December 2011 Archives

Over a million pensioners are facing Christmas alone, according to Dying Matters, the coalition dedicated to designed to improve attitudes to dying and death. Today it is launching a campaign asking people to look out for and call in on older neighbours and relatives who are on their own, particularly those who have been unwell or bereaved in the past year.

Findings of fault with councils' provision of information and advice on care are nothing new (for example) but charity Independent Age thought it worth highlighting unpublished research from the CQC into authorities' failing in this area.

The 2010 study involved 7,500 mystery shopping calls to assess the quality of information and advice given by English councils. The reason it was left on the shelf (with the exception of a reference to the high-level findings in CQC's state of care report for 2009-10 - see page 46) was because of the government's decision to end CQC's role in assessing councils' adult social care functions in November 2010.

However, explaining her decision to commission a report on the research, Independent Age chief executive Janet Morrison said: We commissioned this report because we felt it would be an appalling waste NOT to do anything with research that took the Care Quality Commission (CQC) nearly a year to undertake and involved around 7,500 detailed mystery shopping calls."

The findings are that:-

• Only five of the 150 councils were rated as good or excellent in exploring users' needs at first contact.
• Only 30 out of 150 were rated good or excellent when it came to asking about needs before financial circumstances.
• Only eight out of 150 were good or excellent at providing information to allow a caller to follow up on initial advice
  

This begs several questions, the two most compelling of which are, what has happened to council provision of information and advice since this research was undertaken; and, perhaps more importantly, what pressure/scrutiny has been brought to bear on them to do so in the absence of the CQC?

Assessment of local authority adult social care functions is now the responsibility of the sector as a whole, through an Excellence Board for adult social care that includes the great and the good (Association of Directors of Adult Social Services, Local Government Group people).

It may well be that sector-led improvement is having a more positive effect than CQC-led scrutiny. However, one consequence of the change, is a loss of transparency that makes it very difficult to work out whether or now and how far councils are improving.

I don't know how many times I have heard that integrating health and social care does not require structural change - bringing together the provision or commissioning of both under one organisation - and that it is really about culture, shared outcomes and goals and good leadership.

Well for a different perspective, read this blog from consultancy iMPOWER, which has been working with Herefordshire Council and the local NHS to establish Wye Valley NHS Trust, the country's first integrated provider of acute and community health services and adult social care. As we have reported before, Herefordshire has a long history of organisational integration with a joint management team for the council and the primary care trust.

The iMPOWER blog post argues that partnership arrangements - of which health and well-being boards are the latest example in England - depend on strong personal relationships to succeed. Where these are lacking, they struggle, and financial problems for both councils and the NHS are bringing increasing tensions to these relationships.

Bringing health and social care together more formally to underpin the health and well-being boards can help to overcome this reliance on strong personal relationships," it argues. "In our experience doing so can make those involved think very differently, and better decisions can be made as a result."

iMPOWER says that in Herefordshire, council reablement and NHS intermediate care services have come together - a sensible move given that they perform a pretty similar role and have similar objectives - and social workers and NHS colleagues have gained a better understanding of what they each bring to services.

However, it warns that such integration only happens very rarely and when there is a strong imperative to do so, as there is too much to lose for both sides. That is why it would be a good idea to take a decision to integrate - organisationally - nationally - though leave the detail of implementation up to local areas, as has now happened in Scotland.

It suggests that this move could change the terms of debate in England in the direction of nationally ordained (though not micro-managed) integration.

Is care funding being delayed until 2025? That's what the Telegraph and the Mail are reporting today, the latter in quite high-pitched terms ("Families betrayed over care funding reform").

Andrew Dilnot, who produced a report for the government on funding reform earlier this year, said he envisaged his proposals - or something like them - could be implemented in 2015, following government legislation (to recap Dilnot's central proposal was a cap on lifetime care costs for service users of £35,000).

There have been rumblings ever since the report was published that the Treasury has got cold feet because of the estimated bill of £1.7bn a year to implement Dilnot. However, the government is committed to some reform of the funding system, whether Dilnot, Dilnot lite or something else altogether, through a White Paper next year followed by legislation. If the implementation of this was to be delayed until 2025 that would be a very serious matter.

But are the Telegraph and Mail right to make this claim? The story originates from a briefing given by health secretary Andrew Lansley to journalists yesterday, attended by, among others Jeremy Hughes, chief executive of Alzheimer's Society. Hughes has been advising ministers on the shape of the White Paper.

A - if not the - key piece of evidence for the 2025 claim is this quote from Hughes (taken from the Mail story):

"One of our pieces of work was looking at what would it take over time to develop insurance schemes that would be marketable and would actually deliver results,' he said. "For all those factors to be in place, we thought 2025 was a realistic timescale."

Now, this seems to be a reference to the development of a market in insurance products to enable people to cover the costs of care that the state will not pick up the bill for (i.e. the £35,000). This, of course, is a matter for the private sector, not the government. So it is not a comment on when the government might implement funding reform. Indeed, the development of a private sector market in insurance is necessarily consequent on the government setting up a new funding system.

Don't get me wrong, there is a real danger that Dilnot - or indeed any substantial reform of care funding - will get kicked into the long grass or shelved, and what we will be left with is some tinkering. But the timetable for government action, whether big or small, is likely to be far swifter than what is implied by today's stories.

The Centre for Mental Health has a paper out today on the importance of stable and secure housing for offenders with mental health problems leaving prison.
It is a good overview of the current policy, research and service delivery content and worth a look if you have a moment. But I was particularly struck by the following paragraph:

A persistent theme in this and many other reports is that many services still focus on
addressing single problems and have high access thresholds, meaning that vulnerable people with multiple and complex needs often fail to receive adequate, if any, support.
There must be targeted support for people with multiple needs in local areas and a coordinated response from local services based on a holistic assessment of need
to ensure that people do not continue to fall through the gaps in services.

If I had a penny for every time I've seen a similar paragraph written in my eight years' covering social care I would probably be able to fund a service to support this client group for a few years.

It seems that we know what to do to support people with mental health problems, the risk of homelessness, histories of offending and substance misuse and experience of domestic violence (for example, see this project in Merton, south London) but things do not seem to be changing. And, according to this report, the cuts appear to be driving ever greater wedges between the agencies - the council, the police, the NHS, probation - who need to come together to serve this group.

If you haven't already done so, it's worth anyone working with disabled people checking out the new(ish) code of practice for providers of community equipment.
Despite an estimated four million people receiving 12 million pieces of equipment each year, and safety and quality issues being so important for service users, there is no system of regulation for community equipment.
The code of practice is designed to fill this gap.
Equipment providers or commissioners are invited to become registered users of the code, which means that they self-monitor their performance against it, or accredited users, which means their standards are independently verified.
The organisation behind the code is the Community Equipment Code of Practice Community Interest Company. Registered or accredited users will get to carry an appropriate kitemark.
Users will also gain access to training for their staff.
It sounds a good scheme, though there is obviously a cost attached for both registration and accreditation. The argument for providers is that it should show commissioners, users and others that you are worth buying equipment from.
It will be interesting to see how well it takes off.

Personalisation pioneer Simon Duffy (formerly head of In Control, now boss of think-tank the Centre for Welfare Reform) has just published a paper on what other countries can learn from England's experience of implementing self-directed support. It seems particularly pertinent for Scotland as it seeks to roll out the approach.

His key message appears to be one of early promise and enthusiasm not being delivered upon, mainly because of personalisation being captured by central government from disabled people and local practitioners. This resulted in the ambition of giving disabled people genuine citizenship (how Duffy has always characterised personalisation) being converted into targets and processes (that were simply layered on top of other processes in the social care system) that in many cases delivered nominal self-directed support without real control for people.

Worth a read if you have time.

The troubled (to put it mildly) Care Quality Commission has had some respite from its travails as an MPs' hearing into its effectiveness, due today, has been postponed, reportedly because of David Cameron's statement on Europe.

Chief executive Cynthia Bower was due to face a grilling from the House of Commons public accounts committee, mainly about the findings of the National Audit Office's recent report into the regulator, which concluded that it was not providing value for money. However, the committee would almost certainly have quizzed Bower on recent calls for her to resign from a member of the CQC's own board, Kay Sheldon.
This is particularly pertinent today as it emerged over the weekend that the Department of Health has commissioned a review into Sheldon's claims about the way the CQC is run, made to the public inquiry into the Mid-Staffordshire Hospital scandal.

The CQC also doesn't come off well in relation to the big adult social care story of the weekend - the proposed introduction of a TripAdvisor-style website in which service users and families can post comments and ratings on adult social care services in England. This would be coupled with reports from the local HealthWatch (the latest incarnation of organisations to represent patients and service users' interests in the health and social care system) and the CQC.

Social worker ermintrude2 blogs today that the idea appears to be an attempt to "plug the holes in the CQC by resorting to 'Big Society'.

The full details are due in next spring's White Paper on adult social care. It would be extraordinary if the new ratings system for adult social care relies on scores provided by those consumers who have the time and inclination to post them and from local HealthWatches, which will lack the capacity to investigate and report on all services in their local areas. The missing ingredient is, of course, a rating derived from the judgement of the regulator, along the lines of the old-style star ratings abolished last year.

Care services minister Paul Burstow has signalled that he doesn't envisage a return to star ratings. But while I can't see this system working without it, we would need a significant revival in confidence in the Care Quality Commission for star ratings to make a comeback.
And that begs the question of whether a change in leadership is required for that to happen.

(Addition: 3.49pm: It's worth checking out this opinion piece on the future of regulation from two big beasts of the care provider world: Martin Green from the English Community Care Association and John Adams from Voluntary Organisations Disability Group, not just for the content but the comments below it. The essential narrative is that we need to return to more of a focus on improvement - something like the regulatory approach of the Commission for Social Care Inspection - as opposed to compliance with minimum standards).

(Image on Flickr courtesy of World Economic Forum)

A study as found that most care home residents experience of living in a care home exceeded their expectations.

With nearly a fifth of disabled people saying they have trouble accessing public transport, disability rights group Radar has published a guide to help these individuals.

The guide is written by and for disabled people and is full of real-life experiences of using trains, buses, coaches, undergrounds, light railways, ferries and more. It also tells people what to do when things go wrong.

While there is still a barrier to transport for many disabled people, Radar says there has been improvement in recent years. Low-floor wheelchair access in buses, for instance, went up from 53% of buses in 2004/5 to 89% in 2009/10. There has also been an increase in training of underground staff, bus drivers and railway staff to make them more aware of the needs of disabled people.

By Anthea Sully, LDC, and David Cole, ALDS Forum

Lianne is 47-years-old and has a severe learning disability. For all her adult life, she has been attending a day care service five days a week and is very settled there. With the support of her mother and social worker, Lianne applied for a personal budget, but was only offered enough money to cover one day per week at the same service. After she appealed this decision the council offered to increase the allocated sum to cover one and a half days.
                                   
Lianne's story is just one example of the challenges many commissioners of learning disability services face current climate. Demand for services is increasing at a time when public budgets are being squeezed. These pressures are very real but in this context, it is vital that commissioners, providers and people with learning disabilities work together to ensure that is front-loaded cuts do not promote short-term decision-making at the expense of commissioning innovative services.

Whilst learning disability funding within social care budgets is not ring-fenced, there remains a moral ring-fence for local authorities to fund high quality services for people with learning disabilities. This is important protection that must be extended to all with learning disabilities and not just those with 'critical needs'. In the same way it is important to maintain a broad range of services, including residential care, so that people can access the service that is best for them and their families. 

The Adult Learning Disability Services Forum (ALDS) and the Learning Disability Coalition (LDC) are concerned that blanket cuts or reductions in eligibility risk removing vital support from people like Lianne, who rely upon services to enable them to live fulfilled adult lives.

When the pressure is on, it can seem tempting to reduce eligibility criteria; however, in the medium to long term, this approach undoes the positive work of early intervention and will ultimately lead to worsened outcomes for adults with learning disabilities.

Lianne's mother Sandra said "It is not possible for me and my husband to cope as carers if Lianne cannot attend the centre for the complete 5 days. We visualise that we would reach breaking point very quickly."

Lianne's story provides a powerful case for  health and social care commissioners, providers and people with learning disabilities to work together to find innovative solutions to the funding problems that are jointly faced. The ALDS Forum and LDC want to engage with commissioners to improve value for money whilst maintaining local services for vulnerable people. This can only be delivered through developing a strategic approach to commissioning decisions and avoiding blanket cuts that will have a negative impact on services and outcomes for adults with learning disabilities.

The ALDS Forum and the LDC welcome the publication of the NLGN's Commissioning Care in the 21st Century. The report's recommendations are important in encouraging widespread best practice that embeds outcomes in commissioning decisions and the co-production of services.

In difficult times, it is only by working together that we will we be able to ensure that adults with learning disabilities  have access to the high-quality, personalised services they need.