long as you are working with people on the fringes of eligibility criteria and having picnics in the park with them, it may carry a very different status when involving more serious safeguarding issues that arise – indeed, that would be my question back to the Topaz team – how do they deal with safeguarding investigations? Do they go back to the local authority for that or hold them within the team themselves?

My other concern is the terms and conditions of those employed in the service – they are employed on locum type contracts – as the article says

No pension, sick pay, maternity leave or job security beyond next year might not sound like ideal terms and conditions. But for a group of pioneering social workers in Lambeth, the risks of working in a community interest company are worth taking because it’s enabling them to do use all of their social work skills.

Well, you know what? I believe I make full use of all my social work skills in the job I have now. And I have sick pay. Who’d have thought that should be something I should be surprised at expecting as a social worker.

And this team won a wonderful award last year in an award scheme which, like most, operate by either self-nomination or endorsement by senior managers. I can see why it is completely in Lambeth’s interest and the government’s interest to promote these social enterprise teams. I can see why they want to be presented as ‘pioneering’ but actually is this going forward or is it going backwards? Isn’t this about the roots of community social work so actually far from pioneering?

Perhaps I’m overly cynical. I do want more scope for social work in communities however I’m not convinced by this model and propaganda which brushes over working conditions and limited contracts will not help allay my scepticism.

Because my worry is that it is a slippery slope towards pushing essential services away from the democratic mandate and when the cuts come, these services which have been presented as the ‘pioneers’ will be the forerunners as far as models go but when the other core services follow, these will be the ones which will be the ones to go when the cuts come. And the cuts will come.

So tell me if I’m wrong or just over sceptical because I want to find hope in the future of social work but I don’t want to be blind to the risks that may exist if we embrace these ‘practices’ without critical thought.

The Costs of Home Care

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

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

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

Also stating

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

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

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

Eligibility criteria are moving upwards.

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

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

More people refusing care on the basis of cost

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

Longer term costs as people supported at home less

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

Personal budgets and the ‘personalisation’ agenda.

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

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

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

Commissioning decisions

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

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

What is ‘support’?

There’s a great post over at ‘The Small Places’ that I highly recommend everyone interested in adult social care read (OK, I do realise that that has immediately cut the proportion of people interested but that’s my brief).

The post refers to a case – A London Local Authority v JH – and to sum up, it is a Court of Protection Case which balances on the Article 8 ‘right to family life’ and presents a different side of it to the rather hilarious example misquoted by our esteemed Home Secretary

Inky the Burmese Blue Kitten

(I wasn’t going to miss an opportunity to post a picture of a cat!).

The Local Authority in question have proposed that Mrs H is placed in a Nursing Home because her husband, while being offered what they describe as a substantial care package, is basically asking for more support than has been assessed as a need and is not ‘wholly cooperative’ with the process of the support.

I refer you back to ‘The Small Places’ for much better detail about the case.

For me, this reflects the reality of social care much more than the visions of personalisation that exist with other user groups like younger adults with disabilities (although that may change with all budgets reducing).

It highlighted some of the thinking of the local authority and what it means to ‘meet needs’ of a person in a legal sense bearing in mind responsibilities under Section 47 of the 1948 National Assistance Act.

The council deems that 52 hours of support are needed. Mr H feels that he needs 63 (which had been offered in the past when the package was funded through continuing care procedures).

The council offers 3 hours of respite and Mr H feels he needs24 hours of respite.

The council offers Mr H a direct payment (I bet they really wanted him to take that to absolve themselves of some of the responsibilities) but he refused.

The council deemed that Mr H was ‘uncooperative’ because he did not agree with the package which they imposed on him.

He is quoted in the judgement as saying

“If I have refused services on her behalf it is because of our frustration that she was not provided with the level of support that I was told she would receive.””I found myself so frustrated by the lack of support from social services I gave them an ultimatum, provide us with the support we require or do not bother. I had reached the end of my tether at this point …”

He feels very let down by services. He thinks that the financial cuts are more important than patient care.”The judge in the case found that Mrs H should remain with  her husband and receive care at home and work with the local authority to establish a support plan but there are a number of assumptions made by the local authority that override the underlying process of choice for the service user and, in this case, carer.

He had been offered 3 hours respite a week and the local authority were not adapting their criteria to look at his individual circumstances. He was offered care in a particular way at particular times.For me, this is the reality of people receiving care in their homes. Different faces, different professionals who claim to ‘know better’, different carers, different nurses, all asking for keys for access or asking for equipment to be installed in what remains a family home.

The one thing that strikes me what can appear to be the tyranny of the system I am a part of. We dictate. We ‘know better’.I thought this was supposed to be behind us with the new way of working towards ‘personalisation’ and ‘personal budgets’ where everyone can CHOOSE.

Mr H was offered a direct payment where, no doubt, he would have had more flexibility to decide his wife’s care but his choice was to refuse it and have assistance in managing the care package. His choice remained a Hobson’s Choice

I think anyone working in social services and adult social care should look at the way we offer choices and what choice we are actually offering.‘You have been assessed as needing x hours of care’ when x = the bare amount needed to continue to exist’ isn’t much of a choice.Even less so if your ‘choice’ involves not taking on direct payments which  is the way the government is pushing.Unfortunately, ‘A London Local Authority v JH’ has much more reality for me than some of the idealised ‘personal budget’ planning models that are knocking around various government departments.I’m glad this case came to court and am only disappointed that there has not been more press interest in it because it reflects a reality in social care that really needs to be addressed and challenged if there is every going to be a transformation in the way that services are delivered and that includes my taking a long and hard look at myself and the way that I become a part of this system while considering the best ways to challenge it at the same time.

I became a social worker to embrace ethical practice, not to file it away with my pay check.

Social Care in a Time of Cuts

When I went into social work, and still from time to time, I come across more experienced colleagues who have been working in the field for far longer than I and they tell me about the ‘golden era’ of social work.

They tell me about the joys of real generic social work where they might start the day liaising with foster carers and end the day supporting an adult with a mental health need. Where they might have been involved in ‘real community work’ rather than the staid and procedural role that seems to have forced its way into the profession in recent decades.

It seemed to me, as an extension of the human propensity to reminiscence about times and experiences ‘in the past’ with a certain sugar coating. Just as ‘schooldays are your happiest days’ type memories.

As I move through the stages of my career, such as it is, I feel some mild thoughts of ‘how it used to be type nostalgia’ creeping into my own narratives.

I never thought we had particularly ‘good’ times but when I compare the types of care planning and support that was available and look at the bare bones of support provision now, I can’t help but thinking that perhaps we are moving backwards as opposed to forwards.

Social Work in a time of cuts presents a whole new world of ethical dilemmas that previously we might not have faced.

There are some improvements. The roll out of  ‘Direct Payments’ whereby people who  need services were ‘given’ the pot of funding available and were and are able to choose ways to spend it on different and more creative services has been a big step forward.

However this has led to the ‘personalisation’ agenda or the ‘transformation’ agenda or ‘any-kind-of-large-mostly-meaningless-word-you-want-to-add’ agenda which wants to use this model and extrapolate it out. While this certainly provides better systems for some groups of people, the agenda has left others behind, but I’ll come back to that another day.

Regardless of the detail the fact that choice is extended (however poorly in practice it is done – and it is done poorly) and that users are put at the heart of service provision is generally a good thing.

It’s a shame that the push towards ‘choice’ has come in an era of cuts or perhaps it is and always was wholly inevitable. We are seeing an attempt to push the responsibilities present in the NHS and Community Care Act (1990) and the National Assistance Act (1948) away from local authorities and towards individuals. For some individuals this is wholly appropriate and welcome but as we march towards another type of ‘one size fits all’ provision I do worry where it might lead.

We have fewer provisions to ‘hand out’ and eligibility criteria are rising so that fewer people fall into the ‘service user’ category. As a result, fewer carers will be entitled to what sparse support is available for them and the local authority responsibilities shrink accordingly.

My hope as a part of this blog and as a social worker who has and does work with adults is to monitor and process the ‘dying of the light’ or perhaps, on a very negative day what might be perceived as the ‘dying of the support’.

While less state involvement is exactly the right thing for a lot of people, we have to remember those for whom it remains necessary. The old tired ‘throwing the baby out with the bathwater’ phrase can be overused but I’m going to take the liberty of referring to it here because it explains to me what I see as happening to our social care and health services at the moment.

We, who see it from the ‘inside’ have a duty to report and share with those who might not be aware as it’s happening.

We need to fight.