Just over two years ago, I was at the helm of a well respected organisation for social care workers as it finally ran out of funds. It had existed at the behest of the same social care workers themselves for 63 years and had always had as it central tenet, the promotion of good practice in social care.
That ‘user’ control - in this case the workers themselves being the ‘users’ - and the taking of responsibility for good practice on themselves by the workers was what made it unique. For most of its existence it produced good practice information written almost wholly by people who were practitioners and many of its documents provided the foundation for best practice models that continue to exist today. We did discover that whilst law and systems changed and we needed to amend documents to accommodate them, the values underpinning good practice did not change.
There has always been too little academic research in social care on which to build a firm foundation that leads to a professional body of knowledge. One only has to look at the level of research grants in Health with whom Social Care is still set to work much more closely. The journal has appreciated the work of Universities in particular who have recognised the vast size of the social care sector and its desperate need for evidence to support the definition of good practice.
The rapid fragmentation of the sector starting in the 1980's and moving from a largely public sector provision, like the NHS but in the hands of local councils, has evolved into a massive private provision with almost fifty thousand companies delivering care to our most vulnerable (and loved?) people. The large number hides the fact that enormous care providers occupy the lion's share. Local authorities still worry about the risk of a failure like the recent Southern Cross collapse where they have less and less in the way of ability to respond.
The enormous companies distract from the plethora of small providers of all sorts of shades of capability and quality, many of whom are the only ones who will accept the diminishing fee rate offered by local authorities to provide care.
Our articles in this issue all deal with the aspirational aspects of the health services, local authorities and the government and I commend them to you. Personal Budgets for example, have become the device of choice to provide care in many local authorities, stripping down the involvement of Social Workers and the costs to local authoritiesFootnote1. Their ability to manage, maintain and monitor these budgets with more than three hundred thousand people already receiving Direct Payments and the number set to rise with the advent of the Personal Budget solution is doubtful.
At a time of reduced spending, the BBC reported a 20% reduction in adult social care spending over the last decade, the aspiration may be beyond the reach of CouncilsFootnote2. The preventative work described by Miller et alFootnote3 is a creative response to the financial pressure, trying to get further up the process chain to see if higher spending later can be avoided by preventative spending now. It makes sense and where it has been done there have been positive results. However, it is a brave Council that turns resources away from a front line that is creaking today for something that promises results tomorrow. That is not to say that such innovations are not being attempted - the ‘Think Local: Act Personal’ (TLAP) initiative for example. It is just that there is no coherent overarching evidence base for the best direction of travel, so we are committed to a ‘thousand flowers blooming’ in a random spread of responses. It is also unclear how we will learn from what is best, most robust and successful with inadequate research investment to projects as they run.
The Better Care Fund promised an easing of pressure by transferring some health spending to local authority control but that seems to have arrived, if indeed it has, with spending commitments already attached to it, only to be released as the current recipient ceases to use it. A similar effect was experienced with the funding of private residential care in 1992 with the funding moving from the then DHSS (now DWP) to local authorities but already fully committed to the people being cared for.
As I write, we are about one hundred days away for the general election and Europe is reeling at the impact of the election outcome in Greece where people have voted strongly to indicate they have had enough of austerity. We can easily criticise other countries for what they do or do not do but it does seem to be the case that the world is now run on condition that the books balance, regardless of the people and that seems the wrong way round to me.
All systems should be devoted to the health and welfare of the human being. The care of someone in old age should be an unconditional value, not something that will inevitably be based on how much cash they can pull together for an annuity.
One of the impacts of the Coalition on the UK has been to divide groups and control them. During this period of government, we have targeted the bankers, tax avoiders, benefits scroungers, well off older people, young people not in education, employment or training (lovingly called NEETS), hard working families, terrorists, immigrants - who attract all sorts of different sub titles, depending who is speaking, apprentices, zero hour contract workers, three generation households, student loan beneficiaries - I could go on.
This social construct of creating an ‘other’ to blame for the shortcomings we believe we are experiencing has become a state of the art activity. All of them are people and in most cases, all of us have a link with one or another, or some of them, that would make us baulk at being too critical as the example may be too close to home. In many cases, there is a counter story that is positive and any polarised reaction will help no one. We are a community and need to pull in those who think they don't need us as they are so rich and those who think we don't want them, and everyone has an obligation as a member of the community to take part in that effort.
The need to pay the bills and balance the books was grudgingly accepted by most people on the basis that most of us have a personal recognition of debt and how undesirable it is for our personal, social and psychological welfare. But of course national finance doesn't look like our purse or bank account and even when Ministers are speaking about fiscal performance, it is not always clear what they are actually saying and what it actually means. In a recent review of Winston Churchill's life at the fiftieth anniversary of his death, it was noted that during a period that he was Chancellor of the Exchequer and responsible for the nation's finances, he was teetering on the edge of personal bankruptcy and was totally unable to control his own spending.
Despite the Social Care sector being the most positive source of new employment opportunities in the United Kingdom throughout the recession that began in 2008 with steady growth in job opportunities, though many are of questionable quality with zero hours, it remains of marginal interest to people in power despite being readily used as part on the improving level of unemployment. It is a vast workforce and with those hidden in the Direct Payments system is likely to exceed two million (Skills for Care NMDS data)
The longer life of older people across the world should be a celebration of better health, diet and lifestyle. Instead we obsess about the minority but still a large number who, having paid into the system all of their life, now call on its services. Promises of financial caps to begin next year to allay the fear of older people as they approach the point of needing help, hide the fact that this will only cover ‘care’ costs and the cap is more than double that recommended by Andrew Dilnot in any case. The living costs or ‘hotel’ costs will be separate and will still need to be met. Some of the bigger private providers have already started to show in their charges where the difference lies.
There is a clear unwillingness to plan ahead that starts with young people who should contribute to a pension as soon as they start work. In our early twenties, we are short of money, can't imagine getting old and are not interested anyway. Recognition of that behaviour was the reason we set up a state pension scheme and why politicians should have defended its existence and managed it so that it was resourced (by us) to deliver a proper pension to people as they need it.
Active older people are the same. My own neighbours, eighty nine and eighty eight respectively, up to a couple of years ago had a motor cruiser, drove a small car, maintained a busy social life and were fully independent. In the last year the husband started to have memory problems whilst still being physically able but his wife remained sharp though with reduced mobility. All was good until in November she was admitted to hospital with fluid on her lungs. She got out just after Christmas only to die in her sleep, leaving him unable to live at home - and there was no plan!
The emerging lesson for us all is that we need to have arrangements in place so that those who find themselves trying to sort out what they should do, should at least have our wish list and whatever resources we can muster to pay for it. In an individualised and personalised world, we have won the right to take responsibility for ourselves.
I have been suggesting to Council colleagues for years that adults with learning disabilities being cared for at home by very ageing parents present a much bigger financial risk than many of the older people about whom they worried endlessly. I suggested every case file should have a ‘Plan B’ in case the parent dies in the night.
It is clear that we are at a stage that we should all have a ‘plan B’ that helps those around us to do what we would most want should the need arise. The first stage that will lead us to that wisdom and consequent willingness to plan. will be an acknowledgement that despite the gym, super diets and long life - we are all going to die!
Notes
1 Council-managed personal budgets for older people: Improving choice through market development and brokerage? Kate Baxter and Parvaneh Rabiee, this issue.
2 BBC Online 28 January 2015 from a survey by Independent Age
3 Evidence, insight, or intuition? Investment decisions in the commissioning of prevention services for older people Robin Miller, Iestyn Williams, Kerry Allen, Jon Glasby, this issue.