Winterbourne View owners sponsor learning disability nursing award. Satire dies.

The abuse of people with learning disabilities that took place at Winterbourne View “care” home was utterly horrific. Castlebeck, the company that owned the home, took £3500 per person per week from the taxpayer for mostly unqualified staff to abuse and assault its residents.

I have to thank Mark Neary for spotting this. He noticed exactly what Castlebeck are doing with their dirty money, and who’s taken it. The Nursing Standard, the weekly magazine of the Royal College of Nursing, has announced its Nurse of the Year Award. Scroll through the categories, until you get to the Learning Disability Nursing Award. This is “for nurses working within the field of learning disability who can clearly demonstrate that their initiative has improved the health, well-being and social inclusion of people with a learning disability.”

And who’s sponsoring the award? Unbelievably, it’s Castlebeck. While I’m hardly surprised that this sordid company wants to try to mend its shredded reputation by associating itself with such an award, I’m utterly shocked that the RCN would accept their tainted gold.

Remember that when Castlebeck trousered public money to take in these deeply vulnerable people, they didn’t provide the Winterbourne View residents with psychology input, or an occupational therapist. They didn’t even have that many learning disabilty nurses. The overwhelming majority of the staff were unqualified support workers. Tragically, some of them turned out to be the sort of thugs that I wouldn’t trust to look after my cat.

I’m not entirely surprised by the RCN. They’ve always had a bit of a reputation for shameless establishment schmoozing. It’s for that reason that several years ago I switched my union membership from the RCN to Unite. Even so, this is an appalling decision on their part. I don’t know how they keep a straight face and a clear conscience from doing so.

Exposure and the CQC

Last night, ITV examined the state of residential care and regulation of the sector in Exposure. While I watched the programme through the lens of someone who has had significant experience of the sector, I’ve also followed the birthing pains of the Care Quality Commission avidly so some of the information given wasn’t ‘new’ to me. I probably didn’t approach the programme as an ‘average viewer’ might.

There were a few issues raised that I think useful to explore. The programme seemed to rightly raise the void of inspection that took place through the initial years in which the CQC was established. The organisation was established with less money than it’s predecessor bodies, the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection.  While focusing on registering services, the CQC dropped the ball on maintaining inspections and relying on previous ‘good and excellent’ reports to step back on regular on-site checks.

An ‘excellent’ service can fail very quickly if there are changing in funding and personnel in a home, for example and the lack of attention to frequent unannounced inspections was something that was highlighted in this programme.

However while not resolving the organisation of responsibility, this focus has changed and the CQC has stated that regular, unannounced inspections are taking place now.

The website has long been a gripe as far as I’m concerned. There seems to be less information with each iteration and the scope and searchability isn’t as helpful as it used to be. The CQC website remains the only one I have come across at work which has become progressively less user friendly  with each iteration  (and yes, I have always given feedback on the changes when it’s been an option!). The lack of reports from both predecessor organisations (for example, not being able to access CSCI reports or reports when an organisation has changed hands – as was highlighted in the programme) is a big issue. As members of the general public, we can determine how useful or not historic information is but we have to have access to it. More information is better.

Reports need to be very easily understandable and clear about what is expected and what good and bad care look like. They are better than they were. People liked star ratings because they were easy to understand. They were abolished but the star ratings remained on the website for a long time afterward which was poor information in the extreme. While the government excellence scheme was shelved, I think there’s a real desire for people to have an understanding beyond a care home being compliant or non-compliant – people want to know if St Matthew’s Home in Hull is better than St Francis’ Home in Bridlington and a TripAdvisor type comment site won’t always provide an independent and authoritative understanding of that. I’m not sure if it’s the place for the regulator but it was in the past and understanding what good care looks like as well as bad is something that Behan, the new CEO of the CQC has stated he wants to work on.

The footage of Cynthia Bower at the select committee was positively painful and her links with Mid Staffordshire made her a particularly poor choice of CEO initially. They could never establish any credibility in the sector with that background and proved that she was not up to the task. The only concern was how much damage she did in the meantime.

I do have more hope with the new CEO, David Behan and some of the changes that have taken place but the programme showed the need for a strong and authoritative regulator within health and social care.

The problem is that all these cuts happened in the regulator as commissioners like local authorities were hammered by substantial cuts which – certainly in my experience –  have seen monitoring units slashed. You see the monitoring teams – they were the so-called ‘back office’ which were cut but the input that had on day to day care is significant.

The only way forward is for commissioners (local authorities/NHS and yes, private funders), regulators and providers to work very closely regarding responsibilities and tie information in with each other but most important to make that sure those who use the services and local communities, families and advocates can understand and know cohesive lines of communication with organisations responsible for developing and regulating good care.

It doesn’t help for organisations to be siloed when life is more complex and while I would never want to absolve those government bodies like the CQC of their responsibilities, I think the structures and information streams need to be better regarding lines of responsibility.

If the organisation isn’t able to do its job properly due to cuts, it needs to return to the government and tell it.

I have become more hopeful that there will be a change in culture in the regulator with a change in leadership. Use of more and more ‘experts by experience’ and experienced specialist professionals in inspections is also a positive move but it’s not good enough to stand still.

As Barbara Young said in the programme, the CQC needs to the a regulator for people and particularly for people who have their voices quietened by organisations which can display power in terms of delivering care. It isn’t good enough to rely on families complaining as many people in residential services don’t have families who visit. Proactive regulation needs to happen alongside proactive safeguarding investigations by local authorities and proactive monitoring. Organisations which provide care can’t resolve their own responsibilities to provide quality care. If money is cut by local authorities, it has to be challenged and challenged hard before quality slips rather than afterwards as an excuse.

There is room for hope though. I do think the CQC consultation is positive and the move towards regular unannounced visits is a good one. It should never have been otherwise but we can’t change the past.

If we want a regulator that works, it has to be given the tools and the resources to regulate in a way that we want and expect it to. That costs. So be it, it is a necessary cost.

I want a responsive, responsible, proactive and mostly a listening regulator. I’m willing to give them time seeing that some progress has been made, but there really does need to be a change noticed in the reports that feed back to Parliamentary committees and published reports next year.

Jeremy Forrest and the Abuse of Trust

A couple of years ago, I was working as a nurse in child and adolescent mental health services (CAMHS) with a 16 year old girl. One day, out of the blue, she confessed an attraction to me.

My immediate response – other than to put in a referral to an optician’s, obviously – was to politely but firmly remind her that I was her nurse, that there was no prospect of anything but a professional relationship, and to suggest to her that she look for a boyfriend her own age. I also made sure that I didn’t work with her again unless there was a female colleague present.

Despite what you may think from Mills and Boon novels (those aren’t grounded in social realism? Who knew?) sexual relations between nurses and patients are strictly verboten under the Nursing and Midwifery Council Code.

20. You must establish and actively maintain clear sexual boundaries at all times with people in your care, their families and carers

If I hadn’t kept my boundaries, I wouldn’t have only been committing serious professional misconduct. I would also have been committing a criminal offence. The girl was 16, and therefore over the age of consent. However, she was in my care, and that would make it a crime under the Sexual Offences Act of “abuse of a position of trust”, which runs up to the 18th birthday. There are good reasons for this. The power of a teacher, nurse, social worker or children’s home worker over a young person can be enormous. With that comes the capacity to do enormous damage to vulnerable kids if boundaries aren’t respected and trust is abused.

I mention this because of a depressing slew of responses – often left in the comments threads to online newspaper articles – accusing the police and media of “hounding” a “young couple in love”. Some of those people seem to think if Jeremy Forrest had waited a few months then it all would have been fine – and for the reasons listed above, it wouldn’t. Others seem to regard the girl as some sort of teen seducer.

Have a look at this comment piece in the Independent. The author, quite rightly, takes the Daily Mail to task over a tacky, voyeuristic article that dissect’s Forrest’s relationship with his wife and with his pupil, by trawling their social networking accounts. If the Independent piece is good and well-argued, the comments left underneath are…..Oh dear.

As his lawyer said, his only crime was that he fell in love with a 15yr old…he was stupid the way he went about it, but I don’t think there will be any more than 5-10% of anyone who knows about this story that thinks he did it with any malice or force/manipulation of the girl, and that she didn’t know what she was doing. Again we’re casting judgement…but all I’m said is that I agree with Martin – love has no boundaries.

Was this a manhunt for murderers and war crimials or just a besotted couple? ………….Sad sad journalism indeed.

There’s been a few surprising voices added to this chorus. Peter Tatchell, for example, is someone I often agree with.

I subsequently had a Twitter exchange with Mr Tatchell. In all fairness, he was very clear that his view was that he’s not defending Forrest, and if he had a sexual relationship with his pupil, then he should be prosecuted for it. Mr Tatchell insisted his only objection was use of the word “abduction” for taking her to France.

Fair enough, but does Mr Tatchell really think any parent would agree that a teacher should be allowed to take their 15 year old daughter out of the country without their knowledge or permission?

Ironically, it’s the tacky Daily Mail article that gives a few hints that describing them simply as a couple in love is dubious to say the least.

[The girl], who describes herself on Twitter as a ‘self-loathing, music-loving, art and fashion-obsessed nostalgic loner’ was reported missing last Friday after failing to turn up at her school in Eastbourne.

A “self-loathing loner”? Admittedly it’s entirely possible to read too much into somebody’s Twitter profile. Even so, it does beg the question of whether that sounds like the self-description of a confident, beckoning Lolita.

One could argue – and admittedly this is speculation on my part – that it  sounds more like a girl who may be quite vulnerable. Perhaps even someone who might be susceptible to grooming.

Ultimately these are questions that will be decided in a court rather than in blogs, tweets and online comment threads. Even so, it ought to give those who depict the girl as an equal partner – or even a teenage seducer – some pause for thought.

Winterbourne View – The Serious Case Review

Yesterday the Serious Case Review written by Margaret Flynn about Winterbourne View Hospital was published. It catalogues the series of circumstances which led to those scenes seen on BBC’s Panorama programme and it makes important and salutary lessons for everyone involved in health and social care.

It is a well-written, detailed report which catalogues a series of holes in the process of provisioning, commissioning, managing and monitoring a long stay hospital for people with learning disabilities but the most important lessons can easily be extrapolated out to many other areas of residential, nursing and long stay hospital care.

In summarising my own reading of the report, I have added some of my own thoughts as I go but I do recommend going to read the full version. No doubt I’ll be reflecting on it more over the next few days/weeks.

Introduction

This sets out the background to the airing of the programme on 31 May 2011 and the scope of the serious care review (SCR) which covers the period between January 2008 – when South Gloucestershire Council received their first safeguarding referral to 31st May 2011 when the Panorama programme was aired.  It explains the terms of reference of the report and some of the specific incidents seen on Panorama which caused concern.  This included illegal restraints procedures and

‘notions of a hospital, nursing, assessment, treatment, rehabilitation and support were emptied of meaning and credibility’

The Place and the Personnel

Winterbourne View opened in December 2006 after a ‘feasibility’ study by Castlebeck Ltd which had assessed that there was a need in that particular geographic location for this kind of service. As seen in the programme the placement of a hospital on a business park seems unbelievable but according to the ‘Statement of Purpose’ quoted in the report, there was local access to ‘amenities and a main bus route’ – one does wonder how much this was important to those in the hospital as opposed to those working at the hospital.

Families were not allowed into the bedrooms of those living there which rings many alarm bells to those of us in the sector but may not have been seen as something unusual if you don’t know how these things should operate.

Learning disability nursing and psychiatry were the only disciplines employed in the so-called ‘multi-disciplinary’ teams. The report explains the structure of the service and staffing which was heavy on support workers, which in itself isn’t surprising however a ‘hospital’ employing no occupational therapy, for example, is particularly surprising.  There was a very high turnover and sickness rate among staff which in itself is a sign of there being something particularly wrong in the structures.  12 hour shifts were the norm which may have suited the service and staff more than those who use the service and there was certainly a lack of detail regarding day time activities and timetables for those who lived in Winterbourne View.

I do wonder where the input from care managers/care co-ordinators were in terms of monitoring care plans and ensuring their were adhered to. My gut feeling is that with out of area placements, there was less impetus to be able to monitor these. Commissioners didn’t seem to make many demands that the operating guidelines for Winterbourne were met in terms of providing a therapeutic and rehabilitative environment.

Chronology

This section details the concerns raised and is an analysis of what was actually happening at Winterbourne along a timeline.  Unsurprisingly there are a string of concerns raised that when seen along a timeline can build a picture of a hospital and an organisation that is not fit for purpose.

Part of the concern as a whole is that the dots were not connected in terms of the series of incidents and concerns to build a coherent picture of what was happening. Whilst it’s ‘easy to be wise with hindsight’ it’s important to remember that we have systems which are supposed to protect vulnerable adults which should include collating and using information, concerns and reports to build cohesive pictures of what is going on – that’s even without the whistleblowing which took place.

It makes very difficult reading – all the more so in the context that it was not sufficiently investigated, not internally, not locally and not by the regulator nor police. The key worry that ran through my head is that this may have continued had it not been for both the intervention of determined ‘whistleblowers’ and the involvement of a BBC journalist. That’s a very very worrying lesson that needs to be acted on.

The Experiences and Perspectives of Patients and their Families

The author of the report spoke to six families in particular and explains their perceptions, experiences and understanding of what was happening at Winterbourne View.  The report gives life to some of those who lived at Winterbourne View and humanises them in a way, it seems that the service itself never did – with hopes, aspirations, character and personality.

One patient said

he had been in ‘loads of worse places than them, all over the country’ and that he had been abused in lots of care homes

And if there’s a key lesson to learn it is that Winterbourne View is not an anomaly and shouldn’t be seen as such.

The patient recollections of abuse and treatment at Winterbourne is very powerful. It evidences the importance both of listening and humanising approaches within residential care and hospital care. The importance of being near families and the disruptions of constantly changing placements seems to be the nature of life for some groups of people who have particular care needs and I wonder where the power in commissioning is coming from to look at different models.

When families raised concerns that their children had brought to them these reports were often disbelieved or families were not given the full details of what was going on.  It also raises the importance of visiting and monitoring – particularly for those who may not have families.

Importantly the report says

A family expressed anger that service commissioners making spot purchases to meet the needs of individuals do not know what they want to buy; they do not seek assurance that the service they believe they are buying is delivered; and they do not follow up on what is being provided.

Perhaps more importantly in terms of lessons to be learnt globally

‘As families recalled some of their distressing experiences, it was clear that they had no collective experience of being regarded as partners deserving of trust and respect or even of collaborating with paid carers.

There has to be a shift in the conceit of ‘paid professionals’ or ‘paid support workers’. We have to work with, alongside and for those whom we support and their families as otherwise we should be nowhere even close to a position in social care. Respect, listening and remembering whom we are serving  is the crux of the profession and that seems to have been lost somewhere.

Agencies

Castlebeck Ltd seemed to have a ‘limited executive oversight’ of Winterbourne View with the geographical distance from their head office in Darlington providing significant lapse in responsiveness when concerns were raised.

Interestingly they seem to place some of the blame directly on the CQC and problems with the transition from the Healthcare Commission to the CQC. While no CQC apologist this seems to be a very complacent and worrying dereliction of duty from the organisation that was paid to provide a service which should include self-monitoring.  The SCR looks at Castlebeck’s own analysis of their failings but finds it lacking with attempts to discharge responsibility for the things that went wrong. As it says

Overall Castlebeck Ltd’s appreciation of events leading up to transmission of Panorama is limited, not least because they took financial rewards without any apparent responsibility. The recommendations fail to address corporate responsibility at the highest level

Which is sad, but unsurprising.

NHS South of England also produced a report about commissioning of care and treatment at Winterbourne View.  Out of the 48 referrals made to Winterbourne View, 13 came from commissioners located less than 20 miles away and 9 of those 13 were from commissioners less than 10 miles away.

Worrying is that there were some placements made with few checks and some not even reading the most recent inspection reports.  Interesting that of the 48 English patients (the experiences of Welsh patients – not being the responsibility of the NHS in England were not counted in these figures) 35 were admitted under a section of the Mental Health Act, 13 were admitted informally and 6 were detained after being admitted informally. Unfortunately there are no details regarding the Deprivation of Liberty Safeguards but it would be interesting to know more about those ‘informal’ admissions legally.

NHS South Gloucestershire PCT was the ‘coordinating’ commissioner being where Winterbourne View is located. They produced another report.  Hospital records were also accessed but there seemed to be no linking of information together and agencies not speaking to each other seems to be a major problem and continuing concern.

South Gloucestershire Council also provided a Safeguarding Review.  South Gloucestershire received 40 safeguarding alerts between October 2007 and April 2011. The system locally to follow up some safeguarding alerts seemed to be flawed in terms of not receiving relevant and necessary information requested back from Winterbourne View.  Many of the alerts ‘tail off inconclusively with no clear decisions and no rationale for decisions’.  Each alert was dealt with discretely and the pattern was not allowed to emerge.

Avon and Somerset Constabulary were also involved as there were a number of assaults reported and they also provided a report. There were some flaws in the sharing of information between the police and the local council.

CQC also compiled a report.  The SCR picks up on some confusion in language in terms of the CQC and notes the importance  to note that Winterbourne View is not a care home but is a hospital. The CQC admits that it’s creation has had a significant impact on inspection of services – something we all knew – but it’s good to see them acknowledge this finally rather than paint the biased hue of everything ‘being better’ under the new regime.

The lack of specialist inspectors is a particular factor that the new systems of regulation have lost. Apparently ‘professional regulators’ is a better way of doing things rather than those with specific knowledge of particular service areas. Perhaps this isn’t quite the right way to develop regulatory services.

Findings and Recommendations

The report finishes with a summary that is robust. Winterbourne View is a particular snapshot which has been able to take place due to a series of circumstances that put the spotlight on the services. These spotlights aren’t often shined into the world of long stay hospitals and residential care. But for a BBC programme, it might never have been picked up. That’s a lesson in itself.

Castlebeck Ltd didn’t provide a poor service because it had no money. It provided a poor service because it didn’t see any reason not to.  There were no reasons to question itself or what it was doing. Those questions weren’t being asked by any of the agencies responsible for protecting those who lived in Winterbourne View.

The recommendations are that the Clinical Commissioning Groups, Local authorities and NHS Commissioning Board should be looking more closely at the services they commission, where they are commissioning them and aim to cut down in-patient services.

The report emphasises

‘Commissioning is a professional activity that should be led by trained specialists who know and develop the market according to public policy’

This made me sigh as it seems in my own experience that we are moving backwards on this. I see fewer specialist commissioners who know their areas and more general commissioners who come from non-health or care related backgrounds and with little understanding of the sector or the needs locally of those who use the services they commission.

The report strongly criticises the commissioning of long stay hospitals for people with learning disabilities as perpetuating the ‘out of sight, out of mind’ type modelling for care services.

Recommendations include a more robust use of the Mental Capacity Act 2005 and particularly that

‘The Department of Health should assure itself that CQC’s current legal responsibility to monitor and report on the use of Deprivation of Liberty Safeguards provide sufficient scrutiny of the use of DoLS’

There was a lesson in poor multi-agency working which needs to be worked on actively and there is a recommendation that those who are subject to provisions of the Mental Health Act or Deprivation of Liberty Safeguards as well as all who make a complaint have access to independent professionals, whether social workers, Best Interests Assessors, IMCAs or IMHAs or more than one. Advocacy is crucial to prevent abuses.

As far as the CQC is concerned, the report explains that the ‘light touch’ regulation, enamoured by the CQC doesn’t work with settings like Winterbourne View. The CQC has been too reliant on self-reporting and trusting providers are complying.

There’s a recommendation that the ‘

Mental Health arm of the CQC should have characteristics akin to HM Inspectorate of Prisons in terms of standards’

That would be an interesting and useful development but I doubt the current CQC is set up to provide a robust monitoring procedure.

Conclusions

I haven’t been able to cover all the points of the SCR. It is worth reading in its entirety. It concludes by emphasising that services like Winterbourne View should not exist as they create no aspirations and hope.

They are not therapeutic environments and were created to provide a funding stream to the private company rather than to improve the quality of treatment and care to those who need them.

Commissioning should look at what exactly is being commissioned and what is needed to achieve the end result of an improvement of quality of life.

I look at this report and it is an excellent report, and I despair. I recognise parts of it but it is a particularly appalling litany of pain, distress and human suffering that could have been identified earlier. We relied on a television programme to identify these issues when there were so many people who should have identified this sooner.

No one comes out of this well apart from the whistle blowers who tried to make a difference.

Good services can and do exist but we need to be very clear about expectations of services and what we expect a hospital built on an industrial estate and factoring in amounts of income possible can achieve as opposed to services which truly exist in local communities.

It’s an awful situation but the SCR offers an opportunity to learn and do things differently. Let’s listen more and better across the whole sector and remember that this job is always a matter of partnership and never should be one of dictation. We have to do things better.

Winterbourne View – Profit from Cruelty

Today I’ve been reading the Serious Case Review for Winterbourne View, and it makes for grim reading. A monumental tale of casual abuse and violence by staff against patients with autism and learning disabilities. Whistleblowers ignored. Police and regulators failing to take action.

But here’s something that makes it doubly sickening, from the opening paragraph to Section 6 of the review.

We have been here before. There is nothing new about the institutional abuse of adults with learning disabilities and autism.

Events witnessed at Winterbourne View Hospital recall the custodial treatment associated with decommissioned, long stay, NHS hospitals. However, unlike the hospitals and institutions described in previous inquiries and reports of institutional abuse, Castlebeck Ltd was not starved of funds. The financial costs of out of area services for people with learning disabilities, autism and or mental health problems are considerable, as reflected in the weekly average fee charged.

The fee they refer to was £3500 per patient per week, paid for by the taxpayer. Putting them up in the Savoy would be cheap by comparison. And what did the patients get in exchange for these generous payments, apart from the opportunity to be taunted and thumped?

The skill mix at Winterbourne View seems to have been surprisingly dismal, given what was being paid. The only professional groups employed were psychiatrists and learning disability nurses, and there weren’t that many of those. The overwhelming majority of staff were unqualified support workers. No psychologists. No occupational therapists. Some activities coordinators to organise recreation, but as is often the case in units with staffing issues, they regularly wound up being used as relief care workers instead.

During 2010, “on the job” training and inadequate staffing levels persisted with poor recruitment practices and further instances of unprofessional behaviour in an increasingly non-therapeutic hospital. Patients lived in circumstances which raised the continuous possibility of harm and degradation. Castlebeck Ltd’s managers did not deal with unprofessional practices at Winterbourne View Hospital. Absconding patients, the concerns of their relatives, requests to be removed and escalating self-injurious behaviour were not perceived as evidence of a failing service. The documented concerns of a whistleblower made no difference in an unnoticing environment.

In all fairness, unqualified support staff can and do provide good quality care, with the right leadership and a good culture. Not that they got it from the owners, Castlebeck Ltd. They seemed happy to rake in the dosh from their remote headquarters in Darlington while an ethos of abuse, over-medication and excessive use of restraint ran rampart at Winterbourne View.

This may be worth remembering as the government applies the rhetoric of “any qualified provider” to the NHS. Castlebeck were regarded as a “qualified provider”. Whether they gave value for money is another matter entirely.

 

 

 

Hobson’s choice – voluntary or compulsory removal of a child?

CA (A Baby), Re [2012] EWHC 2190 (Fam) (30 July 2012)

By an extraordinary coincidence, it was only this week that I mentioned in a blog the case which came to national tabloid prominence four years ago as “the Nottingham baby case”. Extraordinary that I have cause to review it again, so soon, in considering a judgement given on Monday; and coincidence that @suesspiciousmin covered both cases and indeed his blog drew my attention to the case which prompts me to drag it up for the second time. His blog on yesterday’s judgement is here: http://suesspiciousminds.com/2012/07/31/i-need-two-volunteers-you-and-you-how-voluntary-is-voluntary-accommodation/

But, having dug out the Nottingham baby case so recently, I had to find myself reflecting that the issues in this week’s case have been aired before, and indeed to remarkably similar effect.

Hold on a minute, I hear you saying, I have no idea what you are talking about. What is the Nottingham baby case, and what happened this week? OK, one at a time.

The Nottingham baby case By an extraordinary coincidence, in late January 2008 a judicial review by a care leaver of her pathway plan was listed to be heard a few hours after she had given birth early, and her baby had been removed. Thus very publicly, in judicial review rather than family proceedings, the court was asked to, and did, order the baby’s return in the absence of any court order authorising his removal.

A full hearing of the issues took place two months later, and there, the local authority argued that, as the mother knew of the plan to remove her child at birth and had not objected, she should be treated as having consented to the baby being accommodated under section 20. The judgement G, R (on the application of) v Nottingham City Council [2008] EWHC 400 (Admin) (05 March 2008) robustly rejected this argument.

I analysed the case at the time, in an article in Professional Social Work magazine, which you can read here: http://www.celticknot.org.uk/publications/canishouldimusti.pdf

What happened this week? An expectant mother who had had previous children removed for adoption was subject to a plan for the same for her fourth. When the birth came there were life threatening complications, and among other things she received morphine during and after birth. The authority sought to accommodate the child voluntarily but she did not consent. She was asked again over the course of the day until later in the day, while dosed with morphine, she agreed and the child was removed. She challenged the lawfulness of the removal and judgement was given yesterday in CA (A Baby), Re [2012] EWHC 2190 (Fam) (30 July 2012).

This week’s judgement records an agreement to pay human rights act damages for the interference with her family life, and sets out forcefully observations on the use of section 20 in these circumstances. The court was not referred to the Nottingham baby case, possibly because it was a judicial review rather than a family case.

The issues in common

Both cases:

  • concerned the removal of a child at birth in accordance with a birth plan;
  • used voluntary accommodation under section 20 as the vehicle for achieving that removal;
  • involved challenges to whether consent was properly obtained;
  • asserted breaches of the Article 8 right to respect for private and family life;

Lessons on consent – a reminder

The Nottingham baby case resulted in a robust judgement which distinguished acquiescence from consent:

To equate helpless acquiescence with consent when a parent is confronted in circumstances such as this with the misuse (or perhaps on another occasion the misrepresentation) of non-existent authority by an agent of the State is, in my judgment, both unprincipled and, indeed, fraught with potential danger… Submission in the face of asserted State authority is not the same as consent. [paragraphs 55, 61]

This week’s judgement also distinguishes acquiescence from consent [paragraph 36].

Both cases also serve up reminders that the immediate aftermath of birth is not a good time for proper informed consent [Nottingham case at paragraphs 52, 57; this week’s case at paragraph 38].

Both cases also remind us that consent which is obtained in circumstances where the mother believes they have no choice is not proper informed consent either [Nottingham case at paragraph 55; this week’s case at paragraph 35].

Thus far, I am happy. Disappointed, perhaps, that the assertion of non-existent authority by an agent of the State is still being used to procure the removal of children with neither proper consent nor the sanction of a court. But if that is the case, then this is a timely reminder to get it right.

Lessons on capacity – a difference

Yesterday’s case raises the issue of capacity and consent. Effectively, it reminds us that you cannot consent without the capacity to consent. Since the European Court in H.L. v. THE UNITED KINGDOM – 45508/99 [2004] ECHR 471 (5 October 2004) holds that the absence of objection cannot be equated with consent, and those who for reasons of capacity cannot object still need an effective remedy, that judgement seems to draw together the Nottingham baby case and yesterday’s case. One may have concerned a capacitous individual not objecting and the other a non-capacitous one, but the principles which hold that there is actually no consent actually apply to both.

The difference is that in the absence of capacity, in effect there must be a court order, consent being impossible.

Lessons on choice – a problem

But there is, it seems to me, a problem with yesterday’s judgement. The Nottingham judgement explicitly recognises that section 20 consent is at least possible to authorise the removal of a child at birth for adoption – and even cites a precedent – X County Council v C [2007] EWHC 1771 (Fam) (20 July 2007).

Yesterday’s judgement seems to go further. It comes very close to saying that section 20 should not be used in circumstances where a court order could not immediately be obtained.

I am troubled by an issue that brings us up to the furthest reaches of the issues surrounding consent and choice, while at the same time engaging the very nature of social work:

If the only choice you have been given is to hand over your child voluntarily or face an application for a court order, is that a genuine choice? And if you have no real choice, is it effectively unlawful compulsion?

At first blush, a rights-oriented lawyer will deplore the effective compulsion that is involved in the Hobson’s choice between voluntary and involuntary removal. But I also have concerns to see my other profession, social work, engaging in more co-operative practice. Indeed, I think the original ethos of the Children Act – and indeed the statutory guidance accompanying it – assumed that social workers would be trying to work with, rather than against, families even where there were child protection concerns. And I think that such an approach would enhance social work’s standing also.

These concerns lead me to believe that voluntary care and persuasion really ought to be tools in the social worker’s toolbox. And it was with some concern, therefore, that I read @suesspiciousmin‘s analysis of this case which includes the useful summary that the court entered

into a discussion of whether a Local Authority can properly invite a parent to give s20 consent if the circumstances are not such that a Court would authorise separation, before concluding that they cannot.

That, I do not like. I think the more powerful argument is that this week’s case makes persuasion to the use of section 20 more fraught with difficulties and therefore less likely to be attempted, rather than that it outlaws it. After all, the judge does observe,

there will be cases where it is perfectly proper to seek agreement to immediate post-birth accommodation… secondly where a parent has always accepted that the child must be removed and has consistently expressed a willingness to consent (but not of course just to acquiesce)… the right to exercise parental responsibility by requesting accommodation under Section 20 and the local authority’s powers of response under Section 20(4) must be respected  [paragraph 36].

Even so, dissuasion of persuasion (!) is not necessarily helpful. Of course, using section 20 properly means:

  • never pretending that you could get a court order if you couldn’t;
  • always making clear that there are remedies, and parents have access to remedies to test the lawfulness of the authority’s actions and proposed actions;
  • not using a failure to co-operate voluntarily against a parent (this, of course, is particularly pernicious, as explained in this blog)

Surely, if used properly, invitations to section 20 consent should result in:

  • some parents giving informed consent, even though they fully understand that they need not and that they could win an argument that the care threshold was not met – because they are persuaded to work co-operatively with the authority in the interests of a child in need;
  • others withholding consent, and the child’s being made the subject of an Order, without reliance on the parent’s withholding of consent – because we accept that it is their right to challenge the lawfulness of our actions and we don’t hold that against them;
  • still others withholding consent and the child’s not being made subject to an Order – because, let’s face it, if the threshold isn’t met then we cannot and should not be using compulsion, we shouldn’t use compulsion simply in the best interests of a child, only to protect from significant harm.

Precluding the possibility of outcome 1 is not good news in my book. Outcome 3 is consistent with the rights of all involved. My fear is, that if section 20 is confined to cases where the significant harm threshold can be made out,

  • this is bad for children, because it removes a potential tool in the toolbox of social workers to help children in need, and reinforces the notion of ‘significant harm or nothing’ which plagues work with children and families;
  • it is bad for parents, who cannot accept support without the probable stigma of being labelled as bad parents owing to the threshold test being met;
  • and it is bad for social work, reinforcing confrontation because the very fact of social work involvement equates with compulsion and is confined to the more serious cases.

Hobson’s choice? No, the choice between voluntary and compulsory accommodation is a real choice that can benefit us all.

P.S. I have mentioned and recommended two other blog posts on the use of section 20:

And for tonight’s rant‘ from @familoo at http://pinktape.co.uk/ (which makes a strong case for the court’s supervision); and

How ‘voluntary’ is voluntary accommodation?‘ from @suesspiciousmin at http://suesspiciousminds.com/.

Those two blogsites have been very sweetly courting each other this week – or whatever it is that blogsites do when they contemplate partnership – blush, apparently – but even from my gooseberry’s perspective, I can heartily recommend both, as forming part of my regular and essential reading, and being incisive and quick off the mark in commentary!

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

Winterbourne, South Gloucestershire Council and Responsibility

Winterbourne View and the systematic abuse of those people with learning disabilities who were placed there uncovered by BBC Panorama programme last year has had significant repercussions.

That countless attempts by whistle-blowers  were ignored until the BBC took up the mantle that should have been taken by the regulating authorities was a particular failing in the system that should protect those who are most dependent on robust and good quality care.

The CQC was actively moved into ‘defensive’ mode and instituted a number of new inspections of similar type facilities around the country. I’m not sure that anyone in the CQC took particular responsibility for a lack of response to the initial concerns raised.

I saw this story on the BBC this morning that two managers at South Gloucestershire Council have been dismissed.  The two dismissed were a team manager, Kevin Haigh,  and the council’s safeguarding manager, Brian Clarke  – as the story says

It is understood that a-year-and-a-half before the whistleblower came forward and the programme was filmed, Mr Haigh and Mr Clarke were alerted to other allegations of serious abuse.

In their defence, a Unison statement reads

‘We believe that there may be wider failures in safeguarding procedures in South Gloucestershire in relation to Winterbourne View which go far beyond the involvement of any two individuals.

Which is a fair point but I think that there has to be some level of responsibility taken within a local authority when safeguarding procedures fail so badly. Particularly concerning to me are two issues – firstly why it takes a BBC documentary to uncover abuse that had been flagged up clearly and secondly, knowing about how safeguarding investigations are conducted, how this was able to ‘slip past’ what are, in my experience, fairly robust procedures.

Either way, whilst I don’t welcome scapegoating, I think it’s right that those who are responsible for management within public services take responsibility  for things when they clearly don’t work to protect those who need safeguarding.

As for the serious case review, which is due to be published later this year, I can only hope many lessons are learnt so we become less reliant on the press and more able to rely on robust preventative work by commissioning authorities and inspection regime to stamp out institutional abuse and/or to spot it as a priority.

Reporting on Deprivation of Liberty Safeguards

Skyline

If there’s one part of my work which is bound to cause confusion and misunderstanding, I’d say it’s the ‘Deprivation of Liberty Safeguards’ or DoLs as they are shortened to.

DoLs is a complicated corner of legislation that covers particularly those people who lack capacity to make decisions in relation to their care, accommodation and/or treatment (depending on the particular case) who are being ‘deprived of their liberty’ in a care or hospital setting. According to Article 5 of the European Convention of Human Rights, there is a residual ‘right to liberty’ so when someone is ‘deprived of their liberty’ (whether by being detained under the Mental Health Act or in prison) there has to be a legally prescribed process to appeal this and to ground the decision made. The ‘Bournewood Gap’ whereby there was no procedure to deprive people who lacked capacity to make decisions about residence/treatmetn/care was thus ‘closed’ by the introduction of these ‘Deprivation of Liberty Safeguards’ which provide a legal framework to authorise (and appeal, in legal terms at least) these orders.

To my knowledge, the majority of these orders particularly would be made in respect to people with learning disabilities or moderate to advanced dementia.

So yesterday the Department of Health reported produced it’s Third Annual Report (pdf) on data provided in respect to the amount of DoLs across England and the Independent published an article about the ‘huge spike’ in applications made – a jump by 27%.

There was some discussion last night on Twitter about whether this was ‘a good thing’ or not. The article rightly identifies the mess inherent in the current rather confusing and potentially inaccessible system, saying

DoLs are notorious among lawyers, care and health professionals for being overcomplicated and deeply misunderstood. Both the Care Quality Commission and the Mental Health Alliance have criticised the legislation with the latter describing the entire DoLS system as “not fit for purpose”

I’d join in with the criticism to an extent. The current system is overcomplex and the lack of a clear path through the system for service users and for family members is notorious and verging on oppressive. The routes of appeal particularly are unhelpful and challenging DoLs authorisations is a complex process. The other difficulty is that there is a lot of variance in definitions of what ‘deprivation of liberty’ means. This is something that courts reinterpret frequently however thinking back to the safeguards as exactly that – safeguards – mean that by the context of them narrowing we are at risk of providing these safeguards to fewer people.

However regardless of the complexity of the system, these ‘safeguards’ are not bad in themselves. They provide an extra layer of scrutiny into some of the care and treatment of those who lack capacity and can be a potentially very strong safeguard.

The problem is, well, one of them anyway, is that the care home or hospital where the deprivation of liberty is or may be taking place have to make the referral themselves.

Back to the Independent article, it explains that one of the problems is the massive discrepancies nationally and I would concur with this. This is what happens when ‘deprivation of liberty’ is poorly defined.

So

A breakdown of the figures show that whilst a local authority like Leicester made more than 400 applications last year, Reading only made one for the whole year whilst Hull made just three.

This seemed staggering to me. I am astonished/sceptical. Is it really possible that there has only been one person who is in Reading (or for whom Reading is responsible in terms of financing their placement) who was deprived of their liberty in a case or hospital setting over the course of an entire year?

Reading’s response is interesting in itself

A spokesman for Reading Borough Council gave no reason for why they had only authorised one DoLS last year but added: “We advise and support care homes to support vulnerable people, and only use DoLs as a last resort measure.

Well yes, but this more shows a lack of training and advise regarding legislation rather than something that Reading should be proud of. Because to me, it screams that there are potentially a lot of ‘unauthorised detentions’ knocking around.

The problem is that noone is likely to pick up on this.

The Deprivation of Liberty Safeguards are not ‘bad’ per se. They are safeguards and when they kick in, they require two independent assessors to provide a report explaining the terms of the deprivation as it exists, a limit to it and the reasons why it is in that persons’ best interest.

How could they be made better? (and do bear in mind, I’m venturing a little into ‘fantasy land’ here).

  • Streamlining the appeals process so that it is on a par with rights to appeal to tribunals under the Mental Health Act
  • Provide a mechanism to trigger referral that does not depend on the care home/hospital
  • Better define what Deprivation of Liberty is
  • Provide a regulation framework whereby regulators and inspectors are actually aware of ‘deprivation of liberty safeguards’ and the relevant legislation

Will that happen? Unlikely because there is little resourcing available but however much the phrase might make one shudder with confusion, the Deprivation of Liberty Safeguards are important.

They protect the rights of those who have little recourse and for whom some of the most important decisions are made by staff in hospitals and care homes and by local authorities. These need to be scrutinised and considered but the complexity of the system has been its undoing.

The presence of a DoLs authorisation in a care home is not a ‘bad’ sign. The absence of any (or few) DoLs authorisations in an entire local authority is not a ‘good’ sign.

Poorly administered or misunderstood DoLs’ authorisations are very bad though however used properly, it is very important to remember they are safeguards.

Reading’s pride at the existence of one authorisation over a year is not really something for them to be enormously proud of because I worry about the existence of unauthorised deprivations of liberty – not just in Reading (where obviously they advise and support care homes so well) but in all the care homes and hospitals in the country where those for whom Reading may be responsible are living.

Sometimes it isn’t as simple as saying ‘rising authorisations’ are bad or that they are ‘good. It’s about the subtlety of implementation and review.

Most worrying is the variation. If anything points to complex law and poor information sharing – it is that.

Something to learn for local authorities around the country, I hope.

And hopefully a lot more work for those who train people to understand and use the deprivation of liberty safeguards properly!

pic by garryknight Flickr

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

paper stack 1 SQ BW 500X

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

The Queen’s Speech and Adult Social Care

The Queen at the State Opening 2009

I was expecting little from the Queen’s Speech in relation to adult social care and I was exactly right in my assumption.

The one line

‘A draft bill will be published to modernise adult care and support in England’ made my heart sink from the outset.

‘Modernise’ is one of those words that could mean anything. Sure enough the details followed.

The Department of Health website expands on that sentence.

The main elements of the draft Bill are:

  • modernising the legal framework for care and support, to support the vision of the forthcoming White Paper on care and support
  • establishing Health Education England as a non-departmental public body
  • establishing the Health Research Authority as a non-departmental public body
  • creating a London Health Improvement Board
  • carrying out engagement and pre-legislative scrutiny on the draft Bill, as many in the social care sector have called for, to enable government to listen to people with experience and expertise, to make the most of this unique opportunity to reform the law

What is missing is more important that what is contained in that short statement from the Department of Health.

We knew already that the Law Commission report was likely to be incorporated into legislation. I feel confident that there will be a streamlining of legislation and systems around them which will be positive.

As well as improving (or ‘modernising’ as they like to call it) the hotchpotch of legislation into one Act, the recommendations, lest we forget, include strengthening safeguarding processes for adults and imposing duties on local authorities to provide services for carers.

Which brings me on to the part that is missing.

Funding.

There was no mention of tackling the immense funding gap in these proposals. There is talk about rolling out ‘choice and control’ but without knowing that this will be funded (which it won’t – we were always told this would be zero cost process of change) it leaves a bitter taste in the mouth.

The Department of Health talks about ‘building on progress’ of personal budgets and my hope that will mean plugging that gaps that were introduced in the first place. I have my doubts as plugging those gaps will lead to significant funding increases as it will mean investment in statutory advocacy to extend the same levels of choice to wider groups of users.

My concern is that what will actually happen is that we will be given more meaningless targets to reach that will be very beneficial to the few  but will leave a large swathe of people behind as the pot of money available for care simply runs out.

One of the ‘benefits’ the Department of Health elucidates is

simplifying the system and processes, to provide the freedom and flexibility needed by local authorities and social workers to allow them to innovate and achieve better results for people

Now, if anyone can translate this ‘policy speak’ into real language for me, I’d appreciate it.

I read it personally as a push towards ‘social enterprise’ type operations which push social workers away from local authorities but I could be totally wrong on that.

‘Innovate’ like ‘modernise’ is an easy word to throw around, especially by those who have no conception of the actual meaning of the word. Innovation needs a lot more than the proposals on the table. It needs much more inventive and open thinking from areas outside the Department of Health. I’d like to see more emphasis on co-production. We want users to have the flexibility to innovate rather than necessarily the social workers. And I say that as a social worker.

I will wait with interest to see the coming White Paper on Social Care. I set my expectations very low. But I do expect a lot of words like ‘choice’, ‘modern’, ‘innovative’ with no mention of funding at all.

photo via parliament_uk flickr