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.

Go On – Ask a Question Today.

It is very easy to forget that many of the things we take for granted nowadays did not exist 50/60 years ago, or if they did they were in the realms of the elite who could afford such luxuries.

Fridges and freezers, for example, did not become common place until the 1960’s, which, naturally, means frozen foods did not become popular until that time and that food storage was a different kettle of fish (an expression from when fish was boiled rather than sealed with sauce in a soft plastic container!).

Similarly supermarkets did not exist as we know them today, Sainsburys opened their first ‘self-service’ store in 1950 and Tesco’s opened their first supermarket in 1958, and even then it took a while for the supermarket to spread across the country to become the default means of buying the weekly shop.

Obviously before these momentous changes eating habits were completely different, no ready meals, no frozen dinners, food bought according to season and location rather than according to what you fancy. Culturally things were different too. In the 1950’s more women stayed at home and were expected to provide meals for the family which had to be freshly prepared from scratch.

Naturally most people who need older peoples social care services now spent their early, formative years eating in a completely different way to the way we do now.

Now think back to your own childhood, what was your favourite food? What memories does the thought of that food evoke? What other memories do you associate with that? There will, of course, be a whole range of memories because of the different favourites you had at different times in your life and it is the unique tapestry of memories that makes us all unique individuals.

The only way we can find out about the memories of others and what makes them unique is by listening to them and asking them and this, to my mind, is one of the most important things in social care provision.

It does not matter what our position in life or what age we are right now, if someone takes a genuine interest in us and talks to us, listens to us and asks us about ourselves, it makes us feel good. Now if you are a person who needs care services, either at home or in a care home, the knowledge that the person providing that care takes an interest in who we are rather than looking at us just as a ‘task’ to be completed it will boost personal esteem and do considerably more good to an individual.

Obviously cognitive decline may impact on memory recall yet even if the memories have faded the mere act of sitting and talking to someone is, in itself, a worthwhile act.

The more we can engage on a personal level the more we learn about a person and the more we can tailor our service to them but, more importantly, the more we engage with people the more we build their sense of worth.

Go on – ask a question today.

Social Value and Social Care

What did you want to be when you grew up?

Perhaps you wanted to be a train driver or a nurse, maybe you wanted to be a famous sports star or singer, or even, possibly, you wanted to be a princess or a pirate.

The chances are that the idea of being a social care worker did not enter your head.

Then as you got older and you discovered your talents and abilities your dreams will have changed, more professional ambitions may have come to mind, accountancy, medicine, architect, law etc. Perhaps, you were more vocationally minded, and liked the idea of a more hands on job, beauty therapist, mechanic, hairdresser, electrician etc.

The chances are that the idea of being a social care worker did not enter your head.

The fact that social care is well down the list of career choices is also backed up by the facts. The Skills for Care National Minimum Data Set (NMDS) shows that 60% of social care workers are aged 35 or over with just 10% under the age of 24. Social care is a job that people enter into later in life.

The issue with social care is how we value it in society and even though they provide essential front line services for vulnerable people, social care workers are low on social value.

Part of the issue is invisibility in society. Yes we have seemingly endless negative reporting, but generally speaking adult social care only becomes important to individuals when they, or a loved one, needs care services. In popular media social care is often portrayed negatively and infrequently, when fictional programmes portray social care as either inefficient or outright failing. Even where we have had mainstream fiction about care (i.e. Waiting for God) the care staff were not portrayed particularly well.

High social value needs positive role models through mainstream media and fiction often carries more weight than factual programmes. Fiction carries archetypes that embed themselves in social awareness (you’d be surprised how many people think the ‘medieval’ stories of King Arthur are true!) and in order to raise the social value of social care we need more positive archetypes of social care work portrayed through fiction.

That does not mean that non-fiction media doesn’t have a role to play. We increasingly need positive social care stories to underpin the social value of social care. Unfortunately the mainstream media seems adverse to the positive side of social care, which is strange as more and more of their viewers/readers will need social care services or know someone who needs social care services and the relaying of the negative horror stories and experiences, that are not suffered by the majority of care users, undermine the whole system. Yes it is important that these are exposed yet the overall impact has a detrimental effect and probably puts a lot of people off the idea of working in social care.

Social care is important in today’s (and tomorrow’s) society. Increasing longevity combined with a larger population means that social care services are needed more than ever before and more and more people are needed to provide that care. We need to raise the social value of social care, raise awareness in society of social cares importance in society and we need positive role models to encourage people to consider a career in social care.

Dear Jeremy Hunt, Focus on People with Dementia not just the Cost

Today the Government announced a G8 Summit on Dementia.

https://www.gov.uk/government/news/uk-to-host-g8-dementia-summit

While every effort to raise awareness of dementia has to be welcome, the tone of the press release announcing the event shows that the Government is more interested in cutting the cost of dementia rather than helping those who suffer from the condition.

The press release quotes Health Secretary Jeremy Hunt saying,

“Dementia requires long-term health and social care support that can be hugely expensive. Currently 70 per cent of the global cost is incurred in medically advanced nations like Western Europe and North America. But nearly 60 per cent of people with the condition live in developing countries. As their populations grow and age, the pressure on their services and budgets will inevitably increase.” &

“The G8 today have a unique chance to come together to help people manage dementia better, lead healthier lives and deliver real improvements in care and substantial economic savings.”

Yes the increase of the numbers of people with dementia will put pressure on budgets but, surely, the primary focus has to be how to give people with the condition the best possible quality of life as the disease takes hold.

Yes we need to find ways to eradicate dementia but we also need to help people NOW rather than solely focus on cures that could be many decades down the line.

Yes there are still economic troubles yet to focus on the cost of dementia rather than improving care and support for those who need it now is a shameful way for a Government to act. Social care funding has decreased year on year for at least the last five years and the costs of providing social care have spiked – food and energy inflation have a huge impact on care provision – and the Government has done little to redress this issue.

The press release today effectively labels those with dementia as a cost burden to the State and I hope action will be taken immediately to apologise and redress this.

Life and Change

Do you ever feel you could do more in life? Do you feel you could achieve more, earn more, succeed more?

Obviously we all feel like that at some point in our lives, how we deal with those feelings is, however, a completely different matter. Some will do nothing and become increasingly frustrated with life usually blaming the failure to progress on ‘circumstances’ or the people around them, others will be like whirlwinds in a constant flux of change and new projects as soon as the previous one bores them.

Thankfully most of us are somewhere in the middle. As human beings change is inevitable and how we tackle that change impacts on our lives just as much, if not more, than the change itself. How often have you gotten nervous and worried about something new only to think afterwards “Well that wasn’t so bad was it”?

The best way to manage personal change is to plan for it. Decide what it is you want to achieve and then work out what you need to do to get there. Small, incremental steps are usually the best way, if we can succeed in making one step, it makes it easier to move on to the next, if we take a huge jump we could end up flat on our faces, feeling embarrassed and distinctly unwilling to try that again.

We cope with achieving our goals better when we are supported. Top sports people have high aims but they have a support system in place to help them get there, yes they have the raw talent but it is shaped and moulded by coaches, physiotherapists, psychologists etc. in order to maximise the individuals potential.

But what about real life?

Ageing is a change, ageing means changes to our physical and mental make-up, ageing is a challenge that needs to be faced particularly if the ageing process means coping with age related conditions that undermine our own sense of well-being.

Ageing is an inevitability yet it does not mean that the change cannot be supported and goals set to minimise the impact of the ageing process. Obviously there are the standard routes we can take in terms of pension and retirement planning and we can always find support for this.

But the crucial need for support, effective planning and achieving effective goals come when there is a need for social care services as we age.

Naturally most people want to live as long as possible in their own home, this becomes the goal. To achieve the goal we need support, we need a plan of how that support is to be achieve, a plan that needs to be broken down in terms of smaller achievements, what we might need to have now in order to make further changes in the future.

If we go back to the athlete analogy, we need our coaches, physios and psychologists to be working together to support us and work with our plan. In other words we need social care, health care and housing working together to support us and work with our plan!

We need effective integration!

Integration is about services working together to support the individual, not about services working together for the benefit of the services.

The support needed by individuals will vary according to the needs, goals and desires of the individual and the various ‘support’ systems available, social care, health, housing, benefits, employment etc. need to coalesce around the individual, to focus on the individual and provide support for the individuals wishes.

Moving forward in life always presents challenges, as we age those challenges may become increasingly difficult to face without professional support. That support needs to be integrated around the person needing it and that has to be the starting point for any discussion on integration.

Routes, Routines and Dementia

To anyone with knowledge of Neuro Linguistic Programming (NLP) the phrase “the map is not the territory” will be familiar, although the phrase pre-dates NLP and was actually coined by Alfred Korzybski in his work on General Semantics.

To those not familiar with the idea, simplistically, the concept is that none of us sees the true reality of the world. What we see is our perception of it through our own personal filters that are embedded within us as a part of our experiences in life, in other words, our own internal map. An example would be witnesses to an accident or crime who come up with different versions of events. The events are reality but how they are viewed depends on those individual’s experiences and filters.

Our internal maps guide us and guide our responses to the situations we find ourselves in. If there is nothing on our map to help us in certain situations we become unsure or maybe even panicky, in other words the map is our comfort zone. Yet after we have delved into the unknown our map rewrites itself to encompass this new experience and, in the same situation in the future, we are likely to repeat the actions that successfully saw us through it the first time.

Occasionally what we do may not actually be the best way to deal with that situation by we will continue to do it that way because that is how our internal map guides us and we may not bother to think of possible alternatives.

In general terms this is why change is so often difficult. We are moving into the unknown and our minds are guiding us to stick with the tried and trusted even if that is not the best route for us in the long run. That is why certain addictions can be difficult to break because the addiction has become so familiar it means moving off the chart and into the unfamiliar to break the habit.

There are, naturally, conflicting views on this theory but it does give us a useful tool for thinking about social care.

Imagine you have a map and you are using it to find your way to a specific destination, you just follow the shortest possible route from A to B and off you go, with occasional reference to the map to make sure you are on the right road. Now imagine that halfway along your journey your map changes and suddenly there is a huge blank space between your starting point and where you want to get to? How would that make you feel? Panicky? Frustrated? Angry?

How must it feel to those who have dementia when their memories, and therefore their internal map, begins to fail?

Our built in Sat-Navs help us move from task to task without having to think. Our morning routines, for example, are often done on auto pilot, yet if we suddenly did not know what we need  do we could find ourselves unintentionally missing breakfast or completely forgetting to wash. But everyone of us has a different morning routine and those different ‘maps’ could actually cause distress even when we desire to be helpful.

If I tried to impose my ‘route’ on to your morning routine you’d probably speak to me very unkindly!

Even where someone’s own map has developed a blank space trying to impose a new routine may well feel ‘wrong’ even if the person cannot articulate why that feels wrong (that can even happen to us in everyday life sometimes something doesn’t feel quite right does it? So we will question whether or not we should do it even if we can’t quite put our finger on it).

Understanding and supporting someone with dementia is not just about being able to do routine personal tasks for them. It is about understanding the complexities of the disease and how your actions might impact on people’s lives. We need to learn to be able to read other peoples maps so we can provide them with support along their own routes to achieve the goals they want

Purple Badgers and Social Care

Really try hard not to think about a purple badger

Now having mentioned the purple badger it is probably highly likely that, in an attempt not to think about a purple badger that you have naturally conjured up an image of one so that you can try to not think about it! If I were more conventionally minded I probably would have said try not to think about a pink elephant, but now that I have said it has the pink elephant replaced the purple badger in your mind? Or are the pink elephant and purple badger co-exiting in multi-coloured animal harmony?

Naturally I do have a point about this.

To move to a less abstract level, have you ever witnessed someone saying to someone else, “mind the plate it is hot” and the instant reaction of the other person is to unconsciously actually touch the plate to verify that? Children are usually the best example to see this phenomenon in action – saying “don’t step in that puddle” invariable ends up in wet shoes and muddy clothes!

Language can be a powerful thing and what we say can have an impact on the behaviour of others.

Of course there is nothing new about this. Advertisers, marketers and politicians have been using various language techniques to tempt us, draw us in or deflect us for years. And, obviously, it is not an exact science. How we react to what someone says to us varies according to our own perceptions, views and upbringing. So if I were advertising bacon sandwiches you would have to actually like them before any advertising had any impact, and no amount of suggestion of sweet smelling, succulently crisp bacon being taken from the sizzling pan and being placed on deliciously soft freshly cooked bread would work.

So what does this have to do with social care I hear you ask (with a mouth full of bacon sandwich!)

Social care is intensely people orientated. Care workers work face to face with those who need care services, social care leaders supervise and manage those social care workers and the social care leaders interact with other agencies and in order to achieve the best possible care and support down the line we have to be aware of the power of language and the effect in can have on those we speak to.

Imagine a supervision where the manager tells a staff member that that must stop acting so defensively, the usual reaction is to say “I’m not being defensive” in a very defensive manner. If the manager were to say, “it would be good if you allowed yourself to relax more at work” then the reaction would be different and while the person may not actually relax now they would not have the image of being defensive.

Similarly, if a person with challenging behaviours were told to stop being aggressive they have to think about being aggressive before being able to stop it! This is particularly problematic when the individual does not perceive themselves as being aggressive in the first place. In such instances it is far better to focus on positive words such as relax, calm etc, (although calm down can be an issue – calm down from what?) as these words are better suited to the state you wish the person to achieve.

Even on a minor level we have to be careful what words we use. If I were to say – don’t forget to share this blog with others – the possibility is that you would forget! Yet if I said  REMEMBER to share this blog with others I am far more likely to get a positive result.

If you have read this far the purple badgers have probably slipped from your mind, oops they are back again! But in the future any time pink elephants are mentioned you’ll naturally have an image of purple badgers too!

Language is intensely powerful and it is important that, in social care, we are aware of this power. It is by no means easy to consciously and continuously control what you say to others but we have to be aware that the behaviours of others can be a direct result of what we have said rather than being something totally disconnected from us. Effective communication is the cornerstone of quality care and support and must be one of the key skills that is taught at all levels of social care, if we do not understand the importance of communication and language how can we effectively communicate with those who need care services and those we work with.

Issues in Integration

Twelve weeks ago I went over on my ankle, it hurt. The swelling and bruising was pretty nasty but I just put it down to a twisted ankle that would clear itself up. Unfortunately, after a couple of weeks it was still intensely painful so I went to the nearest A & E where they x-rayed it and told me I had a fracture, they gave me a pair of crutches (no other treatment) and told me they would get me an emergency fracture clinic appointment and I could expect a call on the next working day.

Two days later I finally got through to the clinic who mentioned they had seen something with my name on and could I come in later in the week.

At the fracture clinic I was told I didn’t have a fracture (they used the same x-rays) and it was severe wear and tear, even though I protested that my ankle was fine before going over on it, I was summarily dismissed with a piece of paper to give to my G.P. to arrange for physiotherapy.

When I got to the G.P. I was asked what the piece of paper was because hospitals do not normal send that bit of paper to G.P.s! However I had a telephone consultation arranged and was referred to the Physiotherapy Dept.  I then had to visit the G.P. because the pain was still intense and I was simply given a co-codamol prescription, again with little other advice.

It then took six weeks to get a physiotherapy appointment. While, of all the different elements of the NHS involved, the physiotherapy team have, undoubtedly, been the most helpful, once at my first appointment I had to relay all the details of my injury as they had no notes on my fracture clinic appointment or the history so far.

Because of the time lapse between referral and getting a physiotherapy appointment I had a follow up fracture clinic appointment after my second physio session. Again this was another frustrating experience, quick chat with consultant who I told I was still in pain, hour wait for x-ray, then back to consultant who told me there was definitely no fracture just evidence of an old injury. What old injury, I exclaimed, only to be dismissively told, “oh it might have been something minor” and then told to come back in six weeks.

Following week back to physiotherapy, who had no knowledge of fracture clinic appointment and I had to explain what had happened there.

That was last week and I still have bursts of intense pain

The point of this story? We have this long running debate on integration between health and social care yet it is evident within the health service alone there is no real integration and, while mine is a relatively minor injury, I have no doubt people with much more serious conditions suffer from the same frustrations of the lack of ‘joined-up’ care in the NHS.

Social care itself is not a ‘whole’; it is a combination of public sector and private sector services that because of those different sectors cannot fully be bought together efficiently. The bottom line is most of the private sector works for profit and the public sector works toward bureaucratic efficiency.

Integration: The act of combining parts to form a whole.

When we talk about integrated services for health and social care is this what we mean? For those who use services yes it is. Anyone who needs services wants an holistic approach, seamlessly receiving care and support from all aspects of the ‘system’, support with health, social care, housing etc. is, idealistically, delivered in a joined-up way that involves everyone responsible for delivering the services knowing exactly what everyone else is doing and working together toward a single purpose.

From a public sector point of view the issue is different. Technically speaking, integration would mean combining all the parts of the system into one and that is not likely to happen, so the key word here is collaboration rather than integration and this is where the difficulty often arises. Who is responsible for this collaboration, who takes the lead to ensure the individual needing services gets a seamless service?

Naturally people are territorial about their domains, and certainly ‘professionals’ can often give the impression of others not really knowing enough to give a valid opinion, so there is inevitably some tension between ‘professionals’ of different sectors. Yet this approach does not benefit the individuals who need the services which is why there must be clear, defined leadership.

Before there can be talk of, and delivery of, integrated services for those who need them there must be a clear demonstration that those services are themselves integrated as until that happens it means they will be unable to deliver on that which is truly desired.

The Challenges of Social Care Inspection

The appointment of Andrea Sutcliffe as Chief Inspector for Social Care at the Care Quality Commission is a highly commendable one. Not only is she knowledgeable about the care sector (see for example http://www.guardian.co.uk/social-care-network/2013/jul/15/what-good-homecare-looks-like) but she also has her own personal experiences to draw upon (http://www.whentheygetolder.co.uk/finding-care-for-older-relatives/) and that combination, along with her naturally open approach, bode well for the future inspection of social care.

Yet that future is strewn with challenges that Andrea first needs to tackle. The general perception of social care is not great and trust in the Regulators has been severely dented over recent weeks. The first challenge will be defining a model of inspection that will ensure poor provision is identified and stamped out yet this model must also reflect the nature of the care sector and the huge variations within it.

Yesterday, for example, the new Chief Inspector for Hospitals, Prof Sir Mike Richards, outlined a model which he frequently referred to as ‘an army’, 20 or more inspectors marching into a hospital to inspect all aspects of care provision and ensure the meeting of standards. Unfortunately, in social care that will not work as, in many instances that many inspectors would outnumber both residents and staff!

The variation in social care is completely different from that of hospitals. Social care covers care homes and home care, it covers care and support for the elderly and care and support for those with learning disabilities, it covers large care providers with 100’s of homes as well as micro providers with just a few beds. Finding a model of social care inspection that fully encompasses the variation while ensuring consistency is, in itself, a challenge.

The Care Quality Commission has recently stated that it intends to have more specialist inspectors and social care could really benefit from this approach. For example recent reports have highlighted training and development issues with Health and Social Care staff and having learning and development specialists as part of the inspection process can help raise awareness of the importance of staff development, encourage providers to focus on training and development and help identify failings where providers fail to implement staff training and development. Similarly specialists in infection control or nutrition could have a significant impact.

One thing that would be good to see, and may well happen given Andrea’s former job, is a focus on best practice information and its application both by providers and inspectors. Resources, for example, from the three main national bodies, Skills for Care, National Skills Academy for Social Care and, of course, the Social Care Institute of Excellence should be routinely be embedded in care practice and those who inspect should also be fully familiar with this in order to ensure inspections are informed. One challenge has always been getting best practice information through to all providers, it is easy for providers to say they don’t have time to look at these things or, in the worst cases, believe they know what they are doing and don’t need any advice. If providers know their inspectors will look at this then they are far more likely to make to time to look at and use this information.

The regulatory framework has increasingly moved toward an outcome based approach, if providers and inspectors do not access the knowledge of what excellent outcomes look like then that system fails.

Undoubtedly, Andrea Sutcliffe has a challenge ahead, one that I am sure she will meet head on, and, ultimately, social care can only benefit by having such an effective leader at the helm.

Health and Social Care Training: The Real Issues

“There is no minimum standard of training for healthcare assistants before they can work unsupervised, an independent report has found” http://www.bbc.co.uk/news/health-23246066

Actually that’s not true!

Back in March Skills for Health and Skills for Care launched the National Minimum Standards for Healthcare and Social Care workers – see http://www.skillsforhealth.org.uk/about-us/news/code-of-conduct-and-national-minimum-training-standards-for-healthcare-support-workers/ . In addition the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 state quite clearly the Health and Social Care providers must ensure employees are “appropriately supported in relation to their responsibilities, to enable them to deliver care and treatment to service users safely and to an appropriate standard, including by receiving appropriate training, professional development, supervision and appraisal” (Regulation 23)

So, the issue is not whether those standards are in place but how those standards are applied, implemented and inspected.

The first area that needs real scrutiny is the induction process.

Imagine that time when you first started in a new job, there is always an element of nervousness as you enter a new environment, have to learn new routines and adapt to working with new people. Now imagine how much information you are likely to retain when you are bombarded with DVD’s or reading material which is supposed to make you competent in the role you are about to undertake!

While we have, in social care, the Common Induction Standards, it has to be remembered these only form a part of the induction process. Induction must be as much about ensuring that new employees learn about the workplace, its routines etc. and how the induction standards apply to the workplace and the individuals receiving care and support there. A tick box approach to the induction standards will not work and there needs to be a greater understanding by managers and leaders in the home of the importance of mentoring new employees to ensure the induction standards are embedded in work practice.

Learning and development must not stop after a successful induction. Professional development is a regulatory requirement and continuous training is important. Even if you have been on endless health and safety courses the chances are going on another will spark something in your mind that you had forgotten or prompt you to think about a bad habit you have got into and encouraged you to change it. Training, aside for giving us new information, can also make us think about how we do things right now, it brings us into ‘conscious competence’, always a good thing to do on occasion.

Supervision and appraisal also serves the same purpose. It helps us question why we do things in certain ways and can make us consider better ways of doing our work. Too often supervision and appraisal are seen as a means to be critical of an employees work but they should be seen as a means of encouraging employees to think about their own role and how they perform it.  

The key issue is to ensure that those responsible to managing and leading staff are sufficiently trained themselves in staff development.

One of the vital areas of training, often overlooked, is the quality of training itself. Certainly I have stopped using training providers because of the negative feedback I had from staff (the usual complaint is ‘they were just reading from a script’ – how can a trainer engage learners when they a focused on reading their lines?) yet how many providers actually get feedback from staff about the quality of training. It is important that providers do this, not only to ensure the quality of training but also to ensure they are not wasting their money!

There are schemes in place which accredit training in social care the principle one being the National Skills Academy for Social Care, and whilst their list is somewhat small at the moment, it would benefit all those who provide social care training to apply for accreditation (here’s the link https://www.nsasocialcare.co.uk/training-providers ).

Given that standards and regulation already exists the obvious question is how are these actually regulated and inspected. If there are issues over training and development why are these not picked up in the inspection process? It can only be speculated that the inspectors themselves are receiving insufficient training into what to look for and what questions to ask about training and development. One of the proposals from the Care Quality Commission’s consultation on inspection is the introduction of ‘specialist’ inspection teams – personally I hope that includes specialist in training and development to ensure standards and regulations are adhered to.

The training and development regulations and standards are there, the issue is how these are applied and inspected, if we can improve this we can improve the general quality of care across the board.

The Confusion of Westminster

Last week we had an announcement that £3.8 billion will be given to social care yet official sources cloud this. For example the Department for Communities and Local Government describe it as;

“£3.8 billion, including £2 billion of new NHS investment, to improve adult social care and join up with health services. This will help older and vulnerable people to stay healthy and remain at home thereby avoiding unnecessary hospital admissions or emergency visits to A&E. To stimulate real change, £1 billion of this funding will be paid when local results are achieved.”  (https://www.gov.uk/government/news/eric-pickles-hails-council-tax-5-year-freeze-and-38-billion-for-social-care)

In other words the money is for preventative health support to reduce the need for admissions in hospital.

Obviously this has to be welcomed by preventing a health issue becoming a health crisis the pressure on Accident & Emergency departments can be eased a little and, more importantly, being healthier should lead to a better quality of life for those who need social care services.

But what it does reveal is the ignorance of those in Westminster about what social care is.

Eric Pickles demonstrated this with his quote on the DCLG website saying;

“For the last 30 years all too often the care home, social services, and the local GP haven’t been working together to prevent unplanned hospitalisation of elderly or vulnerable people.”

The last set of statistics from the Health & Social Care Information Care show that care home residents only account for 14.6% of council funded care recipients. How, one wonders, does Mr Pickles think the new investment will help the 85.4% of social care users who are not in care home?

If the role of preventative health is to be transferred to social care then considerably more money will need to be ploughed into the sector. Social workers and social care workers are not health professionals and if it is to be their role to work with the health of an individual then they will need significant training in order to do so effectively. If however the onus is on health professionals then the money is not for social care it is simply transferring health funding!

Following on from the spending announcement we have learnt that the Care Bill will set the ‘substantial’ criteria as the benchmark for individuals to access care funding from the state.

The current ‘substantial’ criteria mentions health briefly, the majority focuses on personal dignity, daily living and family and community life and when the Care Bill final goes through there will be a significant increase in funded care users as many councils are currently only funding those with ‘critical’ needs. Therefore councils will need a staffing infrastructure to cope with this increase if current social workers are not to be totally overloaded with paperwork, especially if they also have to assess health needs!

Westminster seems to be clueless about social care and solutions to support people to live life in the way they want to is lacking as Ministers continue to confuse social care and health.

Social care should be about supporting people and bringing together the services they need. Health is just one of those services. A person’s health needs will vary over time and, where social care support is involved, it is social care’s responsibility to ensure the individual is able to access those health services, but social care also has a responsibility to ensure the individual is supported in every aspect of their life, from adaptations in housing to maintaining community links.

Social care is ever more important in society and demand for social care services will grow as the population ages. We need a social care service that is fit for now and the future and that cannot happen until those in Westminster recognise that they need to recognise the true importance of social care.

The Time to End Poor Care is NOW

The morning after yet another Panorama expose on appallingly bad care the media response is, as usual, distinctly underwhelming. No loudly broadcast calls for the resignation of senior civil servants, no demands for inquiries into the care system, in fact, nothing.

One particularly difficult issue with social care is that it is far too easy to spread the blame and for nobody to take responsibility.

Commissioners, Regulators and providers can all blame each other and the Government can blame all three! Yet, ultimately, the responsibility for regulating social care lies in Westminster and it is the responsibility of politicians to ensure safe, quality care is available to all.

Yes appallingly bad care exists but good quality care also exists. The quality of care is solely dependent on the care provider and good care providers have to struggle in a system that treats both good and bad care equally. Both are allowed to thrive in a system that is, currently, more focused on money rather than quality and the needs of individuals.

Of course bad care providers are to blame for the care they provide and such providers need to be shut down and banned from providing care services again yet the system allows them to carry on. Regulators can be blamed for not spotting the bad care being provided yet they are constrained by the regulations they regulate and inspections can only provide a snapshot of care provision and inspecting home care in particular is challenging. Commissioners can be blamed for buying services based on price rather than quality and, perhaps, they rely on information provided rather than going out and inspecting the care services they are commissioning services from.

But all of this can only happen because of the framework in which everyone operates.

Contrast this to the NHS and the calls for action following the Mid-Staffs enquiry. Those who stoutly defend the NHS and campaign for better quality do so because the NHS is a single, national, entity yet few of those people so stoutly campaign the fragmented social care system.

The ultimate responsibility for social care lies with Westminster, it is no use politicians blaming other elements within the system because it is the system itself that is broken and urgently needs to be reformed. There increasingly needs to be a system that promotes and rewards good care providers whilst ensuring those who provide bad care are eradicated.

We are promised a new care rating system soon, which is welcome, but it must, obviously, be one that can be trusted, one that will influence commissioning and one that reflects the care individuals need rather than what bureaucrats believe is essential in terms of paperwork!

Yet beyond this we also need a system that has real accountability. The ability of all parties to pass blame on others MUST STOP NOW. Ministers must admit their responsibility for social care services, commissioners must accept they have a responsibility to ensure the services they are commissioning are quality services, regulators must accept their responsibility to rigorously act and eliminate poor care and care providers must be held fully accountable for any failures in their duty to care.

The time to end poor care is now and this has to start with ending the blame game and all those responsible for social care to stand up and shoulder that burden.

Me, Food & Social Care

Apparently I am an overly fussy pernickety eater although I would prefer to say I have a truly sensitive palate which means that there are many foods that are not palatable to me! Many have tried to test and trick me but always have failed.

It is not something that has any significant impact on my life and I doubt I am the only person like this.

Yet what if someone with a similar palate found themselves suffering with dementia and placed in a care home. Without knowing the persons likes (because the dislikes will be far too many to mention!) it would be easy to try and give the individual just what is on the menu. Personally if that happened to me I would simply not eat what was in front of me, but how does that act get viewed by the care provider? Am I being awkward? Am I refusing to eat? The more I insist that I will not eat what’s in front of is my behaviour becoming ‘challenging’?

If I have no relative’s to speak up for me to explain my eating foibles what happens next?

If I am refusing to eat what is in front of me yet I don’t have the capacity to express that how can I be sure that my behaviour is interpreted correctly? And how will my non-eating be reacted to?

If I lack capacity then someone will make a decision in my ‘best interest’ under the guidance of the Mental Capacity Act. Obviously it would be in my best interest to eat yet if I were forced to eat something that tasted extremely bad to me the more likely my behaviour would become more challenging and I would probably be labelled as such and because of my limited likes it attempts to try different foods would also probably fail and lead to more ‘challenging behaviour’.

This is, of course, hypothetical yet there are, undoubtedly, many people in similar situations, it may not be with food but with other aspects of daily life.

This is why carers and families are so important in the social care system. Social care professionals need to understand the person who needs care services and, where individuals are unable to articulate their needs, listening to carers and families is vital in providing quality personalised care.

The quality of social care is not just about now, it is about the future and the quality of care we want to receive in the future if we find ourselves needing care services. Quality services can only be achieved by understanding the individual and, equally important, their individuality. By the time care ‘professionals’ become involved in a person’s needs it is likely those needs have already progressed to a point where understanding individuality becomes more difficult making it ever more important for those professionals to engage with carers and families to truly get to understand what makes the person needing care service tick.

Carers and families have a responsibility too. As someone they love begins to deteriorate through age-related conditions they should prepare that information to ensure they are able to pass it on. Obviously, as individuals, we also have a responsibility to make sure those things are known in case we need social care services in the future.

In reality the real onus is on those paid to provide social care services to ensure they are providing personalised care based on the information given to them by the individual, their carer’s and their families.

If I ever need social care services I want those people providing those services to understand all of my needs and provide care based on those needs. Undoubtedly you do to. So let’s focus on moving toward that for the benefit of those who need care services now.

Social Care - It's Not Rocket Science

How long has the debate around integrated care been going on? It’s a constant theme running through the social care debate yet one that remains fully unresolved and one that seems difficult to achieve but why?

It’s not rocket science!

Take, for example, the space shuttle. That feat of engineering consisted of 2.5 million component parts, including more than 200 miles of wiring! Thousands of scientists, designers, engineers and manufacturers managed to come together to create a single machine that enabled regular space travel. Even so that would not have happened without the thousands of others who also played a role. The astronauts who flew the shuttle were also products of a system that selected, trained and developed them to ensure they were capable of operating such a complex machine. Then there were those on the ground who made sure the launch and landing were successfully achieved.

Yet we struggle to give individuals the integrated care and support they need!

The component parts of providing integrated care are considerably less than those needed for space travel and the cost considerably less!

Yet bringing together social care, health, housing, benefits and employment for the benefit of an individual seem to be an impossible task for the bureaucracy of the U.K.

Obviously because social care is so low on the bureaucratic pecking order it means that the other elements needed for integrated care tend to take precedent. Social care is a small part of the Department of Health and Housing and Benefits sit within in two other Whitehall departments. At the level of the Whitehall bureaucracy focus is on departmental achievement and policy formation with little or no consideration to the individual yet by changing focus to achieving integrated care for the individual departmental achievement and policy formation could actually improve.

With the space shuttle, the goal was achieving manned space travel that could benefit the space programme by being reusable. All those thousands of people involved in the project came together to achieve that goal, integrating their role into that single achievement. Obviously there were disasters yet overall that particular programme was a success.

Those in Government should learn that if the goal of social care is the life of the individual we can begin to make social care the Primary service under which all other elements needed to provide effective integration are mustered and directed by social care services.

Completely effective social care means having a fully integrated service whose goal is the needs of the individual, why is it so hard after all it’s not rocket science.

The Sense of Adventure

Do you like to think outside the box, push outside you comfort zone, expand your horizons or perhaps extend the frontiers of your knowledge?

It seems to be a naturally occurring part of human nature to seek out new experiences and find ways to enhance our lives by discovering new things. Obviously we all do this in completely different ways. The adrenalin junkie will take to extreme sports to conquer the elements by seeking outrageously dangerous thrills, excitedly relishing the physical and mental challenge they have set themselves. Others may take joy in food, the adventure of seeking out a new restaurant, savouring the ambience, sounds and aromas surrounding whilst eagerly anticipating the new tastes they are about to experience. Others could simply be avid readers who regularly and enthusiastically, seek out new authors to stimulate their imagination and mind.

Essentially, within all of us, to a greater or lesser degree, there is a need to have new experiences to keep us from become to stale and bored with life.

Yet, when it comes to providing social care, what do we do to stimulate and expand the experiences of social care workers to keep them interested in their work and to stimulate them to encourage them to expand their horizons when it comes to how they deliver care services?

Outside of social care, many businesses go beyond general training with such things as ‘team-bonding’ activities and whilst these may have become something of a joke or simply an excuse to have a good time the principle behind the idea is a sound one. It is something different in the workplace and should, if well planned and designed, give sensory experiences that go beyond those normally experienced in the workplace.

Unfortunately regular classroom training does not usually provide the extra sensory aspect, in fact much social care training is done simply to comply with regulations rather than truly benefit the care workers. Additionally training only forms a part of the learning process and without the other elements training becomes little more than a chore, especially if it is one of those courses that has been done year after year!

Add to this the increasing pressure in care services, to do as much as possible in ever decreasing time-slots, little time is left for workers to engage in personal growth through work and take the importantly essential opportunity to reflect on the work they are doing and what they could do to improve that work.

And now to completely flip the coin – what about those we provide social care services for?

There is this public perception of older peoples’ homes being rows of old-fashioned arm chairs filled with elderly people who just sit there between getting up and going to bed. While there a many homes where that may be the case there are many that provide excellently managed activities which stimulate and stretch the minds and senses of those they care for.

There is some great work around at the moment focussing on raising awareness of loneliness amongst older people who may have no family and only see carers for brief visits. But loneliness is not just about having no-one around you. You can be lonely in a crowded space, just like those people who are left to sit around all day in those poor care homes. Loneliness is not necessarily being alone but about being engaged or stimulated in some way. In social care we need to ensure that those we provide care and support are stimulated and engaged and given the chance to have new experiences or re-live the thrills of past exploits.

Cognitive decline does not necessarily mean a loss of all the senses!

We all have a sense of adventure laying somewhere within us and that naturally stimulates our need to seek out new experiences which in turn helps us keep fresh and stops us becoming bored. Social care must be about providing those who need services with a good quality of life and that sense of adventure is an important part of that quality. Similarly we need to keep social care workers engaged and stimulated as this obviously helps in retaining staff and encouraging them to fully immerse themselves in the quality of care they provide.