What makes you, you?

As a follow on from my last post How Do You Feel About Memories I think it is also important to consider how we stereotype those who need care services and what we need to consider, especially when thinking about older peoples services.

Stereotyping is a natural human trait, we find it easier to put groups of people in specific categories rather than struggle with having to think about everyone as an individual. It is easier, for example, to put all football fans, in the same category rather than struggle to think about the 100’s of thousands of individuals within that category.

In many instances stereotyping is used as a political weapon to demonise a ‘group’ of people, as shown recently by labeling all benefits claimants as ‘shirkers’ who live of the hard work of the ‘strivers’ in society. Of course that analogy, much touted recently, fails to take into account,perhaps the worst type of benefit fraudster, those who work but still claim benefits – are they shirkers or strivers? This is why stereotyping politically in dangerous.

Yet even in the social care world, where awareness of individuality is more recognised there is a tendency to stereotype, not as a means of demonization but as bureaucratic convenience. Yet there are pitfalls we must avoid if we are to ensure that social care services are truly personalised.

We don’t just stereotype people we also tend to stereotype history. The bulldog British spirit of World War Two, the Swinging Sixties, etc and there is a tendency toward selective memory of the past. How often, for example, do we see moans about the youth culture of today yet the complaints are made by those who grew up during the era of ‘mods and rockers’ ‘punk rockers’ etc who were on the receiving end of similar complaints.

How does all this apply to social care?

Imagine a care home, in one seat a 75 year old in the next a 100 year old. Both old people in an old peoples home to most, yet there is a 25 year age gap. Now imagine someone 25 years younger or older than you. The 100 year old is actually sufficiently older to be the younger persons parent.

The 100 year would have been born in 1913, just before the First World War and would have reached their teens in 1926 and spent their formative years during the depression and would have been 26 at the outbreak of World War Two and approaching their 50’s as the Swinging Sixties started.

The 75 year old was born in 1938, so just 7 as the Second World War ended. What can you remember about your life as a seven year old? They entered their teens in the early 50’s, the time of rock and roll and the beginning of modern youth culture. Just 22 as the 60’s started so, as someone in their 20’s, their experience of the decade would have been completely different from the older person, now middle-aged.

As the general population ages and degenerative diseases impact on lives more and more it is so important that we take into account all aspects of the individual. Old people are not just old people, their lives can be worlds apart as can be their memories and how life has impacted on them over time.

Our experiences through our life make us unique individuals. Each of us is touched by different experiences which then impact on how we move forward in life. We are influenced by different people and we are influenced by the events of the world around us, and how we see those events depends on our past influences and our age.

We are, individually, a complex make up of different memories and experiences and to deliver the best possible services we have to take time to understand both the individual and the wider world which influenced them. Delivering quality is not just about clinical execution of care duties but of taking time to help people to live the life they want, which is, inevitably, based on their age and life experiences.

Personalisation and Being Human

You would probably agree that there is a part of you that enjoys time alone to relax and reflect yet at times you enjoy the company of others and, if you were being honest with yourself you do, perhaps, enjoy the attention others give you.

Perhaps, at times, you feel that you are not using your full potential in some aspect of your life and that those you are with fail to understand how much more you can offer and improve yourself.

Maybe there is a hidden part of you, one that you can’t reveal to anyone that holds a regret in life, a choice made wrong which, on one hand, is seemingly trivial yet on the other is one that has lived with you for a long time.

We are all the same, and the above holds true for most of us but the degree to which it applies may vary, yet they are fundamental part of our make-up.

Yet do we pay enough attention to these aspects of being human when delivering social care?

Personalisation is the key to delivering good quality social care yet the key to personalisation is understanding what it is to be human and understanding how we tick. Unfortunately the basic training of care work does not include this aspect of understanding which is so vital if quality care is to be universally delivered.

Core training consists of health & safety, infection control, food hygiene, etc. The Skills for Care Common Induction Standards go further but beyond induction training how much training do the majority of care workers get in understanding the individuals they are working with.

There is, of course, a tendency to stereotype people who need social care services (as in all aspects of life) using generic labels such as ‘learning disability’ ‘dementia’ ‘old’ and so on. Such labels have their uses and stereotyping is a human trait which allows us to form our own identity but in delivering care services and treating people with dignity and respect such labels represent just one aspect of who the person is. Although this one aspect may have significant impact on other areas of their life the person who needs social care services is still a person with the many individual quirks, nuances and subtleties that make us all slightly different but with the same underlying aspects of what it is to be human.

Obviously the immediate tool for learning about a person in order to provide personalised care and support is communication. Effective communication is essential, especially about listening to the person about their likes and dislikes but it needs to go further to understand a person’s desires  dreams and hopes. For example if we want to promote a person’s self-esteem we have to understand what that means to the individual, self-esteem involves personal beliefs and emotions not merely the likes and dislikes which are the standard part of any care plan.

Being a person is a complex thing and delivering quality, personalised care and support relies on understanding the individual not merely their personal preferences but also their values and beliefs which form their individuality. Those responsible for delivering care and support services are those on the front line of care and it is essential that their training includes more than the safety and physiological aspects of life.

You would probably agree that if you needed social care services that you would want services that understood what you needed, delivered by people who know when you need company or when you need to be alone, people who knew how to motivate you yet understand when you may be pushed too far, people who understand what dignity and respect mean to you. Isn’t only right then that we should apply this principle to all social care users.

Care, Communities and Questions

I read a quote from Care Minister Paul Burstow yesterday saying “We need to reconnect care homes with their communities” and it is evident he said broadly the same thing today (Thurs) at Community Care Live.

But what does that mean?

I know I will stand accused of being a ‘naysayer’ but have care homes ever been connected to their communities?

For starters a care home should be just that, a home. One that looks after those who are no longer able to look after themselves independently and those who are living there should be treated with the same dignity, respect and privacy that everyone should expect from their own home.

So a question, how connected with the community is your home?

Chances are not at all, it is probably the place where you retreat from the community, the place where you can drop the ‘outside world’ persona we all employ and indulge yourself in your own private pleasures, where you can shut out the pressures of modern society and allow you mind to mentally recharge before stepping back through the front door into the hurly-burly of the world. Obviously not every home is a happy home and, sometimes, what happens behind closed doors is truly horrendous but in most instances the home is the place of privacy and the expression of your personal identity, the only invasion from the community is of your choosing and then probably limited to friends and families.

Then of course we come to the other question – what is a community? The definition is simply ‘a group of people living together in one place’ there is no connotation of that group being connected in any other way. How connected are you to those who live in the same street? The answer will largely depend on where you live, smaller villages tend to have greater connection than large cities but, in general, in even if you know everyone quite well it is unlikely that the community will be the focal point of your life.

Additionally the location of the care home will not necessarily reflect the community of those who live in the home but perhaps the greatest connection with the community already exists as the people working in the home are, more often than not, drawn from the immediate area.

Given all of this it seems something of a something of a meaningless platitude to call for “care homes to reconnect with their communities”

If, however, Mr Burstow means we need to reconnect those who live in the care home with their communities that is a different matter. My last blog focused on the human need for connection (Craving Connection, Fulfilling Personalisation) and, yes there does need to be greater effort made in helping people maintain the social contacts they had before moving into the care home. Our friends our an important part of how we define who we are (and of course who we are not) and by maintaining those social contacts it allows a person to ‘keep hold’ of that identity even when they are in a setting where those around them are there due to circumstance rather than choice. It is equally important that care homes develop a sense of community within the home by finding common ideas and themes that all (or at least the majority) of residents can be involved in.

However, I suspect, and I am happy to be proved wrong, what the Minister actually means is that we need to get communities involved in care homes, particularly the voluntary community who can provide services for the care home and relieve the financial burdens on the state in delivering care services.

There is certainly a case for encouraging volunteers to come into the home especially in the development of community activities within the home but they should certainly not be used as a means of financial avoidance by the state.

It has been stated recently that the ‘Big Society’ appears to be a means of Government misdirection and encouraging ‘communities’ to take over where the Government knife has wielded huge cuts but care of the most vulnerable in society should not be one of those areas and Government MUST TAKE RESPONSIBILITY for those who need care services.

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.

Personalisation: Structure and Agency

A basic common debate within social sciences is the question of structure versus agency, how the social structures of society impact on us as individuals and how our individual choices and freedoms are constrained by those social structures.

These arguments need to be considered in relation to social care, particularly personalisation.

The Social Care Institute for Excellence give us the following definition for personalisation;

"Personalisation means thinking about care and support services in an entirely different way. It means starting with the person as an individual with strengths, preferences and aspirations, and putting them at the centre of the process of identifying their needs and making choices about how and when they are supported to live their lives. It requires a significant transformation of adult social care so that all systems, processes, staff and services are geared up to put people first"

This shows the intrinsic link between structure and agency within delivering personalisation. It could also be argued that it demonstrates why personalisation has been difficult to achieve and why personalisation will never be truly personal unless there is a major change in the way social care is structured.

The SCIE definition describes the individual as being at the centre of the process of identifying their needs and making choices about how and when they are supported to live their lives.

In other words, the person is at the centre of the structure! But, how much is their individual agency constrained by that structure.

Unfortunately that structure is one that limits those choices available for personalised care and support and it is a multi-layered structure, each layer filled with bureaucracy and each layer with, at times, competing agendas.

The big, over-arching layer of structure in social care is, of course, Westminster. Parliament set out the laws and regulations under which social care is practiced in England, it sets out how social care is funded and it sets the structure under which personalisation can operate. This is all administered by the Department of Health who, as is its name suggests, has a primary focus on health and while many aspects of social care may overlap with health there are many other areas, such as housing and welfare, that do not.

The next layer in the structure is the most diverse and, perhaps, Weberian in its nature and that is the delegated bureaucracy. The role of implementing and enforcing the dictates of Westminster is handed down to a myriad of Quango’s (e.g. CQC, NICE etc) who have their own structures for implementing the written law handed down to them and of course, 152 local authorities with responsibility for commissioning state funded care and again with their own structures and political leadership which may vary from that sitting in Westminster.

The next layer surrounding the individual is the providers of care services. This is not just care homes or home carers, it also includes Social Workers who provide a service on behalf of the local authorities, providers of advocacy services, services which provide employment opportunities etc.

Eventually we reach the person needing care and support services.

Whichever way you look at it, as a top down structure or a circle with the individual at the centre, the layers of structure hamper the ideals of personalisation.

Those who provide services can only do so in controlled circumstances, they must be appropriately registered or have an appropriate contract and the services must be provided within the budget available. For those who need to choose services the choice becomes limited by these structural constraints, even those who have personal budgets or direct payments have the budgetary implications to consider. Whatever an individual’s strengths, preferences and aspiration, services can only operate within the structure dictated by the layers that surround care provision and the rules and regulations imposed on them.

This is not to argue that such constraints should be removed but that the structure should be revisited if we are to improve social care services and increase the opportunities for greater personalisation.

We are trying to move from a top down structure to one that has the individual at the centre yet the actual structure remains the same and has the same constraints on agency. If we want to change the outcomes for individuals we need to take a real look at the structure within which social care operates.

Building Social Care

Social care is full of concepts and the problem with concepts is that there are difficult to get across to the wider population as it is difficult to grasp what something actually means, especially when those espousing the concepts of put different interpretations on what they mean.

Take for instance the Social Care Institute of  Excellence   definition: "Personalisation means thinking about public services and social care in a different way – starting with the person and their individual circumstances rather than the service" 

Compared with the Department of Health version: "every person who receives support, whether provided by statutory services or funded by themselves, will have choice and control over the shape of that support in all care settings" 

Broadly similar but the first takes personalisation as being outside the care service where the latter stresses that personalisation occurs within the care settings.

That is, of course, pure semantics but it serves to illustrate how talking about social care is open to interpretation both by the organisations delivering the message and those listening to it and why listeners may simply switch off if they cannot fully understand the message being delivered.

To add to the general woolliness of social care speak many of the more recent concepts, such as personalisation, are being inserted into a system established 20 odd years ago and may not always be totally compatible without significant change to the system.

To illustrate in more, literally, concrete terms.

Most people agree that personalisation needs to underpin social care (and other public services), it needs to be the foundation on which such services are built. Yet if you can imagine social care as being a house exactly how easy is it to change the foundations without tearing the house down and rebuilding it? But, I hear some people cry, surely personalisation could be used to underpin the subsiding house of social care that is sinking rapidly yet is this a wise move using personalisation to simply prop up a house that is no longer fit for the ever growing family that is needs to accommodate.

We can extend the metaphor to the forthcoming white paper. Will it be an instrument that simply attempts to paper of the cracks in the social care house? One that replaces the odd rotten beam rather than tackle the endemic rot in the system, maybe it will knock through a few walls to allow for more space to accommodate prevention or even add an extension out the back to allow room for the ever growing number of people who will need social care over the next few years.

Or will it be a white paper that recognises that the house is no longer fit for purpose and tear the whole thing down in order to build a bigger   higher   social care house with firm foundations on personalisation and one that has personalisation insulating all the walls. A new,   desirable,   house that has more than enough capacity for social care to grow, has wide corridors making it easier for those who live in it to move from one room to another and, perhaps, even adjoin the Health Services house with a single door through which people can move with ease.

To  engage   the public in the importance of social care and   build   public awareness we need to ensure that the language we use is accessible to all and that the message being sent is consistent, whether we undertake extensive repairs to the social care house or rebuild a shining new ‘des res’ the important thing is to get the planning permission through with the support of the general population and the millions who will need to live in the house in the future.

Social Identity and Social Care

Do you prefer to shop in Asda, Morrisons, Sainburys, or Tesco (or any other supermarket). Chances are that you prefer one over the rest even if shop around. It is all to do with social identity and supermarkets often market their image to appeal to a particular social identity. The same is true of newspapers, cars and even political parties.

The issue of our identity becomes more complicated because we combine these various elements to form our identity and differences with others. Two people could both be Guardian reading, Asda shoppers and would have that in common but equally one may be a Labour supporter and one may be a LibDem, so both would consider themselves to be different to the other.

There is a link between social identity and self-esteem, if we can find ‘our place’ in the world we can be considerably more content in our overall well-being.  There are of course, extremes as can be seen in the crowd mentality of football team supporters but social identity seems to be an integral part of being human.

We are all different, we define ourselves as much by who we are not as by who we are and often our social identity defines the choices we make about our lives. Because of that the ‘market’ panders to our wishes in terms of supplying goods and services that we can identify with.

With a serious exception – Social Care

The provision of social care is a market economy nowadays with around 80% of all care provision being supplied by private organisations (Companies & Charities). Now this change has been relatively rapid and the ‘market’ may not have fully established itself but there does need to be a consideration of this if we are to provide services that truly support individuals.

This has to be a key element to the personalisation agenda.

Let’s be brutally honest – you will have chosen to avoid certain people and certain places and you will have made choices that you feel are ‘more’ you.

Are the same sorts of choices available in social care provision? And to what extant do assessments of those who may need social care services look beyond the physical needs of the individual to the needs of sustaining their social identity.

Helping to maintain a person’s social identity is important for mental well-being. Imagine if you were left with no choice in any service you needed, how frustrating it would be to be placed in the company of others that you had little in common with or your day was dictated by what others considered good.

In our everyday lives we choose who we wish to spend time with and generally we choose people who share the same ideas, enthusiasms and outlook on life. Obviously there are times when we have to ‘put up’ with people at work etc. but we will always chose to spend our more intimate moments with friends. So what does it feel like to a person who has to have personal intimate care from somebody they have had no choice in selecting?

Our social identity is the core of who we are and it seems wrong that just because age means we may need support and care from others that this social identity is taken away by lack of choice in social care services.