January 2012 Archives

Just to let you know we've got a conference on safeguarding adults at risk in Birmingham on 21 March.
We ran a similar conference last year in London, which went really well - lots of good debate and interesting insights into issues including latest policy, the role of the Care Quality Commission, serious case reviews, the deprivation of liberty safeguards and managing within constrained budgets.
Be great to see as many of possible of you there.

Anyone interested in serious case reviews specifically may want to also attend our forthcoming conference on SCRs, in London on 29 February. This will look at how to conduct effective SCRs, best ways of learning and disseminating lessons and an introduction to new reviews of domestic violence killings. Do go along.

This ministerial statement is worth checking out for the latest on plans to legislate to overhaul social services in Wales.
The plans are pretty much as we had them last year - getting councils to collaborate with each other more closely in commissioning and decision-making, putting adult protection on a statutory footing etc

We've reported today on Age UK's research showing a £500m increase in the funding gap for older people's social care in the past year. The news story gave no indication as to how they reached this figure so I thought I'd do it in a blog post. Forgive the Q&A format for those who find that irritating

What is the basis for the £500m figure?

It is the gap between how much councils needed to spend on older people's social care in England in 2011-12 to maintain services at the same level as in 2010-11, and the amount that they actually did spend. In this case, between £7.8bn for spend required and £7.3bn for spend delivered. (All of the comparisons below between 2010-11 and 2011-12 show changes in real terms i.e. inflation has been taken account of the equation by basing all figures on 2011 prices).

How was the £7.8bn figure reached?

This was based on research carried out for Age UK by the Personal Social Services Research Unit at the London School of Economics, specifically Julien Forder and Jose-Luis Fernandez who are recognised experts on adult social care economics.
The £7.8bn figure is split into two parts: service costs (£7.0bn) and care management (£0.8bn). Forder and Fernandez calculated that service costs needed to rise from £6.8bn to £7bn from 2010-11 to 2011-12 to keep pace with rising demand/need for care due to demographic change. With a nod to the very tight financial environment that councils are in, they calculated that this could be achieved while massively cutting spend on care management, by 27%, from £1.1bn to £0.8bn. We'll return to this cut later.

How was the £7.3bn figure reached?

This is a bit more complicated. Government figures (from the Department for Communities and Local Government) show councils spent £7.645bn on older people's social care in 2010-11 and are on course to spend £6.961bn in 2011-12. The latter figure excludes the £648m transferred to councils from primary care trusts to spend on adult social care, as mandated by the Department of Health. Age UK has assumed that all of this money has gone on adult social care and been allocated between clients aged over 65 and under 65 in line with existing spending patterns. This mean 51% has gone on older people, boosting council spending on the group by £330m, which, when added to £6.961bn gives you the £7.3bn figure.

Has Age UK overestimated the decrease in spending on older people's social care?

It quite possibly has. I would be very surprised if the £648m transferred from PCTs has been spent as Age UK assumes. This funding is intended to be used to support services at the boundary between health and adult social care that help keep people out of hospital or enable them quicker discharge from hospital. Spending on these services - reablement, falls prevention, intermediate care etc - is concentrated on older people to a greater extent than adult social care as a whole. Therefore you would assume that more than 51% of the £648m has gone on older people.

Moreover, the NHS was allocated £150m in addition to spend on reablement services. We have no idea how this money is being spent. But it is a fair assumption that most of it is going on social care for older people. Also, a further £150m was allocated to PCTs in January to spend in conjunction with local authorities in a very similar way to the £648m figure.

All of these point to Age UK overstating the decrease in funding on older people's social care, so the £7.3bn figure could be, say, £7.5bn.

Has Age UK overestimated the increase in the funding gap?

No, not necessarily. The £7.8bn target spend figure is based on the assumption of a 27% cut in care management costs for older people from 2010-11 to 2011-12. While care management has been cut back, a reduction of this magnitude is highly unlikely. A more modest decrease in care management costs, from £1.1bn to £1bn, would leave a target spend for 2011-12 of £8bn. Were actual spending to be £7.5bn, you'd still be left with a £500m increase in the funding gap.

The £8bn and £7.5bn figures are totally notional. They are just designed to explore the assumptions used by Age UK and to suggest that any risks in these may cancel each other out.

Two blog posts about personalisation have caught my eye this week.

Former head of In Control Simon Duffy (left) - one of the pioneers of self-directed support in the UK - has written a piece about where things have gone wrong with personalisation, under the arresting title: "Is personalisation dead?".

The essential narrative was that we had an ambitious, challenging movement for full citizenship for disabled people through giving them control over their lives, including their care and support; this was captured by government, turned into a policy programme ("personalisation"), subverted and reduced to bureaucracy and renewed control from the state over disabled people's lives.

It's a powerful critique of how government has subverted what it sought to champion in the way it made personalisation official policy, though one Duffy and others have made before.
What is particularly fascinating is an anecdote he recounts about an encounter with a civil servant during Ivan Lewis's reign as care services minister in 2008:

Whilst sitting outside [Lewis's] office one of the senior civil servants rushed into the room to insist that I did not describe 'Individual Budgets' as entitlements. I was told the government were against 'entitlements' and that this was not how the idea was to be understood. Shortly afterwards we were ushered into Ivan Lewis' office and Ivan began the meeting: "So let me get this straight - the basic idea is that people are told their entitlement up-front and then supported to spend it how they wish..." I smiled, "Yes, that's right Minister..."

Duffy's point is that Lewis's vision of entitlement lost out to the nameless civil servant's - hence older and disabled people are either ineligible for personal budgets or restricted in the way they use them, particularly because, their entitlements, under adult social care law, are to services, not resources.

He says that it is only through entitlement to resources that the vision can be recaptured. Duffy's current venture - the Centre for Welfare Reform - is doing a lot of practical work in this direction, which we have featured. I guess the message is don't expect this sort of drive to come from government.

Another person giving a lot of thought to personalisation's present and future - though not its past - is Martin Routledge, a former DH civil servant now at In Control and a leading light in sector coalition Think Local Act Personal, whose job it is to make personalisation work.

One of the biggest topics in this area at the moment is making personalisation work for hitherto excluded groups: people who lack capacity, many people with mental health problems, those with dementia and people who challenge services or have particularly complex needs.

Routledge is honest enough about the challenges - how professionals deal with cuts, question marks over individuals' capacity, a lack of supportive families, crisis situations - but is optimistic that there are solutions, individual service funds (ISFs) for one, in which providers manage a budget with a service user. This has been tested in residential care by the provider Dimensions, with positive results, and Routledge says he is working on testing ISFs with home care providers.

I'll be interested to see what comes out of this work as making personalisation work for these groups is one of the biggest issues for Community Care readers.

Routledge is also very supportive of the point of Duffy's article (of essentially giving people an entitlement to resources, which they are then free to use without controls) and is pushing councils to make progress on this area. So perhaps personalisation's future can recapture some of its past.

It's long been understood that cultural understanding is a vital component of good care and support for people with mental health problems, but a study just out suggests just how important it is.

Clinicians reported increases in overall functioning among patients who had benefited from a "cultural consultation service" as part of their treatment, while service contacts reduced. So what's a cultural consultation service?

The study in question refers to the work of the Tower Hamlets Cultural Consultation Service, who were commissioned by the local PCT over 18 months to develop the local mental health workforce's cultural capability by "developing general aptitude, attitudes and skills for working with culturally diverse populations". The THCCS also delivered consultations to service users directly and worked with commissioners to help shape services.

A link to the report should be here in the relatively near future. I'll let you know if I hear anything further on this.

Good Guardian piece this morning about bringing together health and social care from Pollyanna Perkins, aka a "director of adult social care for a large local authority".

Here's the secret of success in her view: "It's all about relationships, co-working, shared caseloads, but most importantly it's about individual clinicians and managers understanding the whole system - and not just their bit of it - on both sides of the house."

She then cites experience of this working in her area and now social workers are having daily virtual meetings with health colleagues to discuss older people on their joint caseloads.

What good joint working isn't about she says is structural change.

This is a particularly good articulation of a longstanding position. However, it often seems to me that for every person who makes the argument that good joint working is all about relationships, you will find another who will say that dependency on relationships is a dangerous thing. That when people move on, good joint working moves on with them.
We linked to a blog articulating this position from consultancy iMPOWER recently, which made the case for some level of structural change to secure joint working against dependency on particular individuals.

I am sure there is something in both these positions.
That you need strong relationships and also some rules in place to ensure security when people move on.

The secret to both appears to be strong leadership - a point made by Pollyanna Perkins - so the question is whether those leaders are working in local government and the NHS today or not. And if they are, what happens when they move on?

Bit of a news round-up this morning rather than one of my lengthy rambles:

Adult social care funding

The government has been urged to implement the Dilnot commission's proposals on care funding reform by chiefs of 41 councils across the South and Midlands, amid ongoing concerns that it won't, reports The Daily Telegraph.

Meanwhile, the Local Government Association has awarded £1m to 50 councils in a bid to generate £50m in efficiency savings in adult social care. Under its adult social care efficiency programme, the authorities will be supported to implement measures that have been proven to release savings.

Sacked sheltered housing manager

A sheltered housing manager - sacked for breaching moving and handling policies when helping an incontinent resident on to a commode so she could wash her - is seeking to appeal against a tribunal decision that she was not unfairly dismissed, reports The Evening Standard. More than 3,400 have signed a petition in support of Sue Angold.

Direct payments, fraud and abuse

This Guardian article on the risk of financial abuse and fraud from personal budgets and direct payments (and this related one about how poor direct payment monitoring was identified in a serious case review of a service user's murder by his son)  is generating quite a lot of chatter. Top social work blogger Ermintrude2 has done a strong blog post on this topic today, arguing that it is wrong to link risk and abuse to any particular method of delivering social care (i.e. personal budgets) and there is no evidence to suggest that personalised methods of delivery are more risky.

Carers charities merge

The Princess Royal Trust for Carers and Crossroads Care are to merge in April. The charities - two main providers of services for carers - have long worked closely together and, in the current climate, the merger is no surprise. Princess Anne - president of the trust - will be president of the new, as yet unnamed, charity.

The next phase of mental health anti-stigma and discrimination campaign Time to Change was officially launched yesterday by deputy prime minister Nick Clegg.
With funding of £16m from the Department of Health and £4m from Comic Relief until 2015, its forthcoming work includes tackling stigma among children and young people, supporting black and minority ethnic communities and encouraging people from all backgrounds to talk more openly about mental health problems (through adverts such as the one above).

The consensus among ministers, sector leaders (such as the NHS Confederation's Mental Health Network) and celebrity endorsers, such as Alastair Campbell, Marcus Trescothick and Fiona Phillips is that Time to Change has made a big impact on attitudes since it started work in 2007. Though positive interim findings have been issued, it is worth awaiting further results from the ongoing evaluation by London's Institute of Psychiatry.

An interesting looking paper from the National Development Team for Inclusion argues that current plans to introduce payment by results for mental health services risks undermining personalisation for the group.
It suggests some ways in which the two policies can be made compatible and mutually supportive.
The NTDi has also launched a discussion forum on the issue.

The ongoing battle over the government's cuts to (or reform of) disability living allowance is reaching crisis point.
Today, as the House of Lords prepares to debate the proposals in the Welfare Reform Bill, 16 charities have written a letter pressing the government to call a halt to the bill and subject its plans to replace DLA with a cheaper personal independence payment to review.
This follows a feverish day yesterday in which the government announced one concession - agreeing to keep the qualifying period for the benefit following the onset of disability at three months, rather than doubling it to six - while also confirming the sheer scale of the change it is proposing. Replacing DLA with PIP would mean that 500,000 fewer working-age adults would be receiving the benefit by 2015-16 than with the status quo.

Meanwhile, the mainstream media, and not just the Guardian, has taken hold of the issue, with a head-to-head on this morning's Today programme between disability minister Maria Miller (left) and reform critic and disability activist Lord Low over the way forward.
The Lords have already shown themselves ready to give the government a bloody nose over disability benefits cuts, inflicting three defeats on its sickness benefit plans last week.

There is also an amendment to the bill today that will seek to achieve what the charities are calling for by ensuring PIP is piloted before being rolled out.

I'm not nearly close enough to the politics to know whether it will succeed, though I understand that Labour and many crossbench peers - the same coalition who inflicted last week's defeats - will back it.

But what exactly are the issues?

The government's chief beef is that it believes many people are claiming DLA wrongly because they have not been reassessed on their eligibility following an initial claim. Some 70% of claimants effectively get DLA for life.

The campaigners - disabled people, charities and others - believe that the government has not proved its case, and that by pursuing its current course, many thousands of people could be robbed of the opportunity to live independently and free of abject poverty. They also claim that this will not serve to help the government reduce its deficit as cutting DLA will shunt costs onto health and social care.

Reassessing people on their eligibility for DLA or PIP seems fine, so long as the assessment itself is robust and fair.

Disabled people's past experience - based on the hated work capability assessment for employment and support allowance - is that the assessment is likely to be anything but. WCA is now subject to annual reviews to ensure that it improves.

So why not pilot the PIP assessment and see whether ministers' case stacks up?
I imagine that view has some sympathy within the DWP, but the Treasury's demand for the promised savings from setting up PIP to be delivered may make it a non-starter.

(On another note, not all disabled people are opposing the government. Former Community Care columnist Simon Stevens has given a dissenting view, in which he claims that campaigners against reform want disabled people to have "rights without responsibilities").

(Blog updated 3.45 16 Jan 2012)

Lots about care funding in the news today so it's worth trying to unpick what's going on. Here are the main lines in descending order of importance:-

• The government is considering imposing a cap of between £50,000 and £60,000 on people's lifetime care costs, with the state picking up the bill above this point, reports The Daily Telegraph. This is significantly above the £35,000 cap proposed by the Dilnot commission last year and hence quite a bit cheaper for the public purse.
  
• Cross-party talks on forging a solution on care funding are due to start tomorrow, reports the BBC, the first such talks since the acrimonious breakdown of discussions before the 2010 election over Tory allegations of Labour plans for a "death tax" to fund care.
• Three-quarters of people support a cap on lifetime care costs as proposed by Dilnot, an Age UK survey has found, reports The Daily Mail.

The latter is hardly a surprise: who would not want more rather than less help from the state?

As for cross-party talks, who knows? Labour's current position on care funding is unclear and expecting health secretary Andrew Lansley and care services minister Paul Burstow to come together with Labour's Andy Burnham and Liz Kendall on social care when they are at daggers drawn on the government's NHS reforms may be asking too much. But let's be optimistic.

The idea of a £50,000-£60,000 cap is more worrying. Andrew Dilnot (left) was not theological about having a £35,000 cap but instead proposed a range of £25,000 to £50,000. However, he said that £35,000 was "fair and realistic" and that anything above £50,000 would not be fair, on the basis that people with lower levels of wealth may not receive adequate protection from the risks of needing social care.

A £60,000 cap would cut down the bill to the Treasury of implementing Dilnot from £1.7bn a year to about £1bn a year.

However, it would mean the reforms would fail a key test: namely, protecting people from the risk of high levels of care costs in older age.

£60,000 is a considerable sum (and it's worth noting that the cap excludes living costs in residential care, which would be additional to the £60,000); a cap of this level would make people far less likely to save or take out products to insure themselves against future care costs (another key goal of the Dilnot package), meaning that a market in such products would fail to emerge; and while making little difference to wealthy families, would hit those with moderate levels of wealth (for whom the difference between £35,000 and £60,000 is most significant).

(Updated bit) The DH has now distanced itself from the £50,000 to £60,000 figure in a statement to this Guardian story. The story also provides a useful link (see emerging findings on this page) to the source of the story: a paper in November by one of the groups feeding into the government's engagement process to shape the forthcoming White Paper on care reform. 

Contrary to what I have said above, this group, which was looking at the role of financial services in the care system, suggested that a cap of this level could stimulate people to save for their care and encourage the financial services sector to develop suitable products to enable them to do so. However, it's also clear that this figure was also given with a nod to making care funding reform more affordable for the public purse.

The group, which included civil servants and representatives from the social care and financial services sectors, also said more analysis was needed on the impact of different levels of cap. Hopefully, this is being done now and the results of this - rather than efforts to keep the overall bill to the state down - which shapes the White Paper.

I was recently alerted to this research on what service users want out of the adult protection and safeguarding process produced by charity coalition Altrum and the University of Stirling. Here are the key points:-

• Listen to what the person wants to say about their lives, their values and abilities and how they want to use services to live their lives.
• Ask what the person thinks is wrong and can be changed.
• Be ready to share the agenda and give the person choices about how things are done.
• Offer an advocate who can build a relationship with them that will see them through the changes and challenges they may face.
• Find ways to make meetings relaxed with breaks and alternative ways of presenting information if wanted.
• Let the person know the bigger picture and what to expect next.
• Explain why the process is the way it is, for example, why information might need to be shared or withheld.
• Remember that information and trust go hand in hand, one can help build up the other.

In Control is looking for people to share their experiences of what works in terms of implementing personal budgets for a piece of work it is preparing.

Besides the funding gap, this is perhaps the most important issue in adult social care (in England at least) at the moment so it would be worth having your say, particularly given In Control's wider influence in this area as pioneers of personal budgets and a core member of Think Local Act Personal (the sector-wide coalition to aid implementation).

Email your thoughts to andrew.tyson@in-control.org.uk and martin.routledge@in-control.org.uk

How far should self-neglect be addressed by the adult safeguarding system was the topic of an online debate yesterday on the Local Government Group's Adult Safeguarding Community of Practice.
Professor Suzy Braye and Dr David Orr, who recently conducted research into the issue, (the findings of which are summarised in the video above), were taking questions from community members on the topic.
Issues raised included:-

• The fact that self-neglect is seen as an adult safeguarding issue (alongside abuse and neglect) in some areas but not others, and that it is not covered by the definition in No Secrets.
  
• How self-neglect manifests itself and the risk that it masks exploitation or abuse.
• Responses to self-neglect, the need for better inter-agency communication and dealing with issues of capacity.
• The impact of self-neglect on practitioners, including anxiety.

One of Orr and Braye's strongest conclusions is the extent to which good social work, building strong and trusting relationships with the person, was key to successfully responding to self-neglect; yet, conditions to support good social work were often lacking in local authorities.

The other author of the research was Michael Preston-Shoot, who helped Community Care draw up a guide to responding to self-neglect cases last year.

The Care Quality Commission has released the latest 10 reports from its post-Winterbourne View inspections of learning disability hospitals and similar services, and the results are a bit of a mixed bag.
Of the 10, which includes NHS and private sector services, four were fully compliant with the two standards being assessed - safeguarding and the care and welfare of service users - while two had moderate concerns with both (no provider had major concerns with either).
If you work in this area it may be worth taking a look at the inspection reports but the full story from the 150 inspections will be told in an overview report this spring.

It's a big day tomorrow for campaigners against the government's benefits reforms/cuts as the Welfare Reform Bill comes up for debate in the House of Lords.

One issue that has united charities across social care in condemnation is the planned abolition of the discretionary Social Fund, which provides grants and loans to people in crisis. Though the budget for crisis loans and community care grants is being devolved to councils, this will not be ring-fenced, nor will authorities face any statutory obligations to use the money as it is now used.

Now 20 charities from the worlds of disability (Scope), family support (Family Action), children's services (Barnardo's), homelessness (Crisis) and domestic violence (Women's Aid) are urging peers to back an amendment to effectively ring-fence the money.

They say: "As charities, working hard to respond to the needs of vulnerable children and adults in already desperate circumstances, we fear these changes could be catastrophic for some, such as those who resort to illegal moneylenders or high-cost credit, or women who return to live with a violent partner because they have no money to furnish another home for their children."

Let's see if the House of Lords hears this message.

Another day, another report on integration for the government, this time from the NHS Future Forum (the advisory body set up to inject common sense into the government's NHS reforms).

The proposals are pretty similar to those put out in last week's report from think-tanks the King's Fund and the Nuffield Trust: strong support for social care and the NHS to be measured against the same performance indicators, for pooling budgets and commissioning and for building services around patients' needs.

Notably, for professionals, there is a call for every person with long-term conditions to have a named care co-ordinator, who could be a social worker.

The government has, largely, accepted the proposals.

However, the question is, will this work where other initiatives to do the same over previous decades have not? 

Social care academic Bob Hudson thinks not, in a powerful piece for The Guardian today, in which he argues that the whole issue is being looked at from an NHS perspective (with adult social care seen as the "handmaiden" to the health service), weakening its potential impact.

More significantly, he says the agenda amounts to yet more exhortation for health and social care organisations to integrate - precisely the approach that has failed for 40 years, he says.

Also, he notes the big tension in the government's NHS reforms between competition for business between providers and integration of care pathways for patients.

Not an easy square to circle, he says.

I fear we may be revisiting this topic with another mountain of reports in years to come.

(Added 13 January: Just spotted this blog post from social worker and psychotherapist Claudia Megele about the government's integration plans, which raises important concerns about the compatibility of these with other government actions, such as the injection of greater competition into healthcare through the Health and Social Care Bill).

Mencap has alerted me to this nice new video of theirs of some people with learning disabilities talking about their aspirations for 2012.
It's all part of the charity's New Year New Me campaign, which is designed to inspire people with learning disabilities to pursue their own ambitions.
The video's participants won a competition to be the faces of the campaign.
They include Chris Sampson, who wants to be able to teach people symbolic language Makaton, Sarah Arsalides, who wants to run beauty and care sessions for her family and friends, and Eleanor Forrester, who is keen to become a journalist and a screenwriter.

One of the good things about Mencap is the way it combines hard-edged, political campaigning (such as its longstanding and vocal concerns about institutional discrimination in the NHS against people with learning disabilities, which came to the fore this week) with softer campaigns that carry the simple message that people with learning disabilities have lives like everyone else.

Happy New Year! I returned to work today to see social care at the top of the news headlines.

Social care's great and good have written an open letter to the prime minister (in the Telegraph) urging that he and his fellow party leaders deliver on social care funding reform this year to put an end to indignity and isolation for older people, dependence for disabled people and the denial of life opportunities for carers.

It's great to see social care on the front pages and at the top of news bulletins, and you cannot fault the timing: this is, of course, the year in which the government publishes a White Paper setting out how it plans to reform social care, including its funding. Moreover, cross-party talks are due to start.

Before Christmas, we predicted that the government would not deliver on social care funding reform, specifically that it would not implement the proposals of the Dilnot commission to put a £35,000 cap on lifetime care costs for all because of the £1.7bn bill.

An optimist might argue that we made the wrong call, and that the festive period showed that both government and opposition were up for making social care funding reform work.

On this line, Labour has shown how much of a priority it puts on social care by putting out research over Christmas showing how much charges for home care and other community services had risen in the past couple of years (6% for home care). Releasing the research, shadow minister for care and older people Liz Kendall urged Cameron to engage in serious cross-party talks on reform. The positive narrative would also point to action from government in the shape of a £170m injection of cash into social care services for people discharged from hospital to manage winter pressures over the coming months.

This money - one-tenth of the cost of Dilnot - was found from Department of Health savings but meeting the full cost of Dilnot is a call that only the Treasury (and Number 10) can make. Moreover, whatever the pros and cons of the Dilnot package it doesn't, in itself, purport to solve all or most of the problems outlined in today's letter to Cameron.

This is because Dilnot is about expanding the existing publicly-funded social care system to cover self-funders (who would benefit from the cap); it is not about filling the funding gap in the existing system (put at £2bn to £4bn), which manifests itself in rising charges and eligibility criteria, squeezes on providers and inadequate quality.

This £4bn-6bn black hole (Dilnot plus funding gap) is not the whole story. As the government, councils and the sector know, the way social care operates needs fundamental reform  through better integration with health and housing, more personalisation (in the widest sense) and more intelligent commissioning. This should generate efficiencies that would reduce the Dilnot plus funding gap black hole from £4-6bn a year to something less than this.

However, I very much doubt that even the reduced figure would be something the Treasury would stomach, particularly in the current economic climate.

That is why I remain a pessimist - though I would be beyond delighted to be proved wrong.