Older People Are Not a Separate Entity

Today’s BBC Breakfast debate (@BBCBreakfast #LivingLonger) comes on the same day as the news that Saga will no longer be providing state funded care services ( Daily Telegraph - http://www.telegraph.co.uk/finance/newsbysector/retailandconsumer/11347858/Saga-withdraws-from-NHS-care-after-funding-cuts.html) and together they show the need for a more immediate, national rethink on care services in the UK.

Sometimes, contributors to the debates on care for older people seem to forget that, one day, they will be older too. Older people are not a separate entity within society, they are an integral part of society. We have to remember that many of those we label as elderly were also labelled as “rebellious youth” back in the 1950s and many of those with the “youth” label today will be the “older people” in 60 or so years. Too often there is a focus on “what to do about older people” rather than the recognition that many people that socially created label have, in fact, contributed hugely to the society that they are now dependent on for support.

Society also has to recognise that this is an issue that is relevant NOW, not further done the line as Governments like to portray it. Many older people need support and help today but, unfortunately they are being faced with reduced services because of cuts in spending as a result of a recession that was really no fault of theirs!

A part of the debate focuses on individual planning for the future, and while such things may sound good it can be idealistic rather than realistic because individuals have to cope with the ups and downs of real life. Those over 65 now have lived through many recessions (including two double dip recessions), annual inflations rates of up to 26% (1975), as well as periods of high unemployment in the country. Very often people are forced to live in the financial now rather than being able to plan for a future that is a long way off. We have seen a dramatic rise in the use of food banks over the last couple of years, have many of those forced into this can, realistically, put money aside for their needs in older age?

So while individuals can take some responsibility for planning for their future, government and society must recognise that this is not always possible and there must be a safety net to ensure individuals are sufficiently supported as they need it when they age.

Older people are not an isolated section of society, we are all older people in the making and when we talk about the needs of older people in society we are talking about our future too. The questions should not be about how society deals with an ageing population but about what would I want if that were me right now because that will be me in the future.

Declaring Independence

What is Independence?

Unfortunately it is one of those words that means different things to different people, it is not easily definable. If you quickly ask a dozen or so people what the word independence means I am sure you will get a series of similar, but never quite the same.

A quick Google search of the term independent and we get;

1.    Free from outside control; not subject to another’s authority

2.    Not depending on another for livelihood or subsistence

Yet neither of these terms can really be applied to social care, can they?

Naturally effective social care depends on those who need care services providing the right level of support to help them to live life as fully as possible but, as a result those who need social care depend on others (i.e. carers, care workers etc.) to provide that livelihood and subsistence and, at the same time, that support is subject to local social services authority about the level of support provided.

So how do we define independence in relation to social care provision?

As the term itself is dependent on each persons’ interpretation of it, it becomes ever more important to understand the individuals needs and how they view what independence means to them.  One person may view support at home as a means to help them live independently while another may consider it interference and a threat to independence yet both may be in equal need of support and at risk from the same sort of issues (e.g. falls). Obviously we declare that individuals have the right to take risks, as long as they have the capacity to judge those risks, yet such individualism presents problems for local authorities and health services that have a duty to safeguard the vulnerable.

This can, inevitably, lead to a situation where local authorities and health services then decide what independence means in their world. So, in other words, we become dependent on another’s authority about what independence means for us!

Real independence is entirely individualistic. For example independence may mean being able to do whatever you wish at any time yet giving a person minimum social care support at home may actually inhibit that freedom, they may become house bound and isolated rather than having the support they need to get out and live the life they wish conversely, for some, too much support may seem restrictive and intrusive to them again inhibiting their own sense of independence and freedom.

So if we are to succeed in truly providing independence to those who need social care services the first question always must be “What does independence mean to you?” followed by “How can we help you to live the independent life you want?”

Obviously there are restrictions on what public services can actually do yet those restrictions should not halt those first two questions. After those two questions co-production (I still do not like that terminology!) can begin as you work toward a support package that brings the best possible independence to the individual, an independence that helps them live the life they want.

Workplace Stress: Time to Think About It Now

Many people will be back to work today. Faced with an inordinately high in-tray or seemingly endless list of unread e-mails to be tackled urgently they will feel an immediate ramp up in stress levels after being able to take it easy for a couple of weeks. Of course a few others will feel relief at getting back to work after a stressful fortnight at home with the kids but the majority of people returning to work today will feel an increase in their stress levels as they get down to their days work.

Obviously there are many who never stopped working and workplace stress is a constant factor that never goes away.

The issues of workplace stress are well recorded as is the impact it has on sickness levels and general well-being yet we talk very little about workplace stress in front line social care. The Health and Safety Executive state the 40% of work related illnesses are stress related and that ‘human health & social work’ is one of the areas where the highest rates occur (http://www.hse.gov.uk/statistics/causdis/stress/index.htm)

Front line care workers, whether providing care in a person’s home or working in a care home are subject to stress in the work place as much as (if not more) to anyone sitting in an office, working in a shop or factory etc. Stress is not limited to the ‘big’ events in life, stress accumulates as the small things niggle away at us and without the opportunity to release that stress externally it eats away inside us causing physical illness that, eventually, can do significant damage to our health.

Imagine the pressure on a home care worker who has to do a number of 30 minute visits to vulnerable people. The time pressure to get their work done in that 30 minutes followed by the pressure of travelling to visit the next person who needs support and care, this can be made even more demanding if the worker never knows who they will be visiting that day or they have a workload that means they have even less time to travel between homes.

Working in a care home can be stressful too. Meeting the needs of those who depend on others for many aspects of their daily lives can take its toll on those responsible for delivering that support and care. Imagine dealing daily with incontinence, challenging behaviour and even death. The stress of working in a shop or office is mild in comparison.

And if that stress is not enough for the front line care worker there are also the issues of low pay and unsociable hours to contend with.

Where people have high levels of stress they react by either internalising it, which leads to health problems or they externalise it, usually by demonstrating aggressive behaviour. In front line social care both are dangerous.

Internalising stress can affect our concentration and, in front line social care, which can lead to dangerous errors, stress also impacts on our immune system making us more prone to any bugs or ailments floating around. In front line social care this can lead to spreading those germs to vulnerable adults whose immune systems are already weak. Given the nature of front line social care, with its culture of low pay and only paying statutory sick pay there is a reluctance for many care workers to take time off for illness unless they are physically unable to leave their house.

Externalising stress is even more dangerous in front line social care. It can lead to abusive behaviour.

Yet despite the acknowledgment that workplace stress has a real impact on peoples’ lives, in social care this is something rarely mentioned or acknowledged. For example, the Skills for Care Manager Induction Standards do not mention the need to monitor and address workplace stress (http://www.skillsforcare.org.uk/Document-library/Standards/Manager-Induction-Standards/Manager-Induction-Standards.pdf) and the Care Quality Commission Standards focus more on competency in their “Guidance about Compliance” on the standard of supporting workers rather than tackle the real issue of workplace stress and its potential to lead to failure to deliver safe services (http://www.cqc.org.uk/sites/default/files/media/documents/guidance_about_compliance_summary.pdf).

If we truly want the best services for the most vulnerable in society then we need to recognise the stress that can be placed on those delivering the actual services. Everyone deals with stress in different ways and, because of that, there needs to be a focus on managers and providers having good quality training and awareness of the issues associated with workplace stress and being able to demonstrate competency in dealing with workplace stress issues.

Dear G8 Summit on Dementia

Please, please remember to focus on the people who suffer from dementia as well as the diseases themselves.

It will be very easy for those at the summit on dementia to fall into a medical model discussion on dementia, the medical research on cures and ways to alleviate the symptoms of dementia but it is equally important that there is a focus on how we support and care for those who have dementia now when there is no known cure available and we focus on supporting those families who care for people with dementia, whose levels of stress may increase causing them to suffer from illness as well.

Medical advances have meant wonders for many diseases, many who suffer from cancer for example can live in hope, especially if the disease is caught early, of a cure or remission, for those beyond that hope there is the comfort of pain relief and, hopefully, effective palliative care. This does not in any way ease the distress but it does, to some extent, provide clarity on the future and provides the help of the health system.

With dementia however, there is no clarity nor is there effective medical assistance. Those who have dementia are dealt with by a social care system that is fragmented, under-funded and, unfortunately, largely ignored by social policy.

Whilst there will be a great many politicians, bureaucrats and medical experts at the summit on Dementia the reality that the actual care is delivered by families or low-paid care workers and if we want to address the care and support of people who have dementia now then it is those people the summit needs to find ways to support in order that they in turn are better able to support those with dementia right now.

Medical cures and research success take time, time that many of those with dementia right now will never see come to fruition, in addition to the medical research there MUST be social research looking at what is effective in supporting those with dementia in the absence of medical help. There must be a concerted effort to ensure that best practice in dementia care is applied across the board, there needs to be a policy of high quality standards for care services rather than one of ‘essential’ standards and there needs to be a recognition that social care services provide and equally important role in supporting those with dementia and that dementia services should be funded in the same way as any other long term medical condition.

The G8 summit on dementia is important in raising awareness of the issues but let us hope that the issues go beyond medical science and include the aspects of providing social care support to those who suffer from dementia right now.

Social Care Culture Wars

One of the changes promised by the Care Quality Commission in their “Fresh Start” document published yesterday (http://www.cqc.org.uk/public/news/new-approach-inspecting-social-care-services) was that they will be “checking providers who apply to be registered have the right values and motives, as well as ability and experience.”

This could be challenging!

Whether we like it or not the bulk of social care provision, at present, is delivered by companies, large and small (and every size in between!) who are out to make a profit, because without profitability the business will fail. Therefore private company that applies to register a care service has, naturally, to have the right business values and motives to be profitable in order to be able to deliver the care service.

This fact highlights one of the issues with social care in England and why integration seems such a difficult thing to achieve.

The word ‘silos’ is often used to describe the way in which different parts of the care system are isolated but, in reality, we should see them as different cultures and, as often happens with cultures, the existence of that particular culture is built on difference rather than commonality and those within a culture will defend the values and motives that underpin that culture.

So at the front line of social care provision we have providers who have to make money, even charities and not for profit companies have to ensure their income in order to carry on their business, so they have to exist in a ‘market’ culture where income must exceed (or at least match) expenditure, their actual provision of care is limited by the monies they receive, however good their values and motives are in terms of wanting to care they are constrained by economics. There are over 12,000 registered care providers and each one will have a different organisational culture based on the values and motives of the company owners.

Another culture within the system are the Local Authorities, 152 with social services responsibilities. Each on will have their own ‘corporate’ identity, influenced by working practices, senior leadership and, importantly, politics. All local authorities are over seen by elected councillors and this, obviously, impacts on the organisational culture. Somewhat like the EU, the heads of social services departments gather together to discuss overarching policy but, again like the EU, these can be implemented slightly differently in each council because of the values and motives of those who lead the council.

Within the local authority system are other elements that those who need care services also need to access, e.g. housing. In many areas these are located within a different authority than the one responsible for social care which, again, has its own particular organisational culture.

Then there is the NHS, another completely different organisational culture, founded on a basis totally different from care providers and local authorities. Health services (either NHS or private) have grown from medical science with a fairly rigid hierarchy of who is allowed to do what and developed a clinical culture that is different from other fields of work. The NHS itself is more fragmented now, which is why individual hospitals or trusts have failed because of inadequate leadership, but the overall structure is the same. In this realm we have the Royal Colleges which underpin the professional expertise of those who work in health, and which elevate the roles they undertake, all of this creates the values and motives of the NHS and other health services.

The problem for those who need care services is that all of these different cultures have different languages and practices, all have different values and motives that underpin their roles.

Because different cultures defend their identity through maintaining difference with other cultures, the integration needed by those who need care services is hampered and will continuously be so unless we develop a culture which recognises that the individual is more important than any of the organisational cultures involved.

To achieve connected services for people who need care services all involved need to recognise the commonalities in their services and who they benefit the individual.

Before care providers can be judged on their values and motives we need to establish what those values and motives are and how they benefit the individual rather than imposing values and motives that cannot be achieved at the ‘market’ end of the system and which, ultimately, impact negatively on the care service provided.

Do the Media Really Care So Little about the Vulnerable in Society?

Last week (12^th Sept) the Health & Social Care Information Centre published their provisional report on the Abuse of Vulnerable Adults in England 2012/2013. (https://catalogue.ic.nhs.uk/publications/social-care/vulnerable-adults/abus-vunr-adul-eng-12-13-prov/abus-vuln-adul-eng-12-13-prov-rep.pdf)

The report reveals that of the 86,000 completed referrals to social services 43% were substantiated or partially substantiated.

That means around 37,000 cases of adult abuse occurred.

Yet the news reporting on this staggering statistic has been woefully small, there has been no obvious political indignation that such a large number of vulnerable people have suffered abuse and there has been no official comment from Westminster on the matter.

The statistics are similar to the previous year but that should not mean a lack of interest in protecting those who are vulnerable in society nor should it mean that the abuse of so many should become less news worthy. In fact there should be a national outcry that nothing has been done to reduce the number over the last year.

Another aspect of the released figures should also be raising eyebrows. Of the 86,000 completed referrals more than a quarter (27%) were inconclusive – neither substantiated nor unsubstantiated after investigation. And, while adult protection issues can be notoriously complex, this seems a high number yet there has been no call for an explanation of why this may be the case and what action is taken to protect those who may be at risk following an inconclusive investigation.

Do we really care so little about the plight of the most vulnerable in our society?

Obviously the Health & Social Care Information Centre can only publish the official statistics and given the high amount of abuse in them there must also be concern about the level of unreported abuse of vulnerable people. If there is so little news and Government interest in the numbers of those we know have been abused what is the likelihood of action being taken to help those who are vulnerable and abused yet unknown to the system.

There has always been a lack of interest in social care by the mainstream media and, for that matter, by central Government, yet it is people at their most vulnerable who are suffering from various levels of abuse who are left unprotected by Government and, importantly, by social pressure through the media.

This has to change.

How can we call ourselves a society when we ignore the needs of those who need our help the most and by allowing these levels of abuse to continue? How can the public know of the staggering numbers of people being abused if the media is not interested in them?

We need change but that change can only come if there is enough social pressure on politicians and that can only come from the media.

Do the media really care so little about the plight of the most vulnerable in our society?

Zero Hour Contracts, A Cautionary Approach

This week the Trade Union Congress will call for the outlawing of zero hours contacts (http://www.tuc.org.uk/the_tuc/tuc-22485-f0.pdf pg12) and while, personally, I dislike the practice there has to be caution in either outlawing the practice or, indeed, modifying it.

It is estimated that around 300,000 social care workers are on zero hours contracts (http://www.socialcareworker.co/2013/08/02/300000-social-care-workers-on-zero-hours-contracts/), around a third of the total workforce.

Before we puts jobs at jeopardy or social care services at risk by outlawing zero hours contracts there first needs to be a comprehensive look at why the use of zero hours contracts has risen in social care and, obviously, an understanding of the impact to services if those contracts are outlawed.

Is there, for example, a link between the increased use of zero hour contracts and the increased use of ’15 minute’ social care services being commissioned?

A survey last year by the UKHCA found that

·         Short homecare visits being commissioned by councils to undertake intimate personal care, with risks to the dignity and safety of people who use services;

·         Continued downward-pressure on the prices paid for care, where lowest price has overtaken quality of service in commissioning decisions;

·         Contracting arrangements which have resulted in visit times and the hourly rates paid for care as the decisive factors in the viability of the sector.

(http://www.ukhca.co.uk/pdfs/UKHCACommissioningSurvey2012.pdf)

If providers are fighting to compete on price then, from a business point of view, it means having staff on zero hours contracts makes sense if it helps reduce overall staffing costs. So the issue is not only about zero hour contracts but also about commissioning and funding in social care.

There also needs to be thought about the impact on services if zero hours contracts are outlawed or modified without any real thought of the implications.

Social care is, by its very nature, difficult to plan for. We cannot tell how many people will suddenly need social care services in the near future or, sadly, how many will no longer need care services. So there needs to be a degree of flexibility in social care staffing, particularly in home care where the greater use of zero hours contracts are found.

If zero hour contracts are removed without arrangements for dealing with this need for flexibility then care services could be affected. For example not enough staff would lead to people receiving care services only when people are available rather than when they need them or providers could have a surfeit of staff who would still need to be paid even when there was no work for them, putting pressure on the provider’s economic viability.

Within social care zero hour contracts are as much a symptom of the financial constraints as they are about employer exploitation. Yes let’s get rid of them but in a manner that ensures social care services are improved rather than put in jeopardy and a manner that improves the lives of social care workers rather than puts jobs at risk.