The Culture of Culture Blame

            Many of the failings of Mid Staffordshire NHS trust were blamed on the culture within the service, similarly the abuse at Winterbourne View saw the culture word used to describe how and why abuse was allowed to happen. Blame on ‘culture’ is not limited to health and social care. The rail franchise fiasco last year was blamed on a culture of fear, and the banking crisis which sparked the current financial crisis is often blamed on the culture within those institutions.

            Yet does blaming the culture in an organisation really solve the issue and what does it really mean?

            The culture within an organisation is the result of the leadership, or lack of, and the way those in the organisation react to that leadership. What ensues is a group mentality that becomes self-perpetuating and, if it goes unchecked, something that descends to the lowest possible denominator and is often directed by dominance rather than leadership. Once embroiled within the group mentality it is far easier for members to dismiss personal responsibility and place all responsibility on the culture within the organisation.

            It also makes it harder to challenge the group mentality. People fear being ostracised by colleagues, fear they may lose their job or, in extreme circumstances, fear particularly dominant individuals. Those who believe that something is wrong but fear to speak up eventually feel they have become complicate in the wrong doing, “I will be blamed because I did not speak up earlier”. Others will just ignore what they believe is wrong and reconcile it in their own minds by saying to themselves “that is just the way it is done here”.

            The real blame is not on the culture of the organisation but on the leadership of the organisation and the lack of responsibility and accountability throughout the organisation. People in such cultures prefer to pass the buck about failings, blaming others or the policy framework they have to work in or, indeed, the culture of the organisation rather than being prepared to stand up and say I got this wrong. Those who set the tone for the organisational culture, including those in Westminster, must start to take responsibility for the organisations under their control, they must encourage accountability and they must ensure the culture of responsibility and accountability reaches right down through the organisation.

            In social care we must be aware of and ward against the possibility of a lack of responsibility and accountability and promote effective leadership.

            For example, multi-disciplinary working is common place now but we often hear of ineffectiveness because of people working ‘in silos’ (a jargon term I don’t really like) and the danger is everyone trying to work together defers leadership and responsibility to other agencies with the result nothing gets achieved and the only person to lose out is the person who needs joined up services.

            Effective leadership, responsibility and accountability are the best ways to promote good practice and if we are to provide the best possible care services they are the things that need to be at the top of the Health & Social Care agenda.

Radically Rethinking Social Care Policy

Naturally many people who need social care services also need health services, but not all of them. Increasingly many may also need housing services, welfare and benefit support or employment support. Obviously for many transportation support is also an issue and we must not completely forget that most social care services are delivered in communities through local government.

For those who need social care support the range of support they need is a combination of many services all delivered by different sectors of local and national Government.

Unfortunately when we hear talk of integrated services the focus is on the link between health and social care.

Hardly a surprise considering that social care is currently under the remit of the Department of Health and the current focus on integrated services has largely been led by the responses to various reports that have highlighted the frankly appalling treatment of social care users in both health and social care settings.

The latest proposal from the Labour Party is to push social care under the immediate remit of the NHS but this fails to take into account individual need as not all social care users need health services and those that do only need health as a part of their overall package.

Unfortunately the proposal is firmly and unequivocally stuck in the current mindset of thinking where social care is subservient to all other services as reflected in its placement within the Department of Health.

Like it or not social care is not a minor area public policy any more. The rapidly ageing population means that social care is ever more important in our society and the services many need are of greater importance that such services 40 or 50 years ago. Those with disabilities are also living longer and those on top of the service delivery chain need to recognise the changing needs of all people who need care and support as they age. They also need to consider the younger population who need care and support from society, including employment and benefit support.

Essentially the primary service is now social care and all other services should be integrated with it for the benefit of every individual who needs social care services. It should also be focused on those who care for those who need social care services, whether or not they are entitled to funded social care support.

It is essential we radically and thoroughly rethink social care and recognise its importance in society today. Naturally this will be difficult, creating change in a firmly entrenched system is not easy but if we are to create a society that truly provides the best care and support then we must try. The first challenge is to put social care first, to completely and swiftly change the outdated mindset that currently exists.

Millions of people need social care services, not all get them funded but that does not mean they should be excluded from social care policy, more than a million people work in social care and how they perform and are managed has an impact on the lives of millions and the workforce must have effective policy in place to ensure high quality care and effective management. Billions of pounds are spent on social care every year and there must be proper leadership nationally to ensure that money is spent effectively for the benefit of those who use care and support services.

There is, undoubtedly, a need now to change the way we think about social care, a need now to radically change how social care policy is created and, probably, most importantly a need to place social care on top of, or alongside, other major areas of social policy which impact on the lives of social care users.

Guest Blog | Training Works Best in a Learning Culture

Guest Blog | Training Works Best in a Learning Culture for Learning Pool

Let’s be totally, brutally honest, Governments don’t want to tackle social care.

Let’s be totally, brutally honest, Governments don’t want to tackle social care.

They may want to be seen as dealing with social care but the reality is to tackle it properly will cost money and Ministers would rather spend that money on things that get them re-elected than on an area which, frankly, does little to ignite the public imagination.

There are, of course, many individual MPs who are intensely passionate about social care as the recent debate on dementia showed, many have personal experiences of dementia, ageing and social care and they bring at least some balance to the lack of real debate on tackling largely unanswered questions on the future of social care.

While social care may fail to ignite public imagination it does, frequently spark public indignation. Widely publicised cases of abuse or of people having to sell homes to pay for social care  lead the social care debate and, while the majority of those who receive social care services are satisfied with their care, it is the negatives that drive Government reaction to social care and influence policy making decisions.

This, unfortunately and detrimentally to social care, means that the reality of today’s society is ignored completely in favour of short term reaction.

The reality is people are living longer and because of that there are an increasing number of people who need or will need social care services as the get older. Ageing increases to probability of age related conditions in turn increasing the need for people needing support in their everyday lives. Whilst, rightly, people are encouraged and supported to remain at home as they age there also has to be a recognition this will not always be possible nor will it always be in the best interest of the person. So we also need to recognise and acknowledge the place of care homes in the social care system.

The perception of care homes is, perhaps, outdated. The image of a home for retired genteel folk is outdated and the reality is that those who do go into residential or nursing care do so at a much later age and those care providers are having to become increasingly specialised in dealing with age related conditions, such as dementia, incontinence and osteoporosis. Yet the need for such specialism, and the cost of it, goes largely unrecognised in Government policy.

Naturally not all care providers are perfect and there are certainly those who do not provide the necessary training in the specialisms required and those whose sole aim is profitability rather than care provision yet they can only exist in a culture that doesn’t focus on the reality of social care and policy that fails to meet this reality.

The ageing society also provides other challenges to social policy that Governments have failed to tackle. People with disabilities are also living longer and need services to meet the challenges of ageing. Many people with learning disabilities are unknown to social services and support during their life by their parents, but as they age, and their parents age or pass away, they are increasingly in need of social care services yet social policy has yet to recognise this demographic and appropriate services are in woefully short supply.

Not everyone who needs social care services is over the age of 65 and that needs to be equally recognised. For these individuals the issue of who pays for social care is unimportant and many of the health related ideas of integration are minimal compared with the need for integrated services in housing and employment.

If society is to provide the best possible social care to those who need it we need to recognise the changes to society and the increasing importance of social care to our society. We need to change how we think about social care and recognise that ageing comes to all of us and our own future is equally tied into social care policy as that of those who need social care services now.

Government, of whatever colour, must lead the change in thinking about social care, it must raise the debate for all who need social care services, no matter what age and it must find the money to meet the demands of social care now.

Front Line Social Care Health & Well-Being

Ergonomics, occupational health, employee well-being. Probably familiar phrases if you are employed in a large organisation, in fact those larger organisations will usually have people employed specifically for occupational health to ensure the well-being of their employees. This is often supplemented, particularly in public sector organisations, by union representatives with specific roles in promoting workplace well-being.

Smaller organisations, generally, do not have any of this and 80% of social care is provided by smaller organisations.

Naturally the principle focus of social care is on those who use services yet in order to deliver those services we have to rely on front line workers and, unfortunately, little attention is paid to ensuring their health and well-being in performing such a vitally important role.

We need a wider focus on those who actually provide care in order to improve the quality of care as well as the quality of life for the workers the nation depends on.

For example, much is made of the 15 minute visit rightly maligned by many as inadequate for those who need care and support services. Yet how often is the effect it has on care workers? Simply imagine the stress of having to complete a visit in such a limited time, or, maybe, think about the pressure of travelling between visits. I am sure everyone has been in a situation where traffic delays get us frustrated as we try to get to an appointment, what impact would that frustration have to a person who then has to rush through a 15 minute visit before heading out onto the road again to get to the next?

What is the impact on the health and well-being on those who daily support those who have challenging behaviours?  What is the impact on the health and well-being on those who daily support those at the end of their lives? What is the impact on the health and well-being of those who daily support those need intense physical support? And, importantly, how does this affect the quality of care delivery?

It is not rocket science to know that how we feel, both physically and mentally, impacts on the way we work, no matter what our job is yet for front line social care it will also impact on those who receive care services.

It is not unusual to hear about the work-place stress on social workers who are becoming increasingly over-loaded in their work. We hear about it because the majority of social workers work for public sector organisations where such things are monitored both by the organisation and unions. What hear little about is the workload and stress of front line care workers because most are employed by small employers with little union representation across the sector.

Whenever those who set policy for social care, national Government or Local Authority, speak there always seems to be an assumption that social care is a public sector service and that it operates in the same way as public sector bodies and that those who work in social care are the same as any other public sector workers. The truth is that the vast majority of social care workers are employed by small, private sector companies who do not have the same ability as larger companies to employ people to manage occupational health.

If we are to ensure the health and well-being of those who need social care services then we have to also ensure the health and well-being of those who deliver those care services. To do so we need Government to recognise that the thousands of small companies that provide care services need support to be able to do this.

Dilnot or Not Dilnot - The think tank question

At the start of the month there was a call from the think tank, Centre Forum, for Winter Fuel payments to be concentrated on those who receive pension credits in order to fund the reforms proposed by the Dilnot Commission, particularly those focused on capping the cost of care for individuals who have to contribute to their care costs.

This week another think tank, the Centre for Social Justice, have called for the Dilnot Commission proposals to be ignored stating, “Whilst the CSJ is not against the Dilnot proposals in principle, it insists this measure must come further down the Government’s priority list. Any new funding, says the CSJ, should be targeted at the poorest people in the current means tested system who have few or no assets. It adds that the Dilnot plans are the wrong priority at the wrong time.”

Naturally the question many will ask is who is right yet, perhaps, it would pay to look a little deeper.

Both think tanks describe themselves as independent organisations. The Centre Forum describes itself as liberal and there can be no doubt of its Lib Dem leanings, just a quick glimpse at its advisory board will tell you that. The Centre for Social Justice has a distinctly Conservative flavour, founded by Iain Duncan Smith and currently chaired by Mark Florman, a former senior deputy treasurer of the Conservative Party.

Obviously it could be entirely coincidental that the Centre for Social Justice raise the issue of the Dilnot proposals in the same month as Centre Forum, in which case we are faced with the equally daunting case of bewilderingly mixed messages being sent out by organisations with very close links to senior coalition Ministers.

So is Dilnot the solution for social care or not?

Perhaps surprisingly of the two messages it is the Centre for Social Justice who stress the current care crisis calling it a broken system stating “People delivering care services can think of much better ways to spend the £3.5billion that is about to be invested in the Dilnot proposals.” The CSJ focus on the elements of the care crisis that will not be settled with the capping of care cost, such as 15 minute home care visits and “Tackling the destructive underpayment from Councils to care homes which forces many providers to cut corners”.

Centre Forum on the other hand focused on paying for the Dilnot proposals and the particularly controversial idea of withdrawing the Winter Fuel Allowance as a universal benefit and calling for “ the "appropriate legislative levers" to be inserted into the draft care and support bill so that the Dilnot Commission's proposals on care financing can be delivered in full by the end of this parliament.”

Certainly, as I have argued before, the Dilnot Commission was limited in its scope, focusing almost entirely on who pays for care and bypassing the crucial question of how much does quality care actually cost. It also has some short comings in terms of the reality of imposing a cap (see The Social Care Capping Debate MUST be Wider) and is unclear on how some of the proposals will impact on younger adults who need care and support services (Isolated and Underfunded). Yet it remains an important part of the debate.

 

The danger is that with two think tanks with close connections to the coalition partners calling for different approaches to social care that the debate with Government will become protracted to the extent we see nothing happening in this Parliament and social care left in the wilderness for another few years until the next Government either acts or, as previous Governments have done, prevaricates over social care to the detriment of the millions who need or provide care services.

The Centre Forum Report 

The Centre for Social Justice Press Release

Isolated and Under Funded

How would you feel if you were unable to wash, dress and feed yourself without support yet that support was denied to you, you would be outraged, wouldn’t you, and certainly agree there was a crisis in the care system.

Talk of a crisis in care often evokes imagery of older people who need care and support as they age, of coping with life as the rigours of life take their toll on the body and mind. Yet new research, published today by five major charities, shows the crisis in care is much wider and that the needs of younger, disabled people are not being met.

The report, ‘The Other Care Crisis’ highlights the fact that nearly 40% of disabled people do not get sufficient support in their daily lives with such things as washing, dressing and eating. Also highlighted is the £1.2 million funding gap in social care support for the disabled under the age of 64 with services being withdrawn because of a lack of funding and the criteria for being entitled for support becoming ever tighter.

It does not stop there, the report estimates that more than 100,000 people will be affected by proposed Government reforms.

It is not just about the clinical financial practicalities of providing care and support, it is about individuals. Being unable to wash without support is bad enough yet the impact on self-esteem is immeasurable, ask yourself now, how do you feel when you are dirty? Being unable to feed yourself without support has much greater impact on health and well-being and while Ministers talk of ‘prevention’ to reduce hospital admissions etc it seems, from this report, that the rhetoric remains more important the any real action.

The most shocking revelation in the report was nearly half of those who were interviewed in the study said the lack of support they receive meant they were unable to take part in community life in a way they wanted to. Once again imagine yourself in that situation, how would it feel to be socially isolated and unable to take part in the activities you enjoyed, the opportunities to talk and engage with friends. Picture the impact such social isolation would have on your mental well-being and the general frustration with life that would start to eat away at you.

In fact just over half of those interviewed for the report stated they felt anxious, isolated or experienced declining mental health as a result of services being cut.

It is time Government, and the wider discourse of social care, changed. When there is talk of integrated services it often basically means integration between health and social care yet the needs of younger disabled peoples goes far beyond that. There needs to be integration with housing services, integration with employment services and integration with benefit services. The debate on social care must encompass all those who need help and support, including those under the age of 64.

There are many great schemes that have been developed over recent years, such as direct payments, but these depend on individuals actually meeting eligibility criteria and as this becomes tighter less and less people will actually be entitled (although Governments will claim success as the percentages will be higher because less people are entitled!).

Today’s report has to be commended for highlighting the care crisis does not just apply to older people nor does its solution solely rest on whether or not property needs to be sold to pay for care. For those under the age of 64 who have life-long conditions the current system is failing many of them.

Yes we live in austere times and economic sacrifices have to be made but that does not mean we should penalise those in society who need societies support to live their lives in a way most of us take for granted.

The report “The Other Care Crisis” has been produced by Scope, Mencap, National Autistic Society, Sense & Leonard Cheshire Disability and is available at

http://www.scope.org.uk/sites/default/files/The_Other_Care_Crisis.pdf