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.

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 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.

Craving Connection, Fulfilling Personalisation

Part of being human is the craving for social contact. You only have to look at the way modern technology has evolved over the last few years a social networking sites have evolved (remember that time when Friends Reunited was all the rave!).

We now Twitter, Facebook, LinkedIn or whatever to maintaining our social circle and, to some extent expand it. Of course it is not just our P.C. that allows us to do this, the vast array of mobile devices allow us to tell the world where we are, what we are up to etc. as well as giving us the chance to check on what are friends and wider social network are doing.

The technology, however, only facilitates this inner desire, this craving for relationships and social contact that is present, to some degree in all of us and has existed since the emergence of man. Family, community, society are hardly the constructs of those who crave isolation.


And if we need to identify  the truth of this  we only need t look at how we punish people - we "send them to Coventry", we ignore them, in prison we use solitary confinement.

Maslow puts this need for connection firmly in the middle of in his classic Hierarchy of Needs, Professor Stephen Reiss identified social contact as one of the 16 basic desires that define our personalities and motivate our actions, the New Economics Foundation identify connecting with people as one of the five ways to wellbeing.

So why don’t we focus enough on this in social care?

Remember the recent Panorama programme where the two care workers roughly washed the resident? When they were doing this they busily maintained their own social relationship by talking in their own language while failing to talk to the individual they were supposed to be caring for? Maybe an extreme example but how many times do we hear of care home residents all sitting around in large lounges in silence? How many times do we hear of cases where care in a person’s home is restricted to 15 minutes or so giving the care worker little or no time to interact with the individual or complaints from care service users that they never know who is going to turn up to care for them?

Part of the problem is, perhaps, that some elements of social care are still to firmly rooted in the medical model of care. Clinical detachment in the health professions serves a purpose, it helps to insulate health professionals from the trauma of getting to attached to people likely to suffer great pain or die, it prevents the psychological transference of distress from those suffering to the professional who, for their own sanity, must remain outside the constant bombardment of anguish and agony not only from the patients but their traumatised families.

Yet can this clinical detachment work in social care? No, for many different reasons. Firstly the clue is in the name SOCIAL Care, social care is not the same as health care, that is the responsibility of the health professionals, social care is about supporting people in their everyday lives, helping them maintain connection with the wider world or, if that is not possible, ensuring that they are able to live as full and active life as possible in their individual circumstances.

We are, by nature, social creatures and while the degree that socialisation is needed by individuals vary, quality social contact still forms an important part of our lives. How can we know what level of social relationship individuals need unless we make the effort to establish a significant relationship to find out?

Personalisation is the social care buzzword at present and it is a goal that we should strive to achieve but how can we provide personalisation through clinical detachment? We need to build relationships with care users to understand their personal needs but more importantly to provide them with the type of social relationship that is cornerstone of being human.

Social Care - What's that then?

What is social care?

To those of us who work in the sector that is probably an easy question to answer, although I suspect many of those answers will actually be slightly different, but what does it mean to the general public and the mainstream media?

It is perhaps the vaguest of all social policy areas after all most social policy is easily understood. Housing refers to where people live and the links between poor housing, welfare and deprivation are fairly easy to see to the average person (obviously to specialists things are much more complicated than that). Education means teaching our children to learn and, while there may be arguments on the best way to do this, when politicians talk about education the general public knows it is about schools, colleges and universities. Employment is about getting people to work and ensuring that the conditions of work protect employers and workers. Welfare is about the State supporting those in need, yes they is a debate about how you define that need but we all understand what is meant by welfare.

Health is also an easy issue to understand, it is about our physical and mental well-being. If we are ill we see a doctor, the type of doctor we see depends on what is wrong with us. We would expect our G.P. to refer us to the appropriate specialist in either physical or psychological issues and then expect to be treated by them, and that the system that the general public expect social policy to support. One of the reasons for the animosity toward the Health & Social Care Bill is the worry that changes may make this system different and more difficult to achieve the best possible results for our own health.

But what about social care? How easy is it for the average person to understand what social care means when politicians and professionals talk about it?

In 2006 the Department of Health described social care as “the wide range of services designed to support people to maintain their independence, enable them to play a fuller part in society, protect them in vulnerable situations and manage complex relationships” (DH (2006) Our health, our care, our say: a new direction for community services.)

Yet does that really mean anything to the average person?

Take, for example, services to support people to “enable them to play a fuller part in society”. The majority of people tend to think of social care as services for the elderly, something not helped by politicians who insist on focusing on how elderly care is paid for, and would find it hard to see what playing a fuller part in society would actually mean. After all for most people life does not involve “society”, it just revolves around work and home life (yes I know that is society but how many people think of it like that).

Social care does, naturally, support people to play a part in society, beyond supporting older people, support for people with disabilities involves trying to enable people to getting employment and if that is not possible ensuring that they receive their full entitlement of benefits (but, says the average person, isn’t that employment & welfare policy?)

Social is, or should be, about promoting and maintaining independence and enabling people to live where they want to live and ensure they are living in accommodation that is most appropriate to their needs. It is about ensuring that people have the adaptations and support in their home or, if their needs are greater that they can find accommodation in a home that will allow them to be as independent as possible whilst minimising potential risk (but, says the average person, isn’t that housing policy?)

Perhaps the mainstay of social care is providing personal support for people who are no longer able to support themselves. The reason for not being able to support themselves is generally down to physical or mental deterioration, age related conditions can be physically disabling and diseases, such as dementia, impact on the mind. The role of social care is to ensure that these people have support in maintaining their physical and mental well-being (but, says the average person, isn’t that health policy?)

There has been a lot of talk about integration in social care but the real fact is that social care is the integrating service.

Social care should be about bringing all other policy areas together for the benefit of those who need them. Social care should be seen as the umbrella under which all other policy areas sit because all of the areas could may need social care intervention. This is especially true if we include children’s as well as adult services in our overall definition, education, housing, welfare, employment and health all have an impact on the “social” and where they fail it is down to social care to step in to aid the individual, whether vulnerable child or adult, and support them to achieve the best possible outcome.

To raise awareness of social care we need to be able to define it in a way that the general population can understand and that definition should be one that shows the importance of social care as a policy area that embraces and sits above m

Social Care: The Public Perception Hurdle

Social care is something that impacts on the lives of millions in the UK, those who use services, those who provide or commission services, those who care, unpaid, for family members and those who work in providing care. Yet the general public and, more particularly, the national media seem less than enthused about the subject.

One clue to this may be found in the health/NHS debate that has been vigorously contested in Parliament and through the media.

A few days ago the Guardian published a list of 30 odd organisation connected with health and where they stood on the Health & Social Care Bill. Of this only 1 was an organisation that directly represented patients yet there were 10 ‘Royal Colleges’ representing various healthcare professions.

The Royal Colleges do, of course, command tremendous respect and it is easy to understand why. These organisations represent the people whom we may need to save our lives and while there may be a general social decline in the trust of ‘experts’ the Royal Colleges carry a lot of weight in terms of public opinion and media attention.

While there is a multitude of organisations connected with and campaigning for social care none carry the same weight and gravitas as those connected with health.

Naturally part of this has to do with history the Royal College of Physicians dates back to 1518 and even the relatively young Royal College of Nursing is fast approaching its Centenary. Yet social care, in its current form detached from the ‘medical model’ is relatively new and there are relatively few ‘professional’ organisations connected with it.

Obviously the College of Social Work has just come into existence and, perhaps, its most immediate task is to embed itself in the public domain as an authoritative voice on social care.

Aside from this though other organisations may be too detached from the public perception of the immediate issue, for example the Association of Directors of Adult Social Services represent the councils commissioning social care rather than being directly involved in delivering it. Compare a Social Services Director (essentially a civil servant) to a Surgeon or Physician who gives hands on (literally!) health care, we have to have more faith in the medical professional because their actions will directly affect us.

Aside from these ‘professional’ organisations most of the others either represent the care users themselves or the organisations providing care services. With the former the Guardian list has shown users groups do not command the attention that they perhaps should but unless the public attention is grabbed by social care it seems unlikely that the users of social care will either. Trade organisations will suffer from the same inertia of public interest particularly as the predominant coverage of social care is where the system goes wrong and providers fail.

The Royal Colleges also act as centralised points for dissemination of research and innovative practice and whilst there is an abundance of excellent research available in social care and many academic institutions carrying out that work the route through to public perception appears fragmented.

Even in terms of ‘think-tanks’ representation of social care is limited. The Kings Fund and the Institute of Public Policy Research both, certainly, provide excellent contribution to the social care debate but their primary focus is elsewhere.

Social care is diverse but no more so than health provision and obviously the two overlap in significant areas. We need to achieve greater public awareness and interest in social care but, at present, lack the structure and gravitas to engage the attention of the majority of the mainstream media and, through them, the general public.

Perhaps we need a Think-Tank solely dedicated to social care to disseminate research and practice, command media attention and generally raise the profile of social care or, perhaps, more professional recognition of those who work in front line care (a College of Registered Social Care Managers?) to add to the College of Social Work.

Putting social care high on the national agenda is important and we need to look at how this can be best achieved for the benefit of the millions involved in social care.

Improve Dementia Care Sooner Rather Than Later

Dementia is a disease, or rather the generic term for a group of diseases that are classified as degenerative diseases of the nervous system. The World Health Organisation classifies these diseases, Alzhiemer’s Disease, for example, is listed as “a primary degenerative cerebral disease of unknown etiology with characteristic neuropathological and neurochemical features. The disorder is usually insidious in onset and develops slowly but steadily over a period of several years” in the WHO International Statistical Classification of Diseases and Related Health Problems 10th Revision, more commonly known as ICD-10.

Given that the various types of Dementia are a disease it seems surprising, yet deeply disturbing, that the NHS is failing to provide adequate care for those who have dementia http://www.bbc.co.uk/news/health-16206169

One of the reasons could be that care for those with dementia in the UK falls under the social care remit rather than the health care one. Therefore the expertise in supporting people with dementia is detached from front line health care.

The problem is, perhaps, exacerbated by the fact that few people access hospital services because of their dementia. The reason for being hospitalised is for other health reason, yet it has to be born in mind that these reasons can be related to the dementia, for example a cut or burn could be the result of failing to remember something, so true, holistic care needs to take into account all aspects of the persons health.

One of the answers being touted is training for NHS staff, while this can only help it may not be enough to solve the problem. Training imparts knowledge but that is all, how that knowledge is used in practice is a completely different matter. To ensure that the knowledge gained through training is used effectively their needs to be both good staff development and effective leadership at all levels of the NHS. And to achieve this, managers and supervisors, at all levels, need both effective leadership and communication skills along with a knowledge of dementia themselves.

An additional area highlighted was communication between hospital staff and relatives of the person with dementia. This is an important area to be addressed. Dementia is a disease that can have a great impact on a family, the worry about a loved one can be tremendous, along with the guilt of feeling inadequate in caring for them. If this is made worse by a) poor care & b) poor communication then it is not only the patient that the hospital is failing.

Again the solution is better knowledge, better practice and better communication skills.

Perhaps it is now time to take a fully integrated approach to health and social care. Why not have social care specialists on elderly wards? Why not recognise that social care is best placed to provide the support for people with dementia in hospital. This is particularly important in ensuring there is sufficient after care when the person leaves hospital, especially if they are returning to their own home.

The numbers of people with dementia are predicted to rise sharply and unless action is taken soon the situation will only get worse, so let’s hope we get action sooner rather than later.