Race To The Bottom Commissioning

Writers are obsessed not just with words but with wordcount. That innocuous, humble figure in the drop-down menu or nestling innocently in the bottom left hand corner of your screen should be a record of achievement. Instead, too often it’s a curse, an ever-tightening straitjacket on the creative flow. Blogging at least allows me to stretch out a bit as opposed to a commissioned piece for another site or magazine, but there’s lots of evidence to show people seldom read to the end of the article or  even past the opening paragraphs. If you’ve reached this point, you might well be in the minority.

Lately I’ve been a victim of the oppression of wordcount for a very different reason. Creativity has no place in the dark murky world of contract compliance and tenders.

These form an increasing proportion of the workload of any independent provider in fostering and residential work. I understand why they have appeared. After all, I’m old enough to recall the old days when social work had no systems for measuring its effectiveness, the days when we just knew and that got us nowhere. However, the last few months have taught me that while it appears we have swung to the other extreme with compliance coming out of every orifice, not only are we no nearer to truly demonstrating effectiveness, it is stifling innovation and good practice that children and young people need more desperately than ever before.

Two weeks ago I completed a tender for an authority in the southeast. I wrote 12,098 words. As each question was limited to 500 words, you can see how much ground they wanted to cover, except that this document, clearly designed by committee, was intensely repetitive. There are only so many ways you can say you are child centred, needs-based, work in partnership and strive to keep children safe.

Anyway, there were four lots to this tender for different groups of children but the responses were similar, so that’s 48,392 words in total, half a decent novel in another world. For this sought-after tender there would be at least 40 providers going for it, which means the authority will have to read and digest 1,935,680 words. The responses  must be processed to ensure the quality threshold is achieved, graded on a scale of 1 to 5 then compared to rank the providers in a tiered system.

My 48,392 words does not include any of the policies and procedures that were requested, nor any of the considerable business, insurance and financial information. Then this whole quality exercise counts for only 40% of the tender because 60% is price. This imbalance between quality and cost is common – one tender went 70-30 in favour of price.

This modern approach to commissioning is an exercise in futility. I simply do not believe that all my words will be read, let alone systematically compared with the other 1,887,288 that have been submitted. It cannot possibly be done.

I resent the fact that quality is less significant than price. More and more, authorities are looking to the bottom line of the balance rather than good practice when it comes to children’s futures. I accept that they don’t have as much money and that the cuts are not their fault. However, this is not the most effective way of using their scarce resources to provide a child centred service.

I’ve said before how prices can be kept down in the sector – you provide a placement without extra services like contact, therapy and other forms of support. Yet carers as well as children need those packages of care as the demands of fostering are ever more complex. A price-based approach does not encourage that.

With the contract comes compliance. Fine, I understand why this is important. However, what happens in practice is that each authority wants very similar information but in a slightly different form. The 5 outcomes are the same, the info they require ever so slightly different. In passing, you can work out the problems affecting every authority by the nature of their requirements. A heavy emphasis on, say, staff checks or allegations means they’ve had a real problem in the recent past.

The lack of consistency means providers have to collect different statistics for every authority. Providers are of course inspected by Ofsted but this seems to be irrelevant when it comes to the tenders and perish the thought that Ofsted might want stats that are in any way similar to those required by authorities. Ofsted for example uses ethnic monitoring categories that do not match with any other I have come across.

All of this costs money. Providers will have to pass on the costs of extra posts and databases in one way or another, and goodness what the local authority staff costs are in processing 1,935,680 words.

Three other southeast tenders are between 3 and 5 months late because authorities are unable to reach a conclusion. Two face legal challenges because they request information that breaches data protection legislation. Some simply do not realise that having a policy for everything does not guarantee better quality. One organisation was censured for not having a child protection policy on gangs, but what do they expect. “For children and young people we do all we can to keep them safe but if they join a gang, sod ’em.” It’s reached the stage where I would be tempted to submit that.

Forgive the ranting. It’s helped me let off a bit of steam. I’ve just spent the day on a Section 11 audit for a council in East Anglia. It’s about safeguarding and that’s important, really, I get it, but question whether this is the right way to go about it. Self-assessment. Frankly unlikely that I’m going to give a score of anything less than perfect. ‘Do you have a policy on such and such?’ Answer: “Yes I do have a policy on such and such.” It will keep them happy because this is the fourth one I have filled in and everyone has been happy with that answer so far. Doesn’t say how good this provider is or the difference good safeguarding and risk-management makes.

The Fostering Regulations require that organisations send their child protection policies to every authority they work with or could work with. I know another provider who sent out 42 responses and did not hear back from one of them, not even an acknowledgement. Utterly futile.

It has reached the point where I don’t know what piece of legislation it is Section 11 of and I’m past the point of caring. 1,974 words, if you’re interested. I’m hacked off – you can tell, can’t you – because it’s a waste, of precious resources and of my creativity and innovation as a practitioner. I have several ideas stillborn because there is simply no time. Putting them into action would improve the well-being of children in care far more than any of the compliance mechanisms do.

But if by some chance you’ve bucked the stats and reached this far, have a look at two recent pieces that are considered, definitely non-ranty but point out the consequences. “Commissioning services drives up costs” from Public Service Europe and “race to the bottom commissioning” from the Third Sector. Commissioning is important. It needs to focus on value and quality. There must be a better way. That’s 1213 words I wanted to write.

Familiarity Breeds Contempt

Over the course of the past months, who could help but feel a plethora of emotion as the horrors of Winterbourne View have unfolded before our very eyes: Absolute disgust that an organisation could get to the point where such blatant institutional abuse becomes a part of daily life, anger at the systems in which we work as they are revealed as insufficient to protect the most vulnerable in our society or perhaps a heart-wrenching empathy towards the vulnerable and a passion that things have to change and something done… but what?

It will hopefully have challenged us all as a professionals.  Is it just possible that as we go about our business there is a very real danger of becoming complecent unless we keep on out toes and remain true to our professional standards and ethical practices?  I’ve been reminded how very important the role of those who commission services and the need for greater accountability when choosing services for individuals who can’t choose for themselves.   Are we pressured into choosing the cheaper option even when we know in our heart that it isn’t the most suitable?  Do we sigh a sigh of relief and accept without question when we find a service that will accommodate the individual with particularly challenging behaviour knowing that the option will be limited? Do unrealistic case-load sizes prevent us from spending time to think outside of the box and identify the very best service and then think how it might be achieved? Do we have a professional relationship with providers when a less formal relationship can be so much easier? If we become too familiar those so important boundaries can become distorted and increase the risk of poor practice or even abuse going unnoticed or being excused.

I started my social care career working in a residential home for children with autism and it must be said that in my experience the majority of carers are decent caring people who go the extra mile.  Most don’t get paid heaps, have to work shifts but still turn up at work asking how they can make the next 8 hours the best they possibly can for those they have come to work for.  However, there are some for whom that isn’t the case and over the past couple of weeks we have seen 11 photos that will probably remain imprinted on our minds long after the media frenzy has died down.

I’d really like to hear how recent events have perhaps challenged you as a health or social care worker as you strive to help deliver the very best services to those who need them. I also look forwards to hearing how the Department of Health is going to drive service commissioning, delivery and safeguarding forwards.  What is agreed upon is that there needs to be a radical overhaul of social care; what doesn’t see so clear is what that will look like.

 

What I would say to Norman Lamb

Working in dementia services at the ‘frontline’ I often consider what messages I’d feed back to the local and national policy makers if I ever had the opportunity. Of course, I don’t have these opportunities as I’m not a manager so I thought I’d imagine I were at an important meeting with Norman Lamb, the minister for Care Services.

This is what I’d say.

Make policy practical. Making the right noises about setting up a wonderful plan to ‘challenge’ dementia is all well and good but I see nothing of that at the ‘frontline’.

What I see are cuts. I see respite narrowing in terms of ability to access. I see provisions which had been helpful, closing. I see a lack of beds in the local hospitals when they are needed and I see people who need support being denied it because there are no provisions left.

So take your pleasantries and policy ideas and come and spend a day with me in the community and you’ll see why I am impatient and unbelieving about the platitudes that emerge from those who don’t seem to understand what is happening ‘out there’.

I’m tired. I’m tired of saying ‘no’ to people whom I see need services because the provisions are so tight. I’m tired of saying ‘no’ to people at the early stages of need when I know it will prevent higher costs in terms of pain and suffering but also in terms of money in the longer run. I’m tired of logging targets that have no meaning in the lives of those whom I work with. I’m tired of jumping through artificial targets so I can ‘prove’ I’m doing my job when neglecting visits to actually talk to people because I have to catch up on the paperwork.

I have waited for years for a fair system of implementing personalised responses to care which include people with dementia but am still waiting because the entire focus on the programmes developed through personalisation have been on those who are more able to be involved in the processes or those who have involved family members to help them. I’m tired of wading through appallingly designed forms, self assessments and RAS (resource allocation systems) that focus entirely on physical health needs and marginalise mental health needs thereby ignoring equality legislation.

I want action and yes, sometimes, action includes money. I know what the people I work with ask for and I know I can’t deliver it – not through a lack of will – I want to be able to go home thinking I’m doing a good job and doing my best – and for the most part, I think I do – but the best I can offer is very sparse. The best i can do isn’t good enough.

We have few residential homes locally and are placing people further from their families. We have nothing ‘creative’ left to offer as those agencies which are helping with ‘support planning’ aren’t trained to offer support in non-directed advocacy and therefore if someone doesn’t ask, they don’t get.

So what would I do? I don’t have a budget and it’s probably for the best as I’d steam through it in five minutes – one of the many reasons I’m not and will never be a manager – but I would focus on trying to create a system of social care which offers equality of access to good and creative support planning.

I’d commission more non-directed advocacy into support planning. I’d roll out Individual Service Funds for people with dementia and I’d allow more time for carers – and for social workers to work with people who have dementia because honestly, that’s what’s needed.

However all we get is platitudes about how wonderful services will be without extra money being provided. Yes, I’m sure early diagnosis is important. It is. But please, please can the Department of Health and local government concentrate their minds on what is happening now and the poor services we are providing now and do something, anything to make them better.

I want to do my job well and I want to support people but all the tools I had available for doing so are being ripped away from me. It’s sometimes hard to keep the motivation up when you don’t believe you are helping anymore.

I’m the person saying ‘no’. Me, not the Head of Adult Services, not the Ministers responsible, not the councillors responsible. I sit in people’s homes and tell them what they are not entitled to anymore. I want those who make these decisions to take responsibility for that and to listen to us who go out there and who see.

That’s what I’d like.

picture by Liberal Democrats at Flickr

World Suicide Prevention Day 2012

Today is World Suicide Prevention Day. This is a day to raise awareness and reflect on the causes of suicide and way that services and support is available or not to those who may be considering suicide.

While it is not difficult to approach the notion that suicide prevention is something that should be promoted, it is hard, at least in my mind, to detach this thought from the need for services to be provided – not just in specific mental health sectors but in broader terms because while it is easy to categorise ‘suicide prevention’ as a specific mental health need, there are those who may choose to take action to end their own lives who do not have what might be categorised as mental health problems.

So what would broader suicide prevention services look like? I think there is clearly a case for formal support (but then, I would say that) through supportive and longer term work through mental health systems. We are struggling in the NHS Community Mental Health Teams at the moment. We aren’t equipped to work with anything except the most acute needs due to decreasing funding. Fancy talk about policy pushes towards prevention mean very little in frontline posts away from Whitehall where these documents are drafted.

Waiting lists for talking therapies can be extensive and the choices between types of therapies (and for that matter, particular therapists) can be limited.

While I would argue (again, I would really) that there are practitioners who want to provide good services, it is becoming more difficult in a climate of cuts and those who pretend otherwise in the government are fooling themselves. Support has to allow time and therapeutic relationships to develop in order to understand what is needed and how. Support has to be provided extensively to family members and friends who support and care for those who have mental health needs in order to reinforce informal support networks. Personal budgets can help but only if they are implemented flexibly and with time and care rather than sped through to meet increasingly harshly imposed local authority and central government ‘targets’ and tick boxes.

My work should always be about people as individuals with wholly different needs, wishes, desires and aspirations but it feels as if it is increasingly turning into a ‘tick box’ culture in mental health services. That is wrong and it only serves to remove an element of humanity from a system that so desperately needs it.

Sometimes, indeed, often, it is not about traditional ‘formal’ services as much as promoting more social interaction and quality networking structures which can thrive  (and are often better) as peer based groups.  We have greater tools now to create different layers of social interactions now – we can build communities on the basis of interests as well as geography through and combat isolation and loneliness. If a shared interest in Dr Who or football or coffee can create communities around them, we are on the cusp of making it easier to find engaging and accepting communities to be a part of.

Perhaps though, with the greater opportunities come greater pressures to ‘find groups’ or to ‘be a certain way’. I am generally an advocate of the positive power of the internet and new communication forms to promote greater support networks and social interaction but there has been a rise in more public bullying and targeting which is the negative side of living life in the open.  I think a greater understanding of the role of those who use these new platforms negatively and to gain a greater platform for negative and unpleasant outlets has to be another focus. Why do people ‘troll’? What are the needs of the bully and what are they missing in terms of their social support in order to use negative outlets to target others?

There are many ways we can and should be looking at suicide prevention but while it remains a very important issue in mental health services, it is not an issue exclusively for mental health services.

We can all take a role in being more open, kinder and more understanding of the needs of others – we, collectively, are not able to prevent all suicide – but there has to be a wider awareness of a different paths to take – whether  formal or informal routes, they all need shoring up.

It’s Not News That Fostering Is Under Pressure

Al Murray’s news-based Sunday radio show on 5Live has a running gag where the panellists read out prominent items from the past week that are not surprising in the least. After each, he adopts an urgent cod-announcer style and bellows, ‘Not News!’ Katy Price might have a new relationship, Big Brother contestant seeks publicity, Camilla’s wearing a hideous hat: you get the picture. Shout out the catchphrase after every paragraph in this piece. Fostering Fortnight, the biggest event in fostering calendar, finished recently and frankly, nothing’s happened. It works for me.

Fostering Fortnight is a series of events to celebrate fostering and foster carers. It presents a positive view of being a carer with the dual aims of valuing those who have already discovered their vocation and attracting new recruits to fill the growing shortage of foster homes. It’s run by the Fostering Network, a charity representing the interests of carers all over the United Kingdom. This year they’ve done an excellent job, with relevant and well-timed research attracting the media’s attention alongside the heart-warming human interest stories beloved by daytime TV, climaxing with a glittering reception proudly showcasing the achievements of children and young people in care.

Children’s Minister Tim Loughton made the keynote speech. Whilst he covered a considerable amount of ground, a couple of weeks on there’s no evidence that anything much has happened. Those of us waiting for a significant initiative from the government or at the very least some leadership to take us forward were sorely disappointed. He made some eminently sensible suggestions about improving day to practice, the level at which much can be accomplished as any regular reader of my blogs will know. Reminding authorities that they should delegate more decision-taking responsibility to foster carers (something Loughton has enthusiastically supported) will improve the lives of children and young people in care, giving them the same social opportunities as their peers. Criticising the risk averse climate in decision-making is music to my ears. A drive for employers to provide fostering leave is an excellent idea and the Department are working to ensure the benefits system, including housing benefit, does not discriminate against carers. We also have familiar favourites, the ‘streamlining’ of the assessment process and introducing greater ‘flexibility’ into the placement process cuddling up to old friends like ‘unnecessary and harmful bureaucracy.’

As I say, much of this is valuable. However, the expected and trailed ‘big announcement’ did not materialise. Normally that wouldn’t unduly bother me -it’s what carers and practitioners do that counts – but fostering is facing perhaps its biggest ever challenge over the next few years and it needed a helping hand from government. In its absence, I’m left only with confirmation that fostering remains the poor relation of the care system.

Adoption has dominated the government’s agenda over the past year or so, which I’ve covered in previous posts. Loughton acknowledged as much in his speech but failed to redress the balance. The examples he gave like the Foster Carers Charter have been around for a long time and the earth hasn’t moved.

Fostering is about the skilled preparation of children and young people for the future. This can be a return to their birth family and fostering itself as well as adoption. Many young people may not wish to be adopted and also evidence shows fostering provides a successful alternative in offering stable permanence and improved life-chances, yet the perception remains that the government (not necessarily Loughton himself) sees fostering as a sort of holding area, the lounge where you rest after passing through security and checking your baggage before rushing onto the plane, the means of reaching your destination.

There are powerful reasons why the government must give a strong lead. This debate takes place within a context of the growing numbers of children and young people being taken into care outstripping the supply of new foster places, especially ones where the complexity of children’s issues can be fully addressed. I advocate an ongoing government advertising campaign for foster carers along the lines of the long-running and successful initiative to recruit teachers. Current means and methods are not enough.

Then we have inertia within hard-pressed cash-strapped local authorities. I have every sympathy but the means of change has been there for some time without there being sufficient action. Take delegated authority. It’s the jargon for enabling carers to take day to day decisions for children and young people like whether they can have a sleepover, go on a school trip, see certain friends or take part in activities where a consent form is required. Normal parenting in other words. Ask any young person in care and they would say the need to call the social worker each and every time is the single biggest impediment to being like their peers. Backed by legislation that came into force in April 2011, the decision-taking authority should now be delegated by agreement to carers and the FN have produced a spot-on format to enable this.

Nothing is happening. Not quite true, of course, but the risk averse culture is so embedded in senior management that many authorities seem hell-bent on retaining responsibility for these decisions, regardless of the fact that children are unhappy, carers exasperated and under-valued and already busy social workers embroiled in tasks others could and should take from them. In fact, the welcome legislation is nevertheless not a radical departure from the guidance that existed before April 2011. It wasn’t implemented then because of the risk averse culture and nothing significant has altered.

Finally, I’ve come across an increasing number of examples from several authorities where the much vaunted ‘streamlining’ means assessments are being rushed and the ‘flexibility’ over placements means foster homes are more crowded than ever as age and placement criteria are being stretched to fulfil demand. This is a natural consequence of fewer resources caused by spending cuts and growing demand as the threshold for coming into care shifts.

It’s not news, however, that this does not contribute to better childcare. Children are given what is available, not what they need. Carers are pressurised to go beyond their areas of preference and expertise. Carers are great, they don’t want to say ‘no’, they want to help, but to do so they require support from us professionals, which is not the case if we take shoddy resource-driven placement decisions. Above all, children’s needs are not being met. Far from addressing the problems, I fear we are merely storing up worse for the future.

Protecting Our Children: Will It Change Attitudes To Social Work?

The excellent Protecting Our Children concluded on Monday evening. The practitioners and programme-makers deserve congratulations for an absorbing, honest and above all human depiction of contemporary social work to sit alongside the two Panorama programmes looking at children in care.

 

In all the meetings I’ve attended over the past three weeks, conversation has turned to the latest programme as soon as a lull in proceedings appeared and often when it didn’t. Generally it’s gone down very well, in sharp contrast to the scant few past series covering our world. I remember one dire effort that I think looked at a social work team in the north. Eminently forgettable, I nevertheless recall it began with a social worker guiltily shovelling down a giant doner kebab whilst at his desk then playing up to the camera in a manner that would have embarrassed David Brent. Gloomily we watched well-intentioned but ill-conceived and executed direct work with a young child and a succession of families unsure about what was happening.

Fostering Aspirations As The Downturn Bites Hard In Tyneside

Another day, another report on the parlous state of foster care. Media coverage, such as it is, homed in on the shortage of carers, variously estimated at between 8000 and 10,000, and on the poor outcomes for children in care in fundamental areas such as educational achievement, incidence of mental health problems and offending behaviour.

None of this is new – the Fostering Network has rendered impotent the word ‘crisis’, so often have they used it over the years – although there is no harm in it being said once again. However the report itself, Fostering Aspirations by the Policy Exchange  has a wider scope, incorporating the views of foster carers and children in care into their analysis of the quality of care and emerging with radical suggestions for tackling the problem, most notably a salary structure for a professional foster care service and an overhaul of commissioning arrangements that would see local authority fostering departments competing alongside the independent sector in a tendering process for placements or a total outsourcing of fostering.

New Year, Same Old Hogwash

Today, David Cameron issued his New Year message, and it’s every bit as vapid as you’d expect.

Yadda yadda Olympics boring boring Big Society boring boring our armed force boring boring excess in the City blah blah…

But here’s the bit that really got me livid.

I am determined to do the bold things it will take to sort out public services, too. Too often our schools aren’t up to scratch, our hospitals aren’t always clean enough and our police don’t catch criminals. Brilliant and committed people work in public services – but somehow the system stops them doing their job. So we’ll change it.

The Truth About Adoption Is That There Are Many Truths

Last night’s Panorama documentary ‘The Truth About Adoption’ was a vivid, honest portrayal of the heartbreak and joy of fostering and adoption. As the adults, the social workers, carers, adopters, parents, the court, went about their business, it was impossible not to be profoundly moved as the stories of the children unfolded and their hopes and fears revealed.

Despite the setbacks they have faced in their short lives, all were remarkably optimistic about the future. Undeterred by delays and adoption breakdowns, they hoped for the love, care and security that we professionals call permanence. And why not: it’s the least our society should be able to offer.

Crisis in Mental Health Care

Crisis Care in Mental Health – both community and inpatient –  is inconsistent and increasingly unable to deliver quality services.  Mind published a report today following an independent inquiry which they have carried out called ‘Listening to Experience’. This inquiry looked at evidence from 400 patients, professionals and providers and was intended to provide a qualitative shapshot of care in England.

While the press release points out that some outstandingly good levels of care were reported, it is useful to note some of the main points of criticism that were raised.

When looking at some of the examples cited in the statement from Mind, it’s hard to separate these issues from the agenda of cuts that is currently underway in public services and despite the government’s vehement denial that this is not going to lead to reductions in clinical staff, all I can say is that on the ground, I see it happening with my own eyes.

We have, and this is personal experience, wards closing, staff with redundancy hanging over them, downgrading of professionals and replacing qualified staff with unqualified staff. These are not management posts. These are all clinical posts. Staff remaining are pushed further and yes, eligibility is rising and service delivery is reaching a smaller group of people.