I was reminded by The Guardian yesterday that there is a policy on prosecuting crimes against older people and this reminds us of the range of crimes that might affect older people (including most palliative care patients):

a) criminal abuse or neglect of older people where there is a relationship and an expectation of trust (for example, by family members, friends, paid workers, volunteers, etc). This includes: domestic violence and where older people are targeted because they are either perceived or known to lack mental capacity; or criminal abuse or neglect of older people living either temporarily or permanently in regulated or un-regulated care settings;
b) crimes which are specifically targeted at older people because they are perceived as vulnerable or potentially easy to steal from (for example, financial abuse or theft, muggings of older people, doorstep theft, distraction burglary or rogue traders);7
c) crimes against older people which are not initially related to their age but may later become so (for example, a burglary where the burglar does not know the age of the householder but later exploits the situation on discovering that the householder is an older person); and
d) crimes against older people which are in part, or wholly motivated by hostility based on age, or perceived age, (for example, an assault, harassment or antisocial behaviour involving derogatory statements associated with the victim’s age).
http://www.cps.gov.uk/publications/docs/caop_policy.pdf (pp 11-12)

There are also extensive guidelines about how to handle such cases. I see also that there is similar guidance on hate crimes against disabled people. Social workers and others involved should know about these: I’m certainly going to ad them to my training on abuse of vulnerable adults.

The CPS policies: http://www.cps.gov.uk/publications/prosecution/index.html

Pics of the rebuilding at St Christopher’s, now under way, in solidarity with all colleagues working through a difficult time, to make things better in the future:
While paths are concrete for the work, the gardens are still open

Today’s explosion from the wards is about a PCT that does its own assessments. There’s a one-month wait, which is one of the reasons why the government has an arrangement for fast-track for palliative care patients, who will probably die before they get assessed at the usual pace. This slow pace is not altogether wrong, because many continuing care assessments will apply for years and are for people with long-term conditions who can accept a slower pace of assessment. In this case, we have a patient in the hospice that the PCT have decided is not going to die soon enough for fast-track – the Greater London continuing care people are trying to enforce a strict ‘we only fast-track if they’re going home to die within the next 48 hours’. This is completely contrary to the national framework document, which says:

45. Occasionally, individuals with a rapidly deteriorating condition, which may be entering a terminal phase, will require “fast-tracking” for immediate provision of NHS Continuing Healthcare.

This does not say imminently dying in 48 hours. In the meantime, social services will pay if she can’t, so refer it to them. However, the social services line is that they won’t consider for funding unless the continuing care assessment has been made, not unreasonably, since we were told that people should be assessed for continuing care first and presumably they were told this too. Round the circle again, and in the meantime the patient is blocking a bed in the hospice that someone else might need, to which the delayed discharge legislation does not apply, and it’s not soical serviecs fault anyway.

Pics of the rebuilding at St Christopher’s, now under way, in solidarity with all colleagues working through a difficult time, to make things better in the future:
Our lovely gravel paths have been made concrete for heavy machinery

An interesting point in a SOLACE booklet making the point that involving patients or the public who only occasionally use a service is unlikely to succeed, they just want it when they want it. Tapping into people who have a long-term condition and are focused on what is needed to help with that, on the other hand, are more likely to have the expertise and experience to provide useful insights for professionals. Of course, Smallwood, one of the authors, would argue that wouldn’t he, he runs a long-term conditions organisations (Diabetes UK). I agree with this and think that we need to be a lot more thoughtful about who we involve with what, and make their involvement really relevant.

Corrigan, P. and Smallwood, D (2008) how the public is on the side of NHS change. In Burton, M. (ed.)(2008) Innovation through People. London: Guardian Public: 34-6.

Pics of the rebuilding at St Christopher’s, now under way, in solidarity with all colleagues working through a difficult time, to make things better in the future:
No way through

Summoned to the ward managers’ meeting to discuss continuing care applications again. This time one of our London PCTs has rejected a form as the wrong one, and when it faxed the right one it was the same form but with their logo on it.

Another wheeze, which the Greater London continuing care leads have apparently signed up to, is that only people being sent home to die within the next 48 hours should be allowed an assessment on the fast track form (in Greater London 7 pages, national 1 page; as opposed to the full glory of the 27 pages of the usual Greater London ‘delay by assessment’ form). This is a serious diminution of the quality of care for palliative care patients. The law has not changed, but under the previous system, virtually all palliative care patients (ie people who are dying) received the predecessor to fast track. It is also directly contrary to the National Framework document, which says:

45. Occasionally, individuals with a rapidly deteriorating condition, which may be entering a terminal phase, will require “fast-tracking” for immediate provision of NHS Continuing Healthcare because they need an urgent package of care. In this case, the “Fast Track Pathway” tool may be used by a senior clinician such as a ward sister, consultant or a GP to outline the reasons for the fast-tracking decision. This may be supported by a prognosis if available, but strict time limits are not relevant for end-of life cases and should not be imposed: it is the responsibility of the assessor to make a decision based on the relevant facts of the case. If possible and appropriate, the initial fast-tracking decision should be followed by a full assessment of need. Careful decision making is essential, to avoid undue distress that might result from a person moving in and out of NHS Continuing Healthcare eligibility within a very short period of time.

Where does this say ‘imminently dying’ or ‘48 hours’? Does it not say no time limits should be applied? Does it not say ‘rapidly deteriorating’ and ‘may be entering a terminal phase’? Fortunately, most of our continuing care people are not following this obnoxious policy. I can only advise relatives to appeal, and if necessary go to the Ombudsman or write to their MP.

The full Framework document:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_076288

To see my previous experiences of continuing care, click the link at the head of the blog.

Pics of the rebuilding at St Christopher’s, now under way, in solidarity with all colleagues working through a difficult time, to make things better in the future:
Revealed

The government published its welfare reform public consultation; they’re calling it a green paper as well, presumably that means the same thing. It is called: No one written off: reforming welfare to reward responsibility. This follows the government approach to welfare, which is increasingly communitarian, that is, rights go with responsibility; you don’t get anything unless you give something. In this case, you don’t get pensions or social security unless you work for them. This is hitched up to a quotation from Beveridge, the man who wrote the original green paper during the war (except that they called it a report then) on the welfare state. He said government and the individual should share responsibility for social security. While this is true, we have always understood this to mean that the government would be there to fall back on if you landed in difficulty. Both medical and social ethics say you should be entitled to the means of life because you’re a human being, we’re all human beings and we’re all in this world together.

Why is this important for palliative care? Social workers know that feeling secure in your home and a reasonable income, no matter what disaster may befall is an important part of being able to struggle on against adversity. The signs for the health service are there. The government wants to sweep up government funding streams together, so that for disabled people social care, housing support, employment support, equipment and adaptations to your house are all connected to one another. This sounds very sensible and joined up, until you wonder what happens if, say, the employment support people cannot make their objective of getting you into work because you are feeling insecure about your health and the social care provided to your sick wife. I just wonder whether failure to keep employed is going to lead to all your help being insecure, and what this will mean to families trying to struggle on with multiple problems, including a sick or dying family member. I can just imagine some private sector employment ‘adviser’ with a target backed up with financial penalties for non achievement, saying: ‘So your wife is dying: what’s that to do with you getting back to work?’

As it is, the idea to make all funding streams connect up is fine: but what if the people managing the funding streams don’t agree with each other? And it is said that they are going to experiment with NHS funding streams to connect with that. So perhaps in future, your wife will not get her continuing care support to go home, if it means you are going to stay off work to help her. At the very least, I would want to hear about some very firm legislation about people’s rights not being affected by how their families behave. And I’d want to see how much consultation is going to be needed between these different funding streams before they are all coordinated. Otherwise, we’ll get massive six-monthly meetings taking a year to make decisions, or ‘we’re not going to help you because they’ve decided they’re not going to give you the benefit they manage,’ Don’t tell me it can’t happen, my daily penance is continuing care.

Department of Work and Pensions (2008) No one written off: reforming welfare to reward responsibility: Public Consultation. (Cm 7363) London: TSO http://www.dwp.gov.uk/welfarereform/noonewrittenoff/noonewrittenoff-complete.pdf

I unusually see a copy of the Municipal Journal (for 10th July 2008) about Hazel Blears’s ‘people power’ white paper. The front page highlights from it that the MJ can dredge up include, for the ‘Third Sector’ cutting barriers to councils commissioning faith groups (that is finding ways of giving power to not very many people in minority groups), grassroots grants (that is small grants for organisations that don’t have the capacity to do very much) and involving the third sector in local management schemes. Are hospices involved in local strategic partnerships? Should they be? According to an article inside, by the authoritative George Jones and John Stewart, there are going to be sustainable community strategies. I think hospices ought to get themselves involved in this sort of thing, which often seems to be the province of planning in deprived urban communities. All communities, but particularly deprived urban communities, are awful at sustaining help to bereaved and dying people. Its still a real syndrome of crossing to the other side. So I’d like to see sustainable communities with a plan for how they’re going to increase the competence of people to respond to dying and bereaved people in their midst.
Jones, G. and Stewart, J. (2008) The democracy of partnerships. Municipal Journal. 10th July 2008: 24-5.

Pics of the rebuilding at St Christopher’s, now under way, in solidarity with all colleagues working through a difficult time, to make things better in the future:
New routes

Good for them. Community Care this week focuses on the evaluation of the social work degree, whose first graduates are coming off the assembly lines in greater numbers. CC focuses on how the report has come out against splitting the social work degree into children and adults work, as some directors of children services are advocating. The child care mafia at work claiming that work with children is oh so much more important than anything else. When is the Department of Health going to stand up and say actually older people and mentally ill people and disabled people and people with learning disabilities are just as important and need skilled work just as much? And they’re also in families with children in, so this nonsense about only some social workers needing skill in considering children’s needs should be firmly knocked on the head. This would set us back 40 years.

The social work degree is not just a qualification for the limited interest (and limited practices) of local authority social work jobs. The government has already interfered far too much in pursuit of its political interests in producing a degree that only qualifies people for its local authority workforce, rather than for the more extensive social work that a lot of Europe and north America has. If we’re ever to maintain a decent quality of social work in the UK, we need to increase the range of social work skills and specialisms.

In particular, minority specialisms like palliative care and end of life social work need a look in; see what I said about the GSCC conference, where it was clear that GSCC, government poodle as ever, is only bothering with adult and child care issues, and not the huge range of other social work skills that are required. The Report has lots of good things in it, and this issue in teresting though it is, actually does not have high profile in the whole thing.

Evaluation of Social Work Degree Qualification in England Team (2008) Evaluation of the New Social Work Degree Qualification in England. Volume 1: Findings, London: King’s College London, Social Care Workforce Research Unit.

Evaluation at (from the University of Glasgow, the Social Work Workforce Unit at King’s College London and Sharpe research):

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086079

To a conference on transforming social care, with a speech by Ivan Lewis, the Minister for Care Services (known to some as Ivan Otherinitiativehere, and you could tell why from the speech, the middle of which was a bit list-like; he needs a less drone-like speechwriter, but he performed it almost as a human being considering what he was coping with).

The overall conference message was that if you look at the plans for social care, you can see the future of the NHS here. In particular, Lord Darzi’s plan for ‘personal health budgets’ connected with something I haven’t seen referred to in quite this way before, that is ‘notional independent budgets’ for social care service users. Apparently, they have recognised that not everybody wants to organise their own care, so they get a notional sum of money allocated to them, which the care manager then allocates to services. Then, if it’s not enough, you know what you’ve got from the state, so you can add to it yourself if you like (having of course in the case of social care, had the amount you had to pay according to the means test taken away first). This fits with the idea that people would be told in advance what the minimum they would get from the state would be for their care, and then they could add to it if they wanted something better or nicer. That’s public choice for you.

A very lively contribution from Imelda (I want to say Marcos or Staunton but actually) Redmond, the very bouncy but sensible Chief Executive of Carers UK (just the sort of person you would want caring for you, I thought). She was asked how effective incentivising GPs to set up a carers’ register of people caring for their patients and didn’t know. Apparently GPs can get points towards their salary for keeping a register of carers they are responsible for. One member of the audience said it hadn’t worked so well in his area, because some GPs who had done it said that the information was patient-confidential, so they couldn’t tell anyone else who was on it. So much for the hope that our brave primary care physicians would cooperate with other professionals and agencies in identifying people who were at risk or needed extra services.

And I got another addition to my register of ludicrous Department of Health job titles: Jeff Jerome has (just) become Director of Social Care Modernisation, but then I can talk, having once been a Director of Psycho-social and Spiritual Care. I was called to see one mentally ill person in reception once, and she looked at my badge and said: ‘psycho-social and spiritual care – I need some of that.’ At least she could read it, but my problem always was that I was never very sure what it was, except a convenient administrative division.

Pics of the rebuilding at St Christopher’s, now under way, in solidarity with all colleagues working through a difficult time, to make things better in the future:
The day centre in the sky

A supplement in Guardian Public (July 2008) makes a distinction between service innovation (which is ‘sluggish’) and clinical and technical innovation which is not. It seems this is from a seminar of managers and people from business schools telling themselves that these professionals just don’t get what they’re trying to do.

In another article, the BMA is said to believe that the government’s central control is the problem: ‘Let the professions lead, hand in hand with the public, and you’ll see the progress our patients want.’ (Clarke-Jone, J. (2009) At the sharp end of change. Guardian Public July 2008: Supplement: How to embed innovation in healthcare. 6-7. Probably the BMA means the medical profession, possibly with a curtsey to nurses; I wonder how they’d feel about some social aims to remove health inequalities in there.

The problem is that good management is needed, but it needs to be done well, and what professionals fear is that constant change is destabilising and prevents them from getting on with the day to day job. Any organisation has this discontinuity between the managers who need to keep the show on the road and the managers who need to look to the long-term. Even doctors are managers, most of them are much more conscientious managers that people who are managers that only manage are, because they have to do a meticulous job and carry the can if they don’t. But doing a meticulous job for the people who are here now requires a different mind set than people who are pushing for the next concept. They ought to have a different mind set, we should accept it and build a management system that respects both.

An article about the registration starting soon of domiciliary care staff (carers contracted by Adult Social Care departments to me and you), claims that GSCC is not a paper tiger – well, it’s a bit too soon to say really – but how much more work they’ll have to do when all carers are registered.

One of the difficulties not mentioned is how personal the relationship becomes between some regular carers and their care-receiver; it really is up close and personal, and bureaucratising it is not going to be easy and might interfere with the quality of many good relationships. It’s not so obvious to care-receivers and families that these people are professionals as it is with social workers, nurses and so on; the essence of it is the personal care. This has been widely expressed around the issue of personal assistants employed through direct budgets, whose employers have been keen to say ‘no, thanks’ to registration, but applies to this much wider group of carers who are being taken onto a register with very little forethought.
I wonder who’s paying for the very glossy, and a bit insubstantial, SCLondon magazine? And why? I think we should be told.

White, M. (2008) Not a paper tiger. SCLondon 1(5): June 2005: 8-10.

Pics of the rebuilding at St Christopher’s, now under way, in solidarity with all colleagues working through a difficult time, to make things better in the future:
Cones alone