Have we become a neglectful society?

Norman Lamb, the Care Minister, gave an interesting interview in the Telegraph over the Christmas period, which was given the rather unfortunate headline, “Neglectful Britons blamed for forcing elderly into care homes”. This picked up on the Minister’s view that we have become a “neglectful society” and that we need to rebuild “neighbourly resilience”, without which, he was quoted as saying, pensioners lead dismal, lonely lives.

Mr Lamb was given a hard time for this by Sarah Ditum, writing in the Guardian, who said that “The government has some cheek to say we’re not caring enough” and pointed out that more unpaid family carers are caring for more hours per week than ever; a huge contribution which Ditum argues the coalition is undermining with cuts to public services.

Ditum is right that, as social care services are being ever more tightly rationed, whilst the impact upon the NHS is starting to show, the impact upon family carers is often hidden, yet very real.

However, I don’t read the Minister’s comments as being about unpaid family caring. His suggestion that we have become a “neglectful society” is strikingly reminiscent of John McKnight’s suggestion, that we (in his case, the ‘we’ being US citizens in the 1990s) have become “a careless society”, in his book of the same name. McKnight was one of the founders of ‘Asset Based Community Development’, an idea which Lamb’s predecessor, Paul Burstow, talked about approvingly in the run-up to launching the social care White Paper. ‘Asset-based’ or ‘strength-based’ approaches start with the premise that seeing only people’s needs and vulnerabilities (their ‘deficits’) will lead to services being designed to impose outside ‘expertise’ at the expense of individual, family and community resilience. In other words, poorly designed, if well-intentioned, social services can become part of the problem, ‘colonising’ communities and ordinary human relationships and leaving citizens who have, in McKnight’s words, “grown doubtful of their common capacity to care”.

So McKnight was not arguing that people had stopped caring about each other, but that they had stopped seeing the active support of those around them as their role, instead believing that only the state was qualified to provide support. It’s a powerful – and by virtue of its power, a dangerous –  argument, but one which needs serious consideration.

A small-state fanatic could see it as an excuse to cut services in the naïve belief that people will start supporting each other as soon as the state ‘gets out of the way’. McKnight was instead arguing for services which were more led by people and which worked alongside and supported their relationships, rather than supplanting them. You only have to look at the isolation of thousands of older people or the disempowerment of many people with learning disabilities living in ‘service settings’, to realise that even well-funded traditional services cannot address isolation, in all its many forms.

I met Mr Lamb a number of times in the Autumn, including to discuss asset

When is Shared Lives just shared living?

Here in the Shared Lives sector we’re used to confusing the people whose job is to fund or purchase social care for the local council or NHS Trust. Shared Lives doesn’t fit the usual boxes, it’s not funded quite in the normal way, it has different boundaries and expectations, and so on.

At a recent meeting wiht the researchers at Kent and LSE Universities (the PSSRU unit) who are beginning to research the outcomes and costs of providing Shared Lives to older people, we started to discuss the small but perhaps growing number of older people who don’t have eligible social care needs (ie needs which the council will pay to have met), but who are interested in living as part of a family.

Some have arrived at the Shared Lives service via a mental health service because living in isolation has resulted in depression. Others simply don’t like the idea of continuing to live alone in a large house with family at a distance and are planning for a future when they be less independent. They have the option of selling their large house to move into sheltered accommodation, but aren’t sure that is what they are looking for.

What’s all this talk of ‘assets’ about?

One of the recommendations which received the warmest welcome from the government, during the discussions which fed into the social care White Paper which we are expecting in the coming weeks, was the idea that we have to move from a ‘deficit’ to an ‘asset’ based view of people. It’s unfortunate that those are horribly jargonistic terms which need some explanation, and which are open to misinterpretation.

‘Deficit-based’ refers to the fact that, at the moment, you may have to prove how bad things are (and often, how little money you have), before you can get a response from the social care system. There’s a reason for this: if services aren’t ‘rationed’, more people might want them and there’s not enough money in the system to pay for them. The problem is that forcing people to prove how little they can do is demeaning and can actually add to the problems a person was facing in the first place.

An ‘asset-based’ approach says that we should always look for people’s strengths, resources and potential to solve their own problems. This has to be right: my kids’ school is open to everyone their age and the teachers are focused entirely on helping the children to grow and become more independent and responsible. It’s a happy place. I feel slightly less positive about my GP surgery – it’s there for everyone, but I only go there with a problem I can’t fix and I’m in the hands of experts who know stuff I don’t understand myself. Social care is often a place of last resort. It is becoming more asset-based, in that

Local Area Coordination

How can we kick start radical change in a care and support system which is suddenly starved of money? Perhaps an equally valid question is, “How can we not?” This second question can only be asked if we genuinely believe that there are ways for communities to face their challenges which aren’t entirely reliant upon services.

Local Area Coordination (LAC) is now at the core of care and support in Australia, after twenty years of development and numerous evaluations. Ralph Broad, who has worked in Australia and the UK remarks upon the fact that outcomes in Western Australia are better than those in the UK, despite the fact that even a recession-hit UK is still better resourced than Western Australia has ever been. LAC is a way of recognising that people are not passive “clients”, “service users” or “customers” of a social care system. It puts professionals in new roles: working alongside people. Local Area Coordinators in each small locality have an open door, access to information and small amounts of funding, but most importantly a remit to nurture local solutions and keep people strong. They help people to access services where they are the only option, but they see services as the last thing to consider, not the first.

LAC is not an initiative to ‘drop in to’ the existing system, with its preoccupation with gatekeeping services for those deemed needy and vulnerable enough to qualify. It is best used as a way to transform the whole system, starting with

Taking gambles that pay off

This is the third blog I’m writing off the back of a seminar with social care leaders which looked at the question of citizen and community-led change. One of the debates we had on the day was the age old debate of whether change is all about changing systems, legislation and funding routes, or all about changing attitudes and culture. It’s one of a number of questions to which I think the answer is both.

We need to tell stories about, for instance, the lady in Wiltshire who was helped to maintain independence by the provision of a £100 grit bin for her hill, plus some encouragement from her neighbours to share the task of gritting, rather than the provision of a special transport service, or meals on wheels. The latter solution would have helped speed her isolation and reduced her mobility. The former could result in any number of knock-on positive impacts as the people involved got to know each better and thought about other ways they might be able to help.

Stories like that inspire. They illustrate the power of focusing on outcomes rather than mandating processes. A councillor who meets older people in their ward may well be more motivated by that story than by any number of cost benefit analyses and statistics.

But Department of Health Ministers can’t go to the Treasury to make the case for social care armed with anecdotes. They need a robust cost benefit case based on evidence gathered from thousands of people. They need to be able to show cashable savings to real services, not notional Social Returns on Investment.

But how do you quantify the economics of making changes like the grit bin example, without codifying and measuring it out of existence? One solution, I think, is for government to do what it does well

An exclusive club no one wants to join

In my last entry, I reflected on some of the questions I was involved in debating at a seminar for senior social care colleagues who are all trying to embed ideas of community and citizen leadership into their local area. I suggested that there is no one way of achieving this, but a number of quite complex ways of contributing to it. Here’s an attempt to unpack that a little further.

We started the session by asking colleagues to think about the journey that people make in and out of the social care system. At present, that journey can feel like being presented with a succession of doors and the challenge to batter, argue or beg your way through each one, with the promise of a service at the end of it. If social care was a nightclub, it would have large bouncers, a strict door policy, a small range of rather expensive drinks and no pass outs: once you’re in, you can’t leave if you want any chance of getting back in later on. I was struck by something Lynne Elwell of Partners in Policymaking said recently: “I spent years trying to get my daughter into the system, and then as many years trying to help her escape again.”  

We can’t afford a social care system which is an exclusive and expensive club, particularly when it’s not a club many people want to be a member of. So, counter-intuitively, to reduce the costs, we need a system which is open to everyone, but which is just as easy to leave, and return to, as it is to enter. Derby have been developing a Local Area Coordination approach

Red tape cut for care and support services

You spend a lot more time lobbying for change than seeing it in our line of work, so today’s new guidance from the Department of Transport, which should make it much easier for care and support services who transport people as part of their wider work, is a rare victory. We’ve been campaigning on this issue for years. Here’s an example of why it matters:

Companions is a micro-domiciliary care service established to provide consistent, responsive and flexible care for a small group of older people, who pay for the service from personal budgets or their own money. The providers consulted widely with potential customers before setting up the service. These older people found it difficult to use public transport and were essentially confined to their homes, isolated and lonely. Top of their ‘wish list’ was help to go out into the community and to meet their friends. Companions designed a service which included using their own cars to take people out but were told that they would have to be licensed as private hire vehicles. The costs and complexity of obtaining a licence were insurmountable, so they have, until now, not been able to provide the service most desired by their customers.

The new guidance takes a pragmatic approach to clarifying a complex area of law, from which other departments could learn. This change may seem dry and technical, but it will result in many disabled and older people being able to get out of their houses for the first time in years.

This will be one of the important regulatory changes highlighted in the new ‘map’ for micro-enterprises which NAAPS UK is developing with support from government and which will be published in the Autumn. You can find out more on the news page at www.naaps.org.uk

 

 

Time to ditch the RAS? Part 2.

In an entry a couple of weeks ago, I identified three problems with the current way in which an individual’s needs are assessed, then their ability to pay, and then their social care entitlement converted into a cash amount, which they are helped to spend. I suggested that, even done well, the system had these problems:

1. The assessment of your needs is based on you proving how bad things are. You might even have to wait for things to get worse before you become eligible for expensive support, when making cheaper, preventative support available would have been much more cost-effective.
2. The addition of extra assessment and planning stages to the existing system, in order to convert your needs into an appropriate cash personal budget, has added bureaucracy. There is actually more gatekeeping than ever in some areas.
3. The process focuses everyone on the money, which makes it harder to focus on outcomes and being creative.

I promised to think up some solutions to those problems, and asked you for yours.

The comments you were kind enough to post were very interesting. There was some consensus around the problems. No one believes that giving people the chance to control the money that is spent on them is the wrong aim, but lots of people would like it to be simpler, quicker and fairer to get to that amount of money, with fewer restrictions on what it is spent on. Several people feel that there is no way round the need for a RAS type system, and we should accept that reality and focus on making it work. If you put identifying the service first, you’ve returned to the old system; if you put identifying the budget first, you need to base that budget on costings based on a range of likely services. Few contributors, I felt, could articulate a practical third way.

Resource allocation systems build in two opportunities for professionals to exert control: first in setting an indicative amount, then in signing off (or not) the final budget. If it is never going to be possible for the state to relinquish budget sign-off completely, how could that control at least be eroded or tempered, without leading to bankrupt councils?

At a corporate level, council finance directors cannot relinquish overall control of budgets: it’s their job not to overspend. There is a tension between this need to exert control at a population level and the desire to relinquish budgetary control at the individual level. We could reduce that tension in a couple of ways:

First, and least likely, we could give council finance directors a breathing space where, if they can produce balanced budgets over five years, their budgets can be guaranteed for that period. This would allow councils to invest in prevention and to look more kindly on individuals who need to invest in non-traditional interventions which might prevent greater need later on. It’s hard to imagine this happening. The evidence base for many preventative services is weak and the government would need to find money up front and underwrite the losses if council’s plans didn’t work out.

Secondly, we could help people who use services act a little more like finance directors,

Dragons return to West Wales

Helen and Tony Woodman are carers with West Wales Adult Placement (Shared Lives) Scheme. Thanks to the work of the Scheme and funding from the council, the people who visit Helen and Tony’s home in the peaceful Cych Valley, Pembrokeshire have the opportunity to create works of art that are sited in prominent positions around Carmarthenshire. These include The Boars marking the gateway into Ammanford, The Drover Sculptures in a busy shopping area in Carmarthen and two Dragons, one welcoming visitors to Carmarthen and the other guarding the gateway to Newcastle Emlyn Castle, which legend says was the place the last dragon of Wales was slain. This latest project was the work of service users, Craig Jenkins and Wyn Havard from Pembrokeshire and Jean John and Rhian Evans from Carmarthenshire.

In addition to creating the dragon, all involved in the project have had the opportunity to make something that they have designed and made for themselves.  Rhian says “I drew out the design for a door stop and I will make that next.  I like coming here to work with Tony.  He is fun to work with.” Another participant said, “I have enjoyed seeing the dragon grow each week and also lunch break when we can all have a chat around the table.”  Craig is now beginning a work training placement in a woodwork company.

Gwenda Thomas, Deputy Minister at the Welsh Assembly Government came to admire the dragon and met everybody involved. She said, “I have been extremely impressed by what I have learnt and I am very humbled by the work of the carers.”   

Myths, cynicism and personalisation

The personalisation of social care – the idea that everyone who is offered support should have maximum choice and control over their service and their life – is beset with some real problems. The biggest one being that making personalisation happen requires changes in services and budgets, at a time when councils are also cutting services and budgets. There have been articles in the trade press recently alleging that, surprise, surprise, the cuts tend to win out over more positive reforms.

But personalisation is also beset with problems which aren’t real. Right from the start, people’s picture of what personalisation means has been as much about the myths as the reality. Of course, when even the people charged with carrying out the policy on the ground themselves have a fairly shaky understanding of what personalisation is really about, myth swiftly becomes reality for lots of people.

The ideas that people should have choices, control over their services and their lives and the opportunity to make a contribution to their community: all of these are real and important ideas. We can’t let them drown in the myths. So there’s a real need for some myth-busting. Here are my top myths in need of busting: I’d love to hear yours.

1, Personalisation is all about personal budgets or Direct Payments.

Personalisation is about people having more choices, more control, more opportunity to contribute. Changing the way the money moves around is only one part of making this happen. People who don’t want control of the money still want control of their lives. And having control of the money makes no difference if there’s no one ensuring that there is a growing choice of small support providers, not a diminishing group of cut-price care supermarkets.

2, Personal budgets and Direct Payments are the same thing.

People are still confused about the difference between personal budgets and Direct Payments. Not to mention individual budgets. A personal budget is an allocation of social care resources. There are different ways to take that allocation, the ‘purest’ being as a cash Direct Payment. But if you don’t want to be legally responsible for spending that cash, you can get the council to manage it for you (sometimes called a managed budget) or another organisation to both manage your budget and provide your service (sometimes called an Individual Service Fund). Individual (sometimes mis-quoted as ‘individualised) budgets were a pilot scheme, now ended, which involved budget-pooling.

3. Direct Payments are just for employing a personal assistant.