Adoption: Threats And Divisions As Gove Loses Patience

We’ve known for some time now that as far as working with children in care are concerned, adoption is the government’s absolute priority. A series of announcements over the past 15 months or so have focused on different aspects of the process. Last week came the latest and potentially most radical, where failing authorities could be stripped of their powers, which would be handed to the voluntary or private sector. There’s £150m purely for adoption, new resources but it’s not new money because it comes from cash previously earmarked for early intervention. Michael Gove just got serious.

The new money for adoption is £150m previously earmarked for early intervention, an area where Surestart and other preventative initiatives that aim to keep families together have already been decimated. A few days before this announcement, Eric Pickles stated he wanted to cut resources available for troubled families. The agenda could not be more stark – prevention and keeping families together is less important than adoption. With devastating irony, this most ideological of decisions uses money specifically set aside for evidence-based initiatives.

Politicians and practitioners agree that the shortage of adoptive carers has to be robustly addressed but surely not at the expense of other children in need. The government’s attempt to say that one sector in need is more important than another smacks of the way their divisive language around the welfare and employment debate tries to set working people against the unemployed, the rest against the “shirkers and skivers”. Child care is a continuum, with support for keeping families together at one end and adoption at the other. They may appear to be poles apart but in fact they are part of the same whole, far more closely related than is convenient for the governement to acknowledge.

Evidence shows that large numbers of children come in and out of care. In foster care, for example, providers have noticed that the rise in placements due to the higher numbers of children coming into care has been accompanied by an increase in the number of short-term placments, where children then return home. It is easy to forget that the original intention of section 20 of the Children Act where children and young people can be accommodated with the agreement of their parents was designed to maintain the ties between children and their families rather than close the door, and that families could use accommodation as a service, a week or two’s respite while they sort out problems with the help of their social worker so that the child can return to where they belong, in a safe, caring home. The Act became law in 1991 but sounds like ancient history. I may as well be writing in Sanskrit for all the sense those last few sentences make in 2013.

On a personal level, as someone who has worked across the whole spectrum but more recently in fostering and adoption, I feel dirty, as if I’m using money that’s been pinched from a child’s piggy bank. This is how awful this low, underhand and cold-blooded financial conjuring makes me feel.

The decision encapsulates all that is wrong in that dark, dank place where politics meets planning for children’s services. These are themes I’ve written about before. Prevention leads to better services and saves money in the long run whether it’s children in care, health and safety or gritting the roads before forecast snow falls. Yet for the government, any government not just this one, there’s little reason to invest in the long-term because another administration will reap the benefit, be it another government or perish the thought, another lot of politicians from another party. Yet we will know the success of our work with children in care only when they are well into adulthood, and anyway, even then people change as they grow older.

Adotpion czar Martin Narey, now Sir Martin, said this week that if even half the children on the waiting list are adopted, that would produce huge savings. He’s right of course, and he’s right to say that children should not have to languish in care with only the hope of a family to hang on to. Where I fundamentally disagree is that one element of the continuum should be prioritised at the expense of another. The twin goals of long-term savings and better choices for children and families for children in need of help from the state could be achieved by investment in early intervention as well as in adoption, not instead of. Also, even if the adoption backlog were cleared, there are others coming through the system in greater numbers than ever before. They too will need placements and the resources to find them. Further, adoption is not the only route to permanence. Evidence demonstrates the value of long-term fostering for many children and for their carers who receive support throughout the placement. These placements cost money but the children are worth it.

I am delighted that the government has made the welfare of children in care a priority, the first to do so in recent memory. However, it’s hard to escape the conclusion that for this long-term, complex issue they are seeking a quick win, the headline and the soundbite that goes with it.

More irony: government proposals in the pipeline won’t grab the headlines but are far more interesting and relevent for me as a practitioner because they directly address many of the problems in the existing system. Most important is the review of the court process that maintains a steadfast focus on the needs of the child within a clear timetable and minimises drift. Support for adopters will increase, with a look at personal budgets so they can decide what their family needs and how to sort out any problems. The purpose of the new national Adoption Gateway is to make it easier for prospective adopters to find out more. Changes in the inter-agency fee place the voluntary sector on the same level as authorties, thus widening the pool of adopters. Finally, there will be more organised gatherings of prospective adopters and children, sometimes called adoption parties. This is a direct result of an evidence-based study by the British Association for Adoption and Fostering that was properly researched, funded by the voluntary sector and fully evaluated. Taken together, these initiatives will do nothing but good. I fully support them. Evidence not ideology.

Every now and again any system in any organisation needs a good kick up the backsidebut in my experience, threats are far less effective than committed, considered leadership that understands a problem and sets goals for change. The government has quickly tired of what it sees as intransigence in the sector. Last week we heard that councils who do not respond will find adoption services removed entirely from them and placed in the hands of the voluntary and private sector. The appearence of the private sector is noteworthy. This requires a legislative change as private companies are not able by law to become adoption agencies.

Once more we are seeing divisions rather than partnership. The voluntary sector wants to work alongside local authority partners. Legions of dedicated, able local authority social workers want to find more adopters, not to be excluded from the whole process. We have to work closely with communities to find more adopters, for example more black adopters, rather than becoming ever more distant. Change must be accomplished by working with the sector not against it.

That Old Chestnut

[Guest post by Sharon Levisohn]

Mother came home from hospital on Friday, having been in over Christmas and New Year. She has advanced COPD (emphysema) and had a respiratory virus that resulted in pneumonia.

However, her lengthy stay was not due to her illness – a week of steroids and antibiotics settled that insofar as it could be – but the inability to plan a discharge to meet her ongoing needs. The hospital wanted to send her home with three (local authority funded) home care visits plus daily district nurse calls. The social worker could not authorise the home care package without it “going to panel” and of course there would be no more panel meetings until January 7th. Then the hospital suggested a nursing home placement but, despite full-time oxygen dependency and limited mobility, my mother did not meet the criteria for a funded admission. Next they suggested a short admission to a cottage hospital. That was rejected as they thought, frankly, that the journey would kill her. Plan D was to be discharged home with the support of the (health-funded) Re-enablement Team; however, she was not open to this as her condition was too far progressed for rehabilitation. All this time, Mother was in an acute bed – one of those infamous bed-blockers – on a ward with confirmed Norovirus, while the family and I rode the Waltzer of uncertainty and conflicting updates, always aware that she might just give up the long battle with COPD.

What is the point of this personal anecdote of woe over the festive period? I suppose it is not a unique case; even on the ward there were several other patients unwillingly playing the Cherchez La Femme game of discharge co-ordination. How many patients and families in how many hospitals were going through similar experiences? What vexed me – and as a former nurse I am not criticising the frontline ward staff – was that the hospital did not seem to know what qualifying factors were applied to the various options – one might have assumed that they had confirmed Mother’s eligibility before informing her and the family only to dash their hopes. The other bugbear is the responsibility for funding. Surely, if a risk assessment has shown that a frail elderly terminally ill patient has been assessed as needing input from various agencies in order to be at home with the people and dogs and personal touches she loves, which give her a little quality of life, and if we believe that it is better for the elderly to live at home so far as is possible, surely then the funding needs to be provided? Or shall we simply abandon that principle as practically unviable?

Rotherham: Truth and Politics

The only time I read my local paper is at the Indian takeaway. Whilst waiting for my korahi chicken yesterday evening, I disinterestedly flicked through the familiar mix of parking problems, noisy neighbours and oversubscribed schools. I nearly skipped the article buried on page 11 about a man who died after an error from his GP, because I was pondering whether to order a popadom. Then I stopped and read it: it was my GP.

Our doctor is kind, caring and hard-working. He treats people as individuals and always makes time for them. On this occasion, the surgery computer system did not indicate that the prescriptions for the drugs his elderly patient required for a heart condition had stopped after the man was released from hospital. Several months on, he relapsed and sadly died. The coroner praised the doctor for his honesty. I can’t recall the actual verdict but the death could have been prevented.

Today’s Daily Telegraph didn’t lead with an avoidable death or for that matter any death. The case of foster carers who allegedly had children in their care removed from them because they were UKIP members has run on all media. It’s been top of 5Live news all day, for example. You would expect Nigel Farage to have an opinion but Michael Gove has swiftly weighed in too. As I write, Milliband is being quoted. Cue outrage at social work.

If UKIP membership is the only reason why these children were moved, I don’t agree with it. They should have stayed where they were. The council said on the news this morning that the children were going to move on anyway. This may be the case. However, the original Telegraph report says the boy was moved the following day and his two sisters soon after. If this is accurate, it does not sound like a planned move to me.

I qualify my remarks with ‘if accurate’ for a couple of reasons. Firstly, the report does not appear to have any corroboration from other sources. They may exist but it’s based heavily on the carers’ account. I thought journalists cross-checked, especially on a headline story, but this is different.

Secondly, it doesn’t chime with my experiences over the years. Judgments about the capabilities of  carers are never made on the basis of a single piece of information, unless of course it relates to a child protection matter or allegation, in which case prompt action must be taken to safeguard the child.

In this case, you would like to think that other evidence would have been considered, such as the history of the carers over their fostering career, the progress of the children in placement, any evidence that the actual behaviour of the carers had negatively impacted on the children (as  distinct from their membership of a political party) and the wishes and feelings of the children. Bear in mind that the Fostering Standards prohibit changes in children’s careplans without consultation unless there is a real and immediate need. If the local authority has other information, they could not possibly break confidentiality and share it publicly, which offers no protection to the storm of media outrage.

Some of the criticism is misinformed. Farage was calling for the immediate reinstatement of the carers but they are still approved carers, it’s just this placement that has ended. Also, he might think about considering the children’s needs first, which is the law after all.

However, what is most significant is why this is a story at all. My doctor will carry on practising, as he should. The competence of the medical profession has not been called into question because a man died. Yet in the case of the Rotherham foster carers, the ability of the entire social work profession has immediately become the issue. This is all the corroboration the Telegraph needed. We know social workers do this sort of thing, don’t we. Leaving aside the fact that as I have already suggested, any judgement is based on incomplete evidence, this is not about the actions of individual social workers or even the authority itself, it’s about how lousy our profession supposedly is in making these judgement.

The implication clearly is that social workers make snap judgments based on dogma and preconceived ideas. More than this, we are driven by political ideology. In much of the coverage, this deeply flawed and prejudiced perspective has not been significantly questioned. This must be the case – what other reason could there be? It shows how little the public still understand about what we do.

This may have been a carefully considered decision or something that was rushed. It could have been a wrong decision. If so, hold up our hands, but it does not prove one single thing about how social work as a whole assesses the needs of children.

You would think the minister, our minister, might at the very least inject a sense of perspective. Not so. “The wrong decision in the wrong way for the wrong reasons,” he said. I humbly suggest he cannot know that for certain. But there are bigger issues at play here and it suits him to use the profession for which he is responsible for other reasons.

Rotherham is holding a by-election. It’s Labour-held, therefore this decision is the responsibility of the Labour authority even though it would have been made by social workers, i.e. officials not politicians. The assumption that this is a political issue has not been called into question. No coincidence.

Also, the consultation period for government proposals to diminish the significance of culture and origin in decisions about adoption placements is coming to an end. This has been well-trailed over the past year – see some of my previous articles – as a way of removing what the government characterise as impediments to swifter adoption. It’s an important proposal that has considerable opposition as well as its proponents. Whichever position you take, it’s disturbing that a matter about the health and well-being of three little children and public confidence in social work becomes a chance for political points-scoring.  We might look back at this episode in future and ask if anyone truly cares.

What The BBC Can Learn From Social Work

One of the biggest problems faced by the social work profession is that everybody else thinks they know what we do, and most of them think they can do it too. Not the nasty bits like taking children away from their families, but knowing when a child is being neglected or abused. I’ve written about this before. It undermines our credibility as a profession and limits the effort people make to understand what we do because they believe they already know the answer.

I have the same relationship with the BBC. The reality is, I don’t know what’s really going on during this latest schmozzle (see how I’m avoiding the ‘c’ word there) but I’m firmly convinced that on the basis of having some contact with the corporation on virtually every day of my life thus far, I understand exactly what’s happening.

From Danny Baker to Jeremy Paxman via David Mellor, the message bellowed by anyone who has a microphone thrust in front of them is that the BBC have too many managers. The Newsnight contretemps (neatly sliding past the ‘f’ word) is full of poor practice but also raises issues that are pertinent to most organisations, about who takes decisions, how much senior managers know about any given topic, how much they need to know and how much power is delegated. Whatever is going on, those sorting out the mess would do well to pause and make considered choices about how to maintain the balance between the professional discretion that encourages creativity and the compliance that spends so much time ensuring things get done the right way, not enough gets done.

Despite Munro’s attempts to focus on practise, children’s social work remains in the grip of a risk averse culture. The waves from the so-called Baby Peter effect are slowly becoming ripples but their effects are still being felt. This manifests itself in a variety of ways. The most noticeable is the high level of care applications before the courts but it’s all around us. I’m writing this in my lunchbreak, seeking respite from a tender application for fostering provision. At this opening stage, the authority will base its decisions on just three pieces of information – the price, the training programme and the Risk Assessment Procedure. Nothing about the quality of service provided for children or outcomes. It’s a revealing insight that lays bare the authority’s current priorities and concerns.

However, the culture of compliance is deeply embedded into the very structure of child care planning. The question has to asked, is this the most efficient way of taking the best possible decisions for vulnerable children and young people?

I’m in favour of built-in checks and balances, and also of the value of independent scrutiny. However, the current system is confusing and stifles the creativity of professionals who work face to face with children, young people and their families, precisely the point where the best social work is done. The balance has to be right.

The Care Planning, Placement and Case Review Regulations in England became effective in April 2011. Reacting to long-standing problems in the planning process, they made it a requirement for foster carers and children and young people to be fully heard and responded to in reviews. They also gave the Independent Reviewing Officers (IRO) greater authority. For example, anyone with a significant interest, including the child or young person, can contact them at any time should there be a problem or implementation delay.

In principle I’m in favour of this. Note the role of the IRO has been beefed up because of perceived failings in the system with poor decisions and lack of implementation resulting in drift. Potentially, however, it creates uncertainly and a lack of clarity.

Typically, the child’s social worker has most contact with the child, their family and their carers. In the current climate, they are at best wary and at worst disempowered from taking the decisions relating to that child, deferring to their manager.

At the Review, the IRO creates the Care Plan. In my experience, team managers sometimes feel powerless. Recommendations may be made that the manager disagrees with or for resources that may not be available. The Care Plan goes back into the mix. The manager may say the resources are not available. Increasingly, the manager and social worker have to go to an eighties-style resource panel where the recommendations of the care plan are effectively reevaluated, but crucially in the absence of key participants.

Meanwhile, the IRO, who as an employee of the local authority is not as independent as their job title makes out, is now feeling undermined. One said to me last week, ‘I despair. This is the third review in as many weeks that when I’ve come back to a key decision I took 6 months ago, nothing has happened due to resource constraints.’

Being connected to but outside the whole process, people talk to me, and anyway I have a kind face. I’ve also got the time to stop and listen, unusual these days. The thing is, managers and social worker feel exactly the same – disempowered, undermined and uncertain. Who exactly takes the decision? It feels sometimes as if any decision is temporary, subject to review at any time. Children require consistency and stability. It saps morale. Managers complain about IROs, IROs grumble about standards. Disharmony where everyone should be working together.

Compliance also takes its toll at an organisatonal level. Independent residential and fostering providers are snowed under with quality assurance demands. Again, I fully accept why this is required and both authorities and children have a right to know they are getting good value for their money and that the best possible standards are in place.

However, it is astonishingly time-consuming and costly. As in any business, those costs are passed on. The unit cost of any placement increases because more backroom staff and/or systems are needed to provide the seemingly endless flow of data for tenders and compliance. And that’s not including Ofsted.

In fostering, although a National Contract exists, few use it. In consequence, all authorities require what is effectively the same information but in an ever-so-slightly different format. This is complex, draining and favours large organisations who can pay for their own compliance unit.

Let me make it perfectly clear – IROs, social workers and their managers undertake some phenomenally good work that benefits so many children. However, in a signficant number of cases that I come across, they are hindered by the system, not helped by it. The unintended effects of well-meaning processes suck up both resources and precious energy. Professional creativity and innovation are stifled. The balance has to be right. The BBC would do well to learn from social work’s mistakes.

… And they’re off! But it’s a disappointing start for the Mental Capacity Act

In the line-up for the 2007 legislation Grand National we see the return of some old favourites.  Waiting for the starters’ orders are the Mental Health Act alongside the NHS & Community Care Act. We also see the return of the Chronically Sick & Disabled Persons Act and … surely not … Yes it is, the National Assistance Act is back for another plod around the course, surely he should have retired by now.  We also welcome along one of the favourites this year, in his first year of entry, the Mental Capacity Act is confidently waiting for what must surely be a resounding victory for all those he represents.   They’re under starters’ orders, and they’re off …

… but it’s a rather lack-lustre performance from the Mental Capacity Act 2005 (MCA).  I’m probably not the only one slightly disappointed by the sluggish start; 5 years into the MCA I have to admit that things probably haven’t gone as some of us may have imagined.  I was prompted to write this blog having recalled a recent occasion concerning a gentleman with a learning disability. He asked his carers for support to obtain an application form for a driver’s license and then to complete the form. Instantly, the carers decided that it would be far too dangerous for the gentleman to be driving around and, quoting the MCA, in his ‘best interest’ decided that it would be better if they didn’t support the gentleman to obtain and complete a driver’s license application form. I think the only correct consideration of the MCA were the two words, ‘best interest’ and even they were out of context! On every level, they failed to apply the MCA correctly or even remotely well. If  they had, they would have approached the decision from the assumption that the gentleman had capacity (which, interestingly he did) and provided the support he was requesting in the first place.

This of course isn’t an isolated incident and only recently was also reported about on the Community Care website.  Poor application of the MCA is widespread, it crosses all levels of care professions and it has to be addressed for the sake of those it should be protecting. If I were the MCA, I would be suffering from a complex right about now. Being misrepresented, misquoted, ignored, it’s enough to make even the strongest legislation question themselves!

Some organisations see the importance of MCA training, but where I often see a glaring hole is in people’s ability to apply the principles and use the MCA as the framework it was intended to be. People can usually quote phrases, provide general themes or even list the 5 principles of the MCA but that is often where knowledge and application stop. Carers and professionals alike should be discussing it daily, in team meetings, formally in supervision and informally. They should be applying it to all decisions being made and actions being undertaken on behalf of someone who may lack capacity. They should be questioning everything and inquisitively discussing whether any action or decision being made is the least restrictive or whether a seemingly unimportant decision made by carers or professionals has just had a significant impact upon individual.

The MCA doesn’t have to be a complex piece of legislation unattainable to anyone who doesn’t have a law degree.  It even comes with a very user-friendly Code of Practice to which of course, anyone working with an individual who may lack capacity must have regard for.  But it does have to be a piece of legislation that is used well and frequently by all concerned to ensure that we really do act in peoples’ best interest.

Home really is where the heart is

Home really is where the heart is.

My other  (less political) blog on health and social care. The above  post summarises a recent report  published on home care in England.

Tell Tim He’s Sacked

One cold evening a couple of years ago I went to hear Tim Loughton, the former Children’s Minister shuffled out of the pack yesterday, speak at a meeting of the All Party parliamentary group for children in care. We queued to the sound of shrill chanting and ominous bullhorns. The Comprehensive Spending Review was being debated in the House, the first indication of the true extent of the government’s spending cuts and Whitehall was closed to traffic as a protest rally gathered.

Accompanied by two young women in foster care, we dawdled through Westminster Hall and the corridors of power. It’s a privilege to be so close to government, never to be rushed. As we hung around in the lobby, the division bell sounded. Members appeared from all sides and dashed into the Commons chamber. They left the door open for a while so we could peer around the corner to see democracy in action.

Given the significance of the evening’s events he could have easily been excused but to his great credit, Loughton appeared as scheduled to address the packed committee room full of young people from all over the country. His speech was a characteristically robust endorsement of the value of foster care and the rights of children and young people in care to the same opportunities as their peers.

With the eloquence of experience, a succession of young people politely but firmly pointed out the flaws in his argument. You say education is important for children in care but you’ve just voted to do away with educational maintenance, the money that supports us. You say jobs are important but unemployment for young people is rising. You say we all deserve good foster carers but there’s a chronic shortage of resources to recruit them. Thanks for coming, though.

And that’s Tim Loughton in a nutshell. Unfashionably sticking up for children and young people in care and defending the social work profession whilst simultaneously his Cabinet eviscerated the resources he claimed were in place  to support them.

That night Loughton bobbed and weaved with the skill of an experienced politician, riding out the storm without properly satisfying anyone in his responses. Most ministers would have ducked out: he was there because he wanted to stay. Loughton is no placeholder or careerist. Shadow Children’s Minister for several years before coming to power, this is the portfolio he sought and prepared for.

The former minister is extremely well-informed about fostering, adoption and children in care. Unusually his main source was the people involved rather than his civil servants. Over an extended period he’s taken the time to understand the sector by making himself available to children, young people and carers. He created a telephone hotline, “Tell Tim”, and met regularly with organisations representing young people and carers, offering an unprecedented degree of accessibility. Last night on twitter they lined up to thank him and praise his commitment. For a group who voice is seldom heard, his willingness to listen meant an awful lot.

One of the things children and young people in care told him was that they were fed up with needing to get permission from social workers for school trips, holidays, activities and sleepovers with friends. You couldn’t mark them out as more different from their peers if you felt-tipped a red cross on their foreheads. A group of young people confronted him on television about this. Loughton shifted uneasily under the pressure, yet he delivered on his promise to respond. His first act as a minister was to write to local authorities to remind them that they had the power to give foster carers discretion on these matters. I showed a copy to one of the young women who appeared in the programme – “You did this,” I said. Now it’s enshrined in the revised Fostering Standards. The fact authorities have still not got the message is not his fault.

It’s not all so positive. He defends social work yet I’ve heard him dismiss the content and nature of assessments with the sarcastic panache of a Daily Mail leader writer. His promised fostering action plan is still to materialise. Hearing him several times subsequently, I continued to admire his grasp of the fostering task whilst growing weary of disingenuous references to the deficiencies of authorities he knew full well were tottering under the burden of  his government’s cuts.

Ultimately his departure may say less about the man and more about the government’s perception of the sector. The adoption agenda has been dominated by Gove and Cameron. Martin Narey joined the chorus of praise and regret but in terms of policy creation made him largely redundant.

They have seized the big issues, relating it to other props of Tory policy around the family and budgets cuts. In this world, an understanding of the details, of the everyday problems facing children, carers and social workers, gets in the way. The struggles with resources, with finding the right placement, with whether a child can stay with her friend this weekend, have little significance. More than this, they may actually obstruct the agenda for change because they don’t fit together with policy as neatly as the Department may wish.

Yet these are the issues that make life better for children and young people in care. For children and carers alike, nothing is more important. Gove’s distance from this awkward day-to-day reality leads to dogmatic policy. It leaves you to wonder if there is ever a place for any minister who thoroughly masters not his brief but an understanding of the people affected by it. It’s hard to understand social work. Loughton did, but in the end all it got him was the sack.

Is Social Work necessary in Assessments?

Hot on the heels of a story which extols the virtues of a ‘new’ social enterprise set up by social workers in Lambeth, comes a report from the Audit Commission, published yesterday, which urges councils to reduce spending on qualified social workers in order to save money on assessments in adult social care.

In some ways, it’s very easy to see these two apparently separate news items discretely but it’s also too tempting to run them together to see a pattern of where adult social work is heading.

Audit Commission Report

I briefly read through the Audit Commission report this morning – it is intended for ‘managers and senior managers in adult social care’ and the scope is to look at how local authorities can save money through the assessment processes in this sector in order to have more money to spend on care services.

Interestingly, it pulls out the ‘personalisation’ card in terms of identifying the different ways that assessments are being conducted (more self-assessments – for example) – and that’s true but I hope I would have always put the individual at the centre of every assessment I did – even before ‘personalisation’.

An assessment is a key to eligibility in adult social care and with self-assessments being introduced, it is basically allowing people to self-exclude earlier in the process without having as much professional involvement – which actually, isn’t a problem for those who are below the criteria but what the report misses is how much the process of assessment by a skilled person (whether qualified or not) can scratch the surface of the forms that are completed – particularly when the forms are tailored towards people with physical disabilities and physical health problems – and uncover needs that would meet the eligibility criteria.

The report pushes the somewhat dangerous opinion (in my view) that delivering personalised services will necessarily create lower costs. That’s a stumbling block which has led to poor implementation in my view. I actually don’t have any problem with support planning/brokerage and assessment being pushed to different organisations – but it still has to be done well. It’s interesting that while the Topaz team in Lambeth are looking at working with people who fall below the eligibility criteria, local authorities are looking at people who are eligible having more support from less qualified people – to save money. Lets not forget that’s what it’s about.

But I don’t want to get too fixated on the qualified/unqualified dichotomy because qualified doesn’t always mean better. But it doesn’t mean worse, either.

A paragraph in the report refers to savings being made in ‘back office’ roles – well, honestly, there is a greater need for administration and ‘bureaucracy’ in personalised care packages because we want to be able to offer people different options to manage their own care – either direct payments, individual service funds, trust funds or managed budgets. Of course we don’t have all those options available for all (yet) but imagining that costs can be cut by reducing ‘back office’ roles is honestly, facile. Cuts to ‘back office’ roles has and does put much more pressure on ‘frontline’ jobs. False economies in the extreme.

The report talks about improving online information and.. oh.. leaflets to provide information and to (they hope) deter people from requesting an assessment in the first place. I can see that being useful – and I’m glad they didn’t get ‘online overboard’ and some of the sites produced by local authorities to signpost people are appalling so it’s good advice, it’s just sad to think a report has to be compiled to give that advice. It is a bit depressing that call centres are seen as a solution in any part of social care though particularly when the role of the call centre is to ‘reduce the need for formal assessments’ – in other words it is to filter people out of the system at an earlier stage – so much for preventative work.

The headline of the report though – is that it recommends ‘changing’ the skill mix in adult social care to ‘reflect’ personalisation by shifting from social workers to social work assistants and that’s where some of my main concerns and thoughts lie.

Does a ‘professional’ need to Assess?

Having worked in adult social care teams, I know that there are some awful qualified members of staff and some fantastic non-qualified members of staff. Experience levels vary and I don’t have a problem with a mix of staff. I have no problem with some assessments moving away to third sector organisations and user-led organisations in particular (I will not give a wholehearted ‘bye’ to social enterprises though as I believe ‘social enterprise’ is a VERY broad term that can have a lot of different meanings). Some assessments are basic, many assessments are best completed without the need of any input but some, and this is the key, really do need expert input. Sometimes it’s the conversation that arises in an assessment (which, by the way, is not merely a ‘form-filling’ process) that can lead to further information being garnered. The more lax the assessment process, the more likely that opportunities to provide ‘early intervention’ or identify harder to define needs may be lost.

I mentioned above that all the assessment processes I’ve seen from adult social care are very biased towards physical health needs – it can take a more skilled assessment to draw out mental health needs or more complex family dynamics between the person being assessed and their families. I worry that bypassing the importance of assessment and the skill needed, we may lose carers’ needs which need to be identified much earlier.

So while I don’t think a ‘professional’ needs to assess in every case, what is very important (and missing from the Audit Commission report’) is an appreciation of the importance that professional training, experience, understanding and working with social work theories relating to assessments and an understanding of current research and a commitment to reflection and sensitive communication is and can be to assessments and safeguarding process.

What is social work?

In many ways, this is the key question for adult services and one that has been asked for years – since the move to the ‘care management’ models after the NHS and Community Care Act (1990) was enacted and it became clear that care management was not a social work exclusive role.

The question is more easily answered, I think, in children services and in mental health services where the social work roles are, I think, better defined. Perhaps the separation and specialisation into different ‘fields’ has damaged adult social work more than the others as it has become harder to define.

In adult social work there’s a need for a much stronger professional voice to explain and expound the importance that social work training has in delivering effective outcomes all round. Assessment is a skill and skills can be trained but it need to be linked with knowledge, understanding and reflection to create a picture in more complex (and sometimes the step between simple and complex can be one question, one statement, one gesture) situations.

As a society we undervalue the social work training and role at our cost but increasingly, I can see the role for social work being pushed back to safeguarding functions and ‘complex’ work – that’s easily said and I’m sure it appeals to the Audit Commission but it’s important for us, our professional bodies such as the College and Adult Social Care departments and academics to push that we often find the ‘safeguarding’ and ‘complex’ work by doing some of the things that could be done by ‘someone else’.

Where next

Community Care has responses from BASW and the College which say similar things. I think it’s important that as social workers in adult services, we also prove our own worth internally. We talk about research we have read in team meetings, in our supervision, we explain why we did what we did in terms of the theories we know and use. We talk professionally, we respond professionally and we become what we want our profession to be.

We need to all take responsibility to prove our own worth.

picture by KatherineKenny at Flickr

A look at ‘Caring for our future : reforming care and support’

A rapid chase through the Care White Paper

The government published it’s long overdue Care White Paper yesterday. There’s been time for a significant amount of coverage to push through to the media and I don’t want to repeat information that’s out there but rather provide a response/analysis from where I am and where I see it. There is a good summary on Community Care though.

It’s a hotch potch of a document. The words are pretty but there’s an underlying tone of ‘saving taxpayers money’ which shines through from every good intentioned statement. Saving money isn’t a bad thing but I wonder how much the intention is to change the way the market in care is delivered in line with the NHS Bill and how much is to actually change the philosophy behind the process of care. I doubt the government’s good intentions.

The White Paper divides into eight chapters. So I’ll follow that pattern in my review of them.

Chap 1: The Case for Change

Here, the paper itself sets out the current difficulties in the system as it is at present which is reactive to crisis rather than focused on prevention. I can’t help feeling a little cynical in noting even the current system wasn’t intended to be this way, but has developed as such due to the pressures on funding.  The government line is to prove the point about crisis response but that’s not really been the agenda all the time.

Believe it or not, there was a time we met ‘low’ needs and while accepting there is a financial limit, the demonisation of the system is hardly a true reflection of what was envisaged and more should be learnt about the ways that systems imposed develop into a ‘race to the bottom’.

So the paper suggests that the answers will be found by providing more services sooner in the process of ageing or a disabling condition.  We will have more support for carers and will be promoting communities to provide support within themselves.

People need more information, without doubt, and that will be provided. That’s hardly revolutionary but too much has been down to local differences – the old ‘postcode lottery’ arguments. This will be clarified so people can move around the country and know what they will be able to expect.

Interesting that the ‘opportunities from reform’ all seem to revolve around financial benefits. It’s a valid benefit and opportunity but an interesting angle so

‘Promoting people’s wellbeing and independence’ will ‘limit future demand for care and support and help to ensure taxpayers’ money is used for effectively’.

Support for carers will enable them to ‘remain in the workplace’ which will ‘support economic growth’. So THAT’S why they are so keen to support carers – don’t want anyone to think that ‘caring’ without pay for a family member isn’t a valid and essential economic contributor.

and ‘Supporting businesses to grow’ – which is maybe what choice is all about.

I’m not against these agendas but I think the framing in economic terms is very very interesting.

Chap 2: Our vision for care and support

Understandably and quite rightly there is a high proportion of ‘control’ wanting to be distributed from top down to users in this section of the White Paper which is all well and good. It’s been (rightly) the movement of travel and needs to go further. As someone who works with people who have not been able to benefit fully from the ‘choice and control’ agenda, I was particularly looking for things that would help and support the people that I work with here.

There’s a lot of focus on promoting communities in being active and enabling to those living in them. There’s a need to promote better information streams – quite rightly – the system is enormously complex and I spot a little line on page 19 about ‘supporting the transformation of the social work profession’.

So the role and place of the local authority to provide care and support will be changing as it says

‘instead of purchasing and providing care and support, authorities will increasingly be expected to take a leadership role in a local area’. That should be interesting.

Chap 3 ‘I am supported to maintain my independence for as long as possible”

So in looking at prevention of isolation and needs the White Paper turns to communities to look for support, quite rightly. There’s a lot of potential here and social isolation is specifically targeted with some wonderful local models explained in terms of the way they work with isolated people to bring them into communities.

Not everyone wants to be a part of a community and there are some people communities tend to be less eager to support but it’s a great initiative for some people and there will be a lovely new Outcome Framework which will identify measures of loneliness for us to work on while local authorities managers and accountants look at ways they can meet targets at low or no cost.

Commissioners will be ‘encouraged’ (whatever that means) to draw on community support networks rather than moving people into ‘formal’ services. I read that along the lines of finding services that are provided at low or no cost but perhaps I’m a cynic.

There’s a line here too about social work pilot schemes which will  ‘liberate’ (I’m VERY suspicious of the word ‘liberate’) social workers from case management. It looks like a push towards more community based social work but I have some concerns. Firstly, case management is only bad if it is implemented badly as a process rather than as a collaboration. Poor case management can have an enormously detrimental effect on someone.

I’m not convinced by social work pilots but will wait for the outcomes of these pilots to see before I make a final judgement. I like the idea of more community work but am worried at what cost it may come in terms of privatising delivery of service and moving responsibilities for provision away from a democratic mandate.

I do like the idea of connecting care homes with their local areas. That is enormously positive and where I’ve seen it happen locally, it has made a big difference. It does seem like a lot of ‘use volunteers’ as the answer to problems but honestly, that’s not a bad thing where there are volunteers. I just wonder if all communities will be as engaged and where there is such a great reliance on community to provide support, what will be done in those areas that aren’t as supportive.

As regards housing, there will be significant investments in housing for older and disabled people. I hope this will encompass people in mental health services and is not limited to those with physical  health needs. There is a muddle over extra-care sheltered accommodation which is described as a way to meet low level needs but also as an alternative to residential care. Oh, I mean a ‘cost effective’ alternative to residential care. Missed the key point there.

Chap 4 ‘I understand how care and support works and what my entitlements and responsibilities are’

Information, information, information. It’s crucial in order to make choices and the government sets out ways, particularly websites, that will provide more information about services and facilities to all rather than just those eligible for them.

Interestingly the NHS 111 number will roll out support for social care. I wonder how this will work as a national helpline when provisioning is so different locally and there will be an extension of services like NHS Direct and NHS Choices into the social care sphere. Look forward to seeing that. I genuinely hope it works.

Local authorities will also be obliged to provide more information online but also in other formats, to those looking at services and providers but it looks like there is intended to be a default move online for many access points – including self assessments online as ‘they provide a better customer experience’. I wonder how this marries with the issues around the digital divide. There will be paper and telephone options available at least.

There will be a national eligibility framework and it seems (although this will only be confirmed later) that it may well be set at ‘substantial’ under current FACS guidelines although there will be a move to a new framework of assessment and eligibility.

People will also  have more options about who assesses them.

‘Our ambition is for many more providers to offer assessment services’. Good business opportunities there and a role for the social work pilot schemes.

Carers will have an entitlement to assessment (which exists) and to the provision of services (which doesn’t at present). I’m glad to see that.

Chapter 5 ‘I am happy with the quality of my care and support’

There’s an interesting diagram on this chapter on page 38 with circles of ‘roles and responsibilities in care and support’ around the ‘service users and carers’ at the centre, with Government, Commissioners, Providers and CQC around them. Interesting that there is no place for social workers. I expect we come into ‘commissioners’ but sad that the profession doesn’t seem to have a place around this diagram and is not even mentioned.

There is talk of better regulation by the CQC with inspections annually (scandalous that they were ever anything but in my view).

Looks like they’ll be a return to some kind of rating system too. Strange that just disappeared.

Statutory Safeguarding Adults Boards will be convened by local authorities with police and NHS organisations inputting to them. There will be further consultation on powers to access someone who might be at risk of abuse or neglect.  Personally, I’d like to have seen more on safeguarding.

Commissioning on quality is emphasised (good) and there seems to be a desire to look at some kind of outcome model to judge this. There’s also an acknolwedgement of the failing of some private care homes such as Southern Cross and

‘Local authorities have a duty to provide accommodation to anyone – publicly or self-funded – who has an urgent need for care which is not otherwise available’ and noone will be left homeless if a provider were to fail.

I don’t doubt that would be the case anyway but more public protection for private companies failing can only lead to additional costs.

Chapter 6 ‘I know that the person giving me care and support will treat me with dignity and respect’.

Here there’s an emphasis on building skills in the social care sector. I don’t believe people go into this field of work to be oppressive or uncaring but the system dictates it and a bullying workplace leads to poor and dangerous service delivery to people who have higher needs.

The government claims to be committed to the plans of the Social Work Reform Board and that the College of Social Work will play a heavy role in improving standards of education and training in social work in universities.

The White Paper supports the position of Principal Social Workers in Adult Services and part of that role will be coordinating feedback from frontline practitioners. I look forward to having one locally as I have a lot to feedback.

Chapter 7 ‘I am in control of my care and support’

Ah, personalisation, that bittersweet word which means everything and nothing. Everyone entitled to care and support will have a personal budget – I genuinely thought that was already on track and didn’t think it was anything new. And look

‘We will push further with our ambition to support as many people as possible to enjoy the benefits of a direct payment’.

I hope that support is extensive and looks beyond the current models which have served some exceptionally well but many others very very poorly.

I won’t mention the ignorant way that advocacy is included in the White Paper which evidences a lack of knowledge by those who wrote the paper but will merely reference Martin Coyle’s (from Action for Advocacy) blogpost which says it all.

There’s some more in this section about integration between health and social care which is becoming more distant in practice rather than more evident.  Use of the term ‘care coordination’ is confusing as it is a generally used term in mental health services and has different technical meaning to the way it is used in the White Paper in terms of physical health. That has already caused us many confusing conversations locally as to someone having two care coordinators – one for physical health and one for mental health – which kind of proves the point about duplicating work and having unfathomable systems. The terms should really be clarified and separated if necessary.

Chapter 8 ‘Making it Happen’

A draft bill was published alongside the White Paper. I haven’t read it yet. I wonder that some organisations seem to have thrown their lot in wholeheartedly with the government which makes me a little nervous. I want to support positive change but I don’t want to be blinded by good intentions and words that lead to little that changes the lives of those who have the most need for support.

Interestingly the ‘financial context’ is stuck at the back of the White Paper like a growing tumour. There are mealy mouthed words about the government putting money into social care but while taking away in the other hand, from local government, they have contributed directly to the ‘crisis management’ only model that they criticise.

Conclusion

I see little if anything revolutionary in this paper. I see nothing that explains a change in the direction of travel and means of delivering social care. I see some positive signs and some acknowledgement of difficulties but we were moving down the path of personalisation at a rate that it could only continue. While there was mention of personal budgets for residential care, I saw nothing about ISFs and developing ways of promoting choice for those who are excluded from communities and who may lack capacity. I saw nothing about changing legislative frameworks. I saw a lot of gaps, not least, the massive funding gap.

Nice words though, fluffy and helpful and a lot of the language of ‘choice’ (where possible), ‘community’ (where free) and ‘market’.

These things are always filled with the right words. I think a lot of opportunity to restructure and rethink adult social care has been lost although there are some springs of hope – there aren’t by any means enough.

Pic by wintersoul1 at Flickr

Children In Care Are Big Business

The encroachment of international venture capital into the private provision of residential and foster care for looked after children is hardly news. It’s been covered regularly over the last couple of years but yesterday’s Times revealed the full extent of what many businesspeople have known for a while now, that the sector offers rich pickings without having to wait an undue length of time for a return.

One of Britain’s biggest independent fostering providers, the National Fostering Agency (NFA) was bought by one such company in 2006 and sold to another for £130m, tripling the original investment. Another fund made a 500% return in six years. Profits are maximised, says the piece, by concentrating residential units in parts of the country where property is cheaper. Rochdale, the scene of the recent child exploitation scandal, is cited as one example. Children in care are not only big business, they are an international commodity. Acorn Care is an investment for the pension fund of Canadian teachers.

In January the Telegraph reported that NFA made £3.5m profit in the last financial year. The previous year, a Deloitte’s survey revealed an annual profit growth of 35% as they came in at number 56 in the 100 most profitable private equity backed companies. Ironically, the Thunderer itself named them as ‘One To Watch’.

As ever with these things, the blanket statements unjustly tarnish the many private concerns who work hard on behalf of children and young people. The Times article (sheltering behind a paywall so no links, I’m afraid) unfairly juxtaposes the private equity information with the Rochdale scandal by puting them on the same page but there’s no demonstrable casual link between the two even if the children lived in a private residential home. Also, the piece leaves the reader blinking at some of the fees (one placement comes in at a cool £378,000 pa) but some of the most damaged young people need the most intensive, expert care.

It’s captured more attention this time round partly because it is in the Times, hardly a refuge of pinko mungbean scoffing sandal- wearing social work types but mainly because it neatly fits the zeitgeist. We accept, or are resigned to,  firms making profits and the people owning those companies making a lot of money but the fallout from the banking crisis has revealed just how wide the disparities can be. Whether it be Jimmy Carr’s tax avoidance or Bob Diamond’s payoff, we know it goes on but there are limits. I’m not entirely sure where they are but with the provision of private equity backed care for children, it feels as if we’ve reached them. Dig deeper and there’s something profound going on – big firms selling to even bigger companies, pension funds in Canada getting fat on cash from hard pressed local authorities reeling from the very cuts that venture capital in part helped to create.

It is questionable whether local authorities are receiving the best value from the majority of providers. How do they know what the unit offers, how that compares with what other places offer, how it best meets the needs of the child or young person and how do they monitor the effectiveness of the placement? In my experience, the commissioning process is often trial and error based on factors related less to a thorough evaluation of the myriad of services on offer and more to what has worked for other children in the past or the small ads in Community Care.

Once in placement, some (not all) residential establishments are virtually impenetrable to the outside observer. Notwithstanding the complexity of some of the work undertaken, there are many places where it’s hard to grasp how the methodology or philosophy is translated into practice in terms of meeting the child’s needs in their day-to-day life, let alone challenge it. That’s of course assuming that the social worker makes more than a cursory visit. From personal experience of many fostering and residential providers, it’s unusual for children to have any sort of meaningful relationship with their social worker.

We live in a mixed economy of care. Private companies can produce excellent care, there’s no question. But venture capitalists are active in the sector because it makes them money. That’s what they do. Often they buy undervalued companies, strip out the profitable assets, let the rest go to ruin, maximise profit and get out.

Venture capitalists exist for profit. This comes at two points in the process, at the point of sale and the costs of providing a service. The sole income source is cash-strapped local authority budgets that are being squeezed beyond breaking point. For the moment, it’s a seller’s market. Outweighing the pressure on authorities to cut costs is the increased demand for places as admissions to care soar at a time when there is already a shortage of foster carers and the local authority residential sector is virtually non-existent.

There are also opportunities to cut costs by limiting the services that are available. Low pay for residential workers has been the norm since I started in the sector 30 years ago. Foster carers are paid an allowance, not a fee, and no placement means no allowance and no outgoings for the company. It’s the extra services that can rack up the costs and eat into margins. Foster carers all value the support they receive from their provider but here’s a way to cut costs. Foster care is a more complex task than ever before. The providers I work with who are most focussed on children have a ratio of supervising social workers to carers of between 1 in 10 to 1 in 14. This of course is not enough in itself to guarantee a good service but it forms a foundation because the staff have the time to focus on the children and their carers, bearing in mind that actually they have a responsibility to both. Some providers, including NFA, have a ratio of around 1 in 22 to 1 in 24 and their staff work from home, thus greatly reducing the fixed costs of office space.

The next thing to do is to push as many services that the child needs onto local health and local authority services. If the provision of, say, psychological services is rationed or not provided at all, children wait for already over-burdened CAMHS provision. The same also applies to more prosaic but vital services like transport to and from school or contact, which these days can be several days a week or every day in the case of a baby involved in court proceedings. Exclude that from the cost of a placement and the local authority picks up the bill. Include it at premium to meet a shortfall in local authority provision and the company can’t lose.

This is not a hypothetical situation. It happens every day. No wonder the sector looks so attractive. These companies aren’t interested in the long-term, or children growing up as I prefer to think of it.

And if things get rough in the placement, the firms can always play their joker. When the going gets tough, the best carers stay rock solid and consistent, knowing that trust is established precisely at these moments of greatest challenge. As one young man once said to me, quite cheerfully, ‘I kicked off for three years, then I knew they [his carers] would stick with me so I calmed down.’ For the venture capitalists, why bother? Why bother supporting a placement that will need extra resources like time, skill and extra input when you can end the placement and move on to something cheaper, because those resources cost and more cost means less profit. Blame the child. Too challenging, unacceptable behaviour, on reflection it wasn’t the right match, we were just responding to the carers, – you name it, I’ve heard it. And so it’s another disruption because the placement was taken without proper consultation. Get them in and get them out again if it’s all too much. Ofsted don’t pick this up. The companies have legions of back office staff making sure the boxes are being ticked, and if there’s one thing that Ofsted likes more than a box, it’s a ticked box. Many inspectors can’t see beyond them and the system no longer encourages it. Blame the child – it’s the perfect businessplan.

The article quotes Kevin Williams from children’s charity TACT. I’ll leave you with his words because they are the perfect summing up:

“There is a moral question about making large sums of money from children who’ve suffered abuse and neglect. If they do profit from such children, can they demonstrate that they’re delivering the best possible outcomes for those children and not simply making money through efficiency savings, by increasing workloads and reducing training and support? I would question whether they can.”