The next steps review (the Darzi Report to you and me) was the Department of Health’s plans for the future, and they’ve just published a document about what it means for the third (voluntary) sector.

See it at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091821

One of the things that’s notable about this is the intention to put ‘frontline staff in control’. This means making it possible to set up local community trusts and other mechanisms for NHS staff to opt out from the NHS and run their services with the same freedoms in the community as foundation trusts have for hospitals (ie no responsibility for anything but their own financial interests).

There’s a great deal of emphasis on social enterprise; an important aim seems to be to encourage NHS staff to set up social enterprises to run NHS services, and they can keep NHS pensions and conditions of service (at whose expense? – their social enterprise? In which case it’s not going to happen). They can only do this, it seems, if they work entirely for the NHS.

This is similar to the idea that was mooted to allow social workers to set up general practices and take on child protection responsibilities from local authorities – I think they might have gone a bit cold on that one since Baby P.

The document says very little, though, about voluntary organisations such as hospices. Do they have to convert themselves to social enterprises and take on NHS staff, doing only NHS work in order to gain from the next steps review? The main aim seems to be to get people to set up new organisations to provide preventive and wellbeing services. This preventive approach is an important priority; the NHS has for too long been an illness service. What about the voluntary organisations that are already there, though? It’s not really much of a plan for them, and it’s very much a plan for advancing the government’s policy by shifting provision outside the inflexibilities of the NHS. But the whole priniple of having a voluntary sector is that it makes its own decisions about what to provide and how to do it; that’s why it’s voluntary.

The Department of Health has published a ‘toolkit’ (that is, a load of questions you can ask in a survey) that enables you to gauge patients’ experiences in hospitals, and compare them with how it was in other places.

Go to http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091660 to see the details.

The five areas that their various questions looked at was

- how easy it was to access the service, and how they felt about the wait, if there was one

- whether they felt the care was safe, high quality and coordinated

- the extent to which they got good information and worthwhile choice

- whether staff went out of their way to build good relationships with them

- whether it was a clean, comfortable and friendly place to be.

There seems to be a lot of sense in most of this. Well worth thinking what your patients might say in a hospice. From the social work point of view, it doesn’t focus too well on how it was for the vistors and relatives. For example, when I was last in hospital, could my wife find somewhere to park to visit me? Only at outrageous expense. This is quite wrong. When she’d seen me tucked up in bed, after midnight, could she get out of the building? Wandering round looking for an unlocked door, she met a policeman doing the same.

Satisfaction is usually about simple things, not how good the nurses and doctors are.

Presumably following up on the fact that the whole world has found out that there are serious case reviews in child protection, a LibDem MP, Paul Burstow, asked in Parliament yesterday what the Department of Health does about serious case reviews in cases where older people are affected. It doesn’t apparently, it’s over to the locals (at least it will be until one hits the headlines, because the same was true for children until Baby P came along). However, the present consultation on the ‘No Secrets’ guidance did lead to research being commissioned from the King’s College London team that does all the research on safeguarding adults it seems and it’s due out soon.

But will it have the same impact as concern about abuse of children? It never has so far; why are we so worried about abuse of children and not of abuse of older people?

To look at the consultation: http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_089098; I posted this in a comment on a comment recently, but I thought that perhaps people don’t always read the comments from people correcting or reproving me and this is important, so I mention it again.

An MP (John McDonnell) asked yesterday in Parliament what guidance is given to Jobcentre Plus staff in conducting their interviews: I looked at the answer because social workers often deal with this set-up, it is the organisation that helps (some would say harries) people in finding new jobs, for example when they are disabled or a carer. Some would also say that it doesn’t really have the resources to do the job of helping people who will struggle to find a job for whatever reason, particularly in these days of credit crunch. Perhaps the MP had the experience that the interviews were either a bit perfunctory for the purpose or the opposite.

Either way, here is the answer, from the acting chief executive ( I don’t know why he or she is acting, but it may be because they’re moving to be head of the college for training civil servants in giving non-answers to Parliamentary questions):

Jobcentre Plus conducts a wide range of different interviews to meet both business and customer needs. Guidance to staff outlines the purpose and content of each interview type and the average length of time these should take to complete. Each interview takes into account the time required to undertake activities that must be covered in every interview and those that are only required as and when individual customer circumstances dictate.

If you have been interested in the National Audit Office Report on end of life care, you may be pleased to know that questions were asked in Parliament yesterday about their building refurbishments: apparently they have asbestos problems. Sounds familiar, eh? Nice to know that the auditors have experience just like ours.

The NAO report on end of life care at: http://www.nao.org.uk/pn/07-08/07081043.htm

…and my comments on 1st December 2008.

Why would an adult hospice like St Chrisopher’s, have a schools project? You can find out by contacting them for a report, which has just landed in my in-basket. Go to http://www.stchristophers.org.uk/ and click on ‘Contact us’.

In his introduction, Professor Mike Richards, the cancer tsar (I bet he hates being called that and I see he’s now called the ‘national director for cancer and end of life care’), explains that not talking about death and dying means that people are unnecessarily frightened of it. Who better, then, to make sure they are aware of and confident about dealing with death than young people?

The Report contains a dvd and has detailed guidance about how to set up a project, and an interesting account of how it worked for one school, with lots of quotations from the people involved, including the children and the patients they met at the hospice.

One of the reasons why I’m often a bit critical of a marketing approach to social care and palliative care (you might have noticed this in this blog) is that I think real understanding and support for something as complex as either social care or palliative care, requires a genuine involvement in it. This doesn’t mean you have to work or volunteer in it, but it does mean a real human contact with it, which a glossy handout or press release doesn’t give you. And what this report shows is how hard and creatively you have to work to really get people who are a bit frightened, or just unknowing, to engage enough to really understand.

It’s not on the EAPC (European Association for Palliative Care) website yet (but you can go there anyway, it’s got lots of stuff: http://www.eapcnet.org/) but they’ve set up a family carers task force. Sheila Payne (no relation) who is chairing the initial working party asks me to let you know about it; this is her document:

More about the Family Carers taskforce

How is a working party different from a task force? I was once on a spearhead group, they haven’t got one of those. But would they want one?

An adjournment debate on the plight of Naomi House Children’s Hospice, which has been caught up in the collapse the the Icelandic banking system, incorporated this exchange:
Mr Mark Oaten: The point that I wish to emphasise to the Exchequer Secretary is the different nature of this organisation. It is not like some of the other charities that have lost money in Icelandic banks, such as local authorities or many of the businesses affected. It is unique in that it provides a service that many people would argue is one that the Government should provide. Many of us were surprised to find, when we came to Parliament, that hospices were not funded by the NHS. If they did not exist, somebody—the Government, we assume—would have to provide such care for children in such awful circumstances.
Mr Oliver Letwin: Does the hon. Gentleman agree that that is particularly the case with children’s hospices? Adult hospices in our constituencies receive significantly more support from the NHS than children’s hospices.
Mr Oaten: The right hon. Gentleman is right. It has always been very peculiar that children’s hospices have been treated in that way, but that is what has happened, and charities such as Naomi House have had to take on a responsibility that should be taken on by the Government…

One does wonder about the awareness of these senior MPs. No doubt it’s a slip of the tongue when Mark Oaten says local authorities and businesses are charities, but let’s be clear most charities are providing services that many people would say ought to be the responsibility of government. Naomi House is not special in this respect, and neither are all the other hospices who could make the same point. I think we really have to move on to say that there are different sectors here who all play a role together in providing services.

It is useful to remind ministers that the NHS would have to spend a lot more money on palliative care if it did not have a large voluntary sector doing the job for it. This is not a matter for commenting gently that that’s the way it is, but asking oneself seriously is this the right way? There are advantages in some things being in the voluntary sector. If it is the right way, what are the right relationships between the different sectors and government?

In a way, this debate is another example of sentimentalism about palliative care. Children with life-threatening illnesses have very important needs, but they are very different from the needs of adults with life-threatening illnesses, and therefore children’s hospices have different ways of doing their work. MPs should be thinking clearly about what is involved, and thinking about the important roles that all other voluntary organisations perform in society and making some judgements about how it should be organised in relation to the state.

See the debate at: http://www.publications.parliament.uk/pa/cm200809/cmhansrd/cm081204/debtext/81204-0019.htm

I’ve learned a new policy word this week: conditionality has come to the fore. This is the principle that you shouldn’t get things (eg social security benefits) from the government without doing something in return. This week there have been a lot of announcements of plans for people caring for others (eg lone parents) to make efforts towards work. This is evidently a very acceptable line for politicians with constituents who don’t like paying taxes for other people to laze around on social security; it’s such a generous system after all, that we’d all do it if we could (I feel the need to explain that this comment is ironic, in case anyone doubts it).

Actually, the proposals are more reasonable than that and also will be introduced on a timetable which stretches quite a way into the future; longer, we hope, than the employment doldrums caused by the recession.

However, our experience at St Christopher’s is that, when operators of schemes like this get the bit between the teeth, they can ride roughshod over the need and wish to care for a dying relative that many people have. Our social work and welfare staff have at times had to lean quite heavily on Department of Work and Pensions staff to acknowledge that it’s perfectly reasonable for people to stop work to care for their dying relatives. And I’m anxious about the prospect of financially incentivised private companies putting their earnings before their human feelings. We need to keep an eye on this.

It’s all based on a review by Professor Paul Gregg, by the way: you can see it at: http://www.dwp.gov.uk/welfarereform/realisingpotential.pdf

Gregg, P. (2008) Realising Potential: A Vision for Personalised Conditionality and Support. London: TSO.

Quite a series of sensible comments in the Lords on Tuesday when Baronesses Greengross and Pitkeighley pressed the government on legislation on abuse of older people. They linked this to the efforts to think again about child protection after the Baby P and other recent cases. However, Baroness Thornton, replying, said: ‘…there are some profound and quite complex differences between the issues surrounding adult protection and children. For example, it is neither possible nor appropriate to scoop up an adult and place them in a care system as one would wish a child in jeopardy to be’.

Hmmm…we ought to think about that. Are we not prepared to act assertively to protect older people, with the same degree of concern that we attach to children? Yes, they are autonomous adults, but our experience at St Christopher’s is that when they complain about abuse, they mostly really do want something done about it. And the policy with domestic violence is not that the abused person is ‘scooped up’, but that the abuser is removed. It ought to be the same with abusers of older people. And is ‘scooping up’ children and placing them in a care system quite what we do with children? Infants possibly, and even with them there is a lot of evidence that scooping is not good for their future developmnet. Many children have their own views about how they want to be protected. I think there is much more that could and should be done to protect older people and the excuse that you can’t act decisively is just that: an excuse.

See the debate at: http://www.publications.parliament.uk/pa/ld200809/ldhansrd/text/81209-0001.htm#08120935000428