Mithran Samuel

To state the obvious, there are few more significant statutory interventions than the use of compulsory powers under the Mental Health Act, and one concerning trend in the last couple of years has been the rising use of these powers.

All of this means that how information is collected in relation to the use of these powers is of vital importance, so it's worth putting away any aversion to statistics and responding to a consultation on this topic from the NHS Information Centre.

This is looking at the case for scrapping the existing standalone data collection on Mental Health Act powers (or KP90 to its friends) and instead collecting this information instead through the Mental Health Minimum Dataset (MHMD), which collects a host of other data about the use of specialist mental healthcare.

As I understand it, the key advantages of the change are:-

• Better information about the care pathways taken by people detained under the Act or placed on community treatment orders and about how long people are detained. Information on this could help improve the commissioning and design of services in local areas.
  
• Breaking down the use of compulsory powers under the Act by employment status, diagnosis and, crucially, ethnicity, rather than just gender, as the KP90 collection currently does.

So it's worth answering the consultation questionnaire if you get a moment.

We reported yesterday on calls to enhance guidance and training for professionals on best interests decision making under the Mental Capacity Act, but I thought it would be worth trying to pull out some of the key lessons from the study in question.

About the research

The research seems pretty solid and is based on an online survey, and telephone and face-to-face interviews with social care, health and legal professionals about best interests decisions they have taken under the Act.
It comes courtesy of charity the Mental Health Foundation, which has done a lot of work on how professionals can apply the Act (for example), and two of the country's major research centres into the two key client groups involved, the Norah Fry learning disability centre at Bristol University and the Bradford Dementia Group.

Though its focus was on best interests decisions, many of the most interesting findings relate to assessments of capacity. (Do see our guide on conducting a capacity assessment, which is based on work by the Mental Health Foundation).

Lack of understanding of MCA

A major finding was that the principles of the Mental Capacity Act were not being adhered to in a significant minority of cases. While people should be presumed to possess capacity, not assumed to lack it on the basis of disability, diagnosis or age, and have the right to make unwise decisions, about one-quarter of best interests decisions followed apparently flawed assessments of capacity related to perceived unwise decisions or to someone's disability, age or diagnosis. Though this finding was based on an online survey - and so may not reflect the complexity of cases - these issues remained when researchers probed deeper through interviews.

Impairments dominating assessments

Researchers found in some cases conclusions were drawn about a person's lack of capacity because of their inability to communicate verbally or respond to the presence of other people.
"In all these cases, it seemed that the impairment did dominate, and that practitioners had some difficulty in adhering to the principle of presumption of capacity," said the report.

Lack of capacity based on lack of 'insight'

An assessment that someone lacked capacity was in some cases based on the finding that they lacked 'insight' into their care needs, particularly in relation to people with dementia. So, for instance, if professionals believed that a person would be better off in a care home and the person disagreed, this apparent lack of insight translated into an assessment of incapacity to decide. But the research points out that 'insight' is not a word mentioned in the Mental Capacity Act code of practice and that lack of insight in this sense does not equate to a lack of capacity. In one striking passage, it says: "Whether a person with dementia accepted a particular course of action recommended by professionals (frequently admission to a care home) influenced whether an assessment of capacity was initially undertaken and, in turn, if a finding of capacity was made."

Making best interests decisions

Some interesting findings on this:

• Best interests decisions in social care were most frequently carried out through a series of multi-disciplinary team meetings. Typical features of successful practice were good chairing and organisational skills, clarity in defining the decision to be made, and an overriding concern for engaging the client at the centre of the process.
• Social care decisions more often related to safeguarding and changes of accommodation, rather than care reviews, direct payments or care planning.
  
• Though best-interests decision makers should consider the person's expressed wishes, feelings and values, the researchers only found a few cases where these had been influential in the decision.
• Outcomes for people were not just based on their best interests but on resources and available services. As a result, for instance, temporary admissions to care homes for people with dementia were often made permanent.

Recommendations

The research makes a number of significant recommendations. Here are a few key ones:-

• Revising the MCA code of practice to clarify the distinction between a lack of capacity, on the one hand, and unwise decisions and lack of 'insight' on the other.
• The code should include case examples that reflect the complexity of the cases experienced by practitioners, as well as examples of successful good practice.
• Pro formas for conducting mental capacity assessments and best interests decisions should also be added to the code.
• Providers should carry out regular audits of compliance with the MCA by staff.
• Care homes should hold weekly reviews of assessments of capacity and best interests decisions.

Hopefully this research should provide a springboard for practice, guidance and training improvements in relation to the MCA. Do have a read.

In these straitened times, effective charities, like their less effective counterparts, are struggling to keep hold of public funding, putting a greater premium on private donors.
But where should philanthropists be putting their money in relation to social care services?

A report out today provides a guide to investing in employment support for people with mental health problems. It comes courtesy of New Philanthropy Capital, which researchers the effectiveness of charities. NPC says this is an area that private donors have neglected in the past, leaving government to take the lead, but says philanthropists have real potential to make a difference.

It looks at the case for investing in four services, providing donors with an idea of which charities are potentially most effective, costs, risks and returns. One service that comes out well, in terms of relatively low risk for high return, is individual placement and support, under which employment advisers are placed in mental health teams to integrate treatment and employment support and service users are, ideally, placed in a job and supported to retain it. (This piece has a bit more about IPS).

However, no charities examined by NPC delivers IPS so may need support to develop the model. Which is where private donors come in. Bill Gates, can you help?

(Image on Flickr from IssacMao)

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?