First, two of the parties in government in particular nations of the UK.

Of those I have not previously looked at, the DUP (the Democratic Unionists in Northern Ireland) have a quite detailed manifesto compared with many others. It wins out on palliative care, among all the manifestos I have seen:

The World Health Organisation recognizes that palliative care incorporates physical, psychological and spiritual needs and it is important that all elements are properly resourced.Three quarters of people indicate that they would prefer to die at home, and this must be respected as services are commissioned.Those in receipt of such care should be informed about benefits available to them and given sound advice around finance and other personal matters as they plan for the end of their life. (p 45)

Can’t say fairer or more thoughtful than that. Then, their final objective on health:

• greater delivery of end of life care in primary and community settings rather   than secondary care (p 32)

Then, mentions of social care:

Opportunities should be freed up for charities and other providers with a proven track record to deliver services.The third sector has much to offer
in social care provision in areas such as mental health,dementia,learning
disability and acquired brain injury. (p 29)

The recommendations of the Bamford Review of Mental Health should be implemented. Approximately 24,000 people currently suffer dementia in Northern Ireland, and this figure is expected to climb to 50,000 by 2051. Health and social care costs for dementia of £200 million will double within twenty years.We need to be well-equipped to treat and support these individuals. A comprehensive dementia strategy for Northern Ireland is required. (p 45)

As well as these specific points, they are good examples of the way the health agenda is markedly preventive and community oriented; it rather nicely recommends asking NICE to identify existing practice that is non-cost-effective, as well as new things that are. There’s a fairly positive section on valuing older people. There’s also a lot on poverty and inequality -  of course they’re sticking up for the protestants against the catholics.

The Scottish National Party has a smallish manifesto; however its summary puts older people right up there at the front:  a fair deal for pensioners with pensions rising in line with earnings and a guarantee to protect free personal care and concessionary travel (Page 4 after the photos). A lot of the manifesto is about being champions for the interests of Scots people; for example:

we believe Scots must not lose out as a result of policy decisions for england. That means there should be no new taxes or contributions, or changes to attendance allowance or Carer’s allowance that will impact on Scots, to pay for reform of care for the elderly down south.

Referring to Sinn Fein, the other power-sharer in Northern Ireland, there still seems to be no manifesto, but there are campaign statements:

Website for these: http://www.sinnfein.ie/election-campaign-statements

I’d like to comment on the Respect Party manifesto, but my browser will not download it. However, the website does not reveal much interest in health and social care, or older people; it mainly focuses on anti-racism and equality issues, particularly around housing, education and work; a party for the working man, I decided.

The website: http://www.therespectparty.net/breakingnews.php?id=864

The British National Party has now published its manifesto; searches for palliative, end of life and social care drew a blank. However, it does mention ’social work’; apparently the police are doing too much of this, politically correctly, and it’s got to stop.

Looking more broadly at the manifesto, NHS funding would be increased if there (in your dreams) were a BNP government by removing the foreign aid budget, and old age pension and public sector pensions would be sorted out. Housing and other public services would be relieved by not having to provide services to any immigrants, and human rights and equality legislation and organisations would be removed. Serious criminals will be similarly removed to South Georgia (the little British colony miles from anywhere in the Atlantic) and the death penalty would be applied to lots of nasty people, especially rapists.

They are also into compulsory volunteering: ‘a Community Award Scheme for our young people which will take the form of a compulsory one year period for all school leavers during which they will work in the community as the final element of their education. This scheme will allow young people to choose between a variety of community service options which might include, for example, caring for the elderly or disabled people, environmental or heritage restoration projects or military training. The final choice of direction in this regard will be dictated by the school leaver’s scholastic record, preferences and suitability. These courses would be character building and would instil discipline, social and community values and work ethics in all young people.’

That’s going to be popular with the gap year middle classes. Yes, when I’m elderly, I want to be cared for by some lout forced to look after me. Volunteering should mean what it says; you should want to do it.

You would laugh at all this, or weep about the attitude to other human beings. But these views are the attitudes of many pub bores across the country. You can imagine them poking you in the chest to emphasise their points, as they down yet another pint. How is it that we are educating people in social and personal understanding so badly that this sort of approach to the world still exists?

Website: http://bnp.org.uk/pdf_files/BNP-Manifesto-2010-online.pdf

I’ve been giving loadsa lectures this last couple of weeks, mostly about multi-inter-professional-disciplinary practice, partnership working and so on.

Strikingly, the lecturer on a course for health service administrators commented that my suggestion that partnership working is a response to command and control managerialism of the 1990s was new to her. Do you remember the time when managers were supposed to manage, and generalist managers could develop more effective services than professionals because they were not caught up in personal commitments to a particular professional approach to services? Partnership working reflects a realisation that that command and control does not create the effective interpersonal relationships within a service and it is solid interpersonal interprofessional relationships that actually makes it work for patients and service users.

Command and control didn’t work, of course, because managers who take their aims from financial and political objectives haven’t really thought through and understood the various aspects of what patients and service users actually need and want: their aims are purely managerial instead of service-oriented. And of course, they can only do what the bosses and the politicians tell them, rather than contributing their judgement and experience.

Professional judgement and experience also contributes to a participation policy based on individual and public choice. The public choice agenda says that if you respond to the individual choices of patients and service users, you accumulate their choices into a service that really responds to their needs.

No: you have a service that does what they want. But professional experience and judgement contributes a commitment to looking wider than what people want and an understanding of what happens as they approach these new issues in their lives and therefore what it is best to do about that to help them. Best for them, but not necesssarily what they want.

In end-of-life care, many of the people we work with have not approached their own deaths before; they do not have a lot of experience of other people’s deaths either. What they think they want beforehand is often wrong for them as they come to the point. Purely personal choice, or purely political sentiment (I say sentiment rather than policy, because I think the political reaction to end-of-life care is often sentimental rather than thought through), is not a good guide to providing the service. But a flexible professional commitment, based on secure professional knowledge and understanding and a strong research base is a necessary part of a good service.

And professional understanding from a variety of points of view also helps. The knowledge management approach to teamwork says ‘forget about having group love-ins as team development. Instead, cultivate appreciation of different knowledges that contribute to your field’. Appreciating and understanding a range of professional knowledges is the strongest basis of good partnership working.

To Hull to attend the final meeting of the research advisory group for the project on spirituality in contemporary funerals, final because it’s nearing its overall report after attending 46 funerals and talking to the participants about them. It seems that while, as most people know from personal experience, funerals nowadays are more about celebrating the person who has died than they used to be, this individualist celebration also reflects their spiritual conceptions; that is, their views about what is important in life. I’ll look forward to the final report, and you can get a copy by writing to the team at their website.

Research team website: http://www2.hull.ac.uk/fass/socsci/research/research-projects/spirituality.aspx

My Metro this morning has a feature about a woman who had a life-size cardboard cut-out of her husband made to take to the funeral, took it to a friend’s wedding and now has it at home. A new aspect of continuing bonds theory, the idea that people maintain relationships with someone in their lives who has died. Is this a new opportunity for hospice fund-raising departments?

Having sat through the first leaders’ debate last night I thought I should start and quite possibly finish my election coverage for the 2010 UK General Election. I didn’t actually see all of it, because our daughter-in-law stranded in California by volcanic ash rang up at the crucial point, not realising that history was being made on UK telly.

I’ve had a look at the main political party manifestos, and give below excerpts about palliative and end-of-life care and social care and social work from each. Of course, nobody much reads manifestos; we rely on news coverage for thinking about what the parties stand for. In general this is sensible, since detailed points in manifestos are likely to be lower priority if any of them get into unfettered power. Probably the best guide to what might happen to end-of-life and social care is the overall picture of the world as seen from a political party, because that’s what we’re going to have to fit in with. You can make the best judgment about that from the press coverage and your view of the general attitudes displayed by the party leaders. On the other hand, end-of-life and social care are so low priority, to politicians and the media-represented public mind, that if some party has bothered to say something specific, it’s quite likely to get taken up afterwards. Why bother to reinvent what you think if you never knew you were thinking it anyway?

One of the interesting features of the main parties, which has not had much press coverage, is the proposal to have more talking therapies (I suspect because people like them more than medication and they’re probably cheaper than doctors dispensing medication and certainly cheaper than putting people in mental hospital).

There’s not much detail about this, but in the Labour manifesto they’re part of the ‘it’ll be cheaper in people’s own homes’ paragraph, alongside tele-care, and note that it’s not for everyone who needs psychological care, but only for those with Alzheimer’s and the like. Good, but scarcely recognising the wish and need for more psychological care.

And for the Conservatives it’s in the public health section and mentions ‘effective talking therapies’. This probably means not clinical psychology (more specific than talking therapies and it would be expensive, whereas rather lesser ‘talking’ therapies would be cheap). Obviously they won’t be supporting anything that doesn’t have a bevy of random-controlled trials to back it up. So that’s all right then, there won’t be a lot of talking therapies to pay for.

Labour Party (2010) The Labour Party Manifesto 2010: A future fair for all. London: Labour Party.

On the web: http://www2.labour.org.uk/uploads/TheLabourPartyManifesto-2010.pdf

This is a chunky document, which as befits the party in power does actually cover the main points. Each main sector of government is covered in separate chapters, which start off with the ‘challenge’ (we don’t of course have problems in modern political discourse) and how their programme of national renewal is going to deal with it (obviously the party in power cannot say it’s gong for change, so we’re all going to be comprehensively renewed)..

Here are the main points on health  (p.4:2)

The challenge for Britain

To build a better health service by protecting NHS spending and by shifting to more preventative and personal care, clear patient guarantees and greater care in the home. The Tories will not introduce the necessary reforms, would fail to guarantee access to services, usher in a care postcode lottery, and put the interests of patients second.

The next stage of national renewal

- Legally binding guarantees for patients including the right to cancer test results within one week of referral, and a maximum 18 weeks’ wait for treatment or the offer of going private.

- Preventative healthcare through routine check-ups for the over-40s and a major expansion of diagnostic testing.

- More personal care, with the right in law to choose from any provider who meets NHS standards of quality at NHS costs when booking a hospital appointment, one-to-one dedicated nursing for all cancer patients, and more care at home.

- The right to choose a GP in your area open at evenings and weekends, with more services available on the high-street, personal care plans and rights to individual budgets.

- Access to psychological therapy for those who need it.

I also looked at the main points on families and older people (p6:2).

The challenge for Britain

To support all families in a rapidly changing world that places new and rising demands on all of us. We will help families to realise their aspirations — whatever their circumstances — and we recognise the huge contribution older people make to society and to family life. The Tories propose a marriage tax allowance that is divisive and unfair, will neglect growing care needs among frail elderly people and disabled adults, and prioritise only the privileged few.

The next stage of national renewal

- More help for parents to balance work and family life, with a ‘Father’s Month’ of flexible paid leave.

- A new Toddler Tax Credit of £4 a week from 2012 to give more support to all parents of young children – whether they want to stay at home or work.

- The right to request flexible working for older workers, with an end to default retirement at 65, enabling more people to decide for themselves how long they choose to keep working.

- A new National Care Service to ensure free care in the home for those with the greatest care needs and a cap on the costs of residential care so that everyone’s homes and savings are protected from care charges after two years in a care home.

- A re-established link between the Basic State Pension and earnings from 2012; and help for ten million people to build up savings through new Personal Pension Accounts.

My searches of the document produced the following – the sole mention of social work as such in any manifesto; obviously Ed Balls has got the presenrtly accepted policy into the manifesto, in spite of the spat about who’s going to run the College:

3:6 …Social work training will be radically overhauled, raising the status and standards of the profession, and we will establish a National College of Social Work. We will publish detailed Serious Case Review summaries that explain the facts, but keep full reports out of the public domain in order to protect children’s identities.

End-of-life care also uniquely gets a mention, but in relation to the voluntary sector role in health care

4:3 We will support an active role for the independent sector working alongside the NHS in the provision of care, particularly where they bring innovation – such as in end-of-life care and cancer services, and increase capacity. We will be uncompromising in expecting high standards from all NHS services – and in the coming period we will expect PCTs to challenge all services to achieve the highest quality. Where changes are needed, we will be fair to NHS services and staff and give them a chance to improve, but where they fail to do so we will look to alternative provision.

They’re also still keen on getting NHS staff to set up social enterprises to run NHS services. Particularly nurses, but no mention of doctors, whose negotiating oomph seemed to scar Mr Blair’s back. Perhaps they think nurses are less business-like, or more pliable and cheaper. They have also heard the message about not keeping on changing everything all the time.

4:4 Central to our agenda for improvement is the hardworking NHS workforce. We will continue the process of empowering staff – freeing them from bureaucracy and ensuring they get proper support. We will expand the role of NHS nurses, particularly in primary care, in line with the best clinical evidence. And across the NHS we will extend the right for staff, particularly nurses, to request to run their own services in the not-for-profit sector. To strengthen local accountability, we will increase the membership of Foundation Trusts to over three million by the end of the next Parliament.

The NHS will benefit from a period of organisational stability: we will make no top down changes to the structure of Primary Care Trusts or Strategic Health Authorities during the next Parliament, and we will ensure stability in the hospital payment system.

Then there is a commitment to palliative care in people’s homes. They’re obviously still bedazzled by the Marie Curie marketing machine, or perhaps they just think someone else has heard of them too; it’s like all of the party leaders in the telly debate mentioning people they met out campaigning in every answer they gave (only those who agreed with them of course, but perhaps party leaders are only allowed to meet people who agree with them). It got irritating after a while, and swooning on Marie Curie has the same effect.

4:5:We will offer more personal healthcare. All cancer patients will be offered one-to-one dedicated nursing for the duration of their care and we will work with Marie Curie Cancer Care and other providers to guarantee everyone who wants it the opportunity to receive palliative care in their own home at the end of their lives.

Like all the other parties, Labour is keen on carers: Keen on Karers will be the new multi-party slogan: they’re so cheap and everyone can agree how wonderful they are. Labour actually admits this is why they’re keen:

6:2 We need services that help families manage these new pressures without creating huge additional costs. We need to go further to secure fairness in later life and ensure that those who plan and save for their retirement are rewarded for doing so. The additional costs and burdens of old age must not fall disproportionately on those who have made provision for themselves and their families.

This leads on a big section on how they are going to do the National Care Service; it mirrors the recent White Paper (see my previous post) and it is actually a good summary of the White Paper. In the context of a manifesto (i.e. something that will be read by non-specialist journalists, re-ablement has become a physio service). Note the regular mention of controlling costs; it’s good to know that physiotherapists will be playing their part alongside social workers in keeping costs down:

6:5-6 The National Care Service and an age-friendly NHS

The cornerstone of a fair future is ensuring everyone who needs care and support, whether through old age or disability, is properly looked after. We will establish a new National Care Service and forge a new settlement for our country as enduring as that which the Labour Government built after 1945. It will be a new settlement for all those who need care, for the carers who devote their time and energy for the good of others, and for families across the country. The care of both older people and disabled adults will be transformed; unfair postcode lotteries removed; more people will be looked after at home; and family homes and savings will be protected from catastrophic care costs. To provide independence and control for everyone with a care need we will continue to expand the use of individual budgets. And to drive up standards, we will develop a skilled and highly motivated workforce.

The first stage of reform will be to create a step-change in the provision of services in the home and in our communities. From 2011 we will protect more than 400,000 of those with the greatest needs from all charges for care in the home, and we will create a national physio support service helping people in every area of the country to regain their independence and confidence after a crisis or the first time they need care. These services are essential if we are to ensure more people are looked after in their homes and overall costs are to be controlled. They will be funded through savings and efficiencies in the health budget and in local government.

During the next Parliament, the second stage of reform will centre on the development of national standards and entitlements to ensure high quality care for all, and an end to the unfair postcode lotteries that affect too many families. We also want to remove the fear that families will lose the family home in order to pay for care bills. So, from 2014, the National Care Service will cap the costs of residential care so that  everyone’s homes and savings are protected from care charges after two years. We will pay for this through our decision to freeze Inheritance Tax Thresholds until 2014-15, by supporting more people over the State Pension Age to stay in work if they so wish, and through efficiencies across the NHS and the care system.

The final stage of reform, after 2015, will be a comprehensive National Care Service, free at the point of use not just for older people, but all adults with an eligible care need whoever they are, wherever they live and whatever condition leads to them needing care. At the start of the next Parliament we will establish a Commission to reach a consensus on the right way of financing this system. The Commission will determine the options which should be open to individuals so that people can have choice and flexibility about how they pay and to ensure that the National Care Service is funded in a fair way.

The Commission will make recommendations in time for implementation of the third stage of reform after 2015, once these proposals have been put to the public at a general election. Across the NHS we will improve and personalise care for the elderly and their families. This will mean more NHS services available in the home, with greater use of tele-care and personal nursing; reform of the GP contract to help ensure those with late-life depression and anxiety are diagnosed and supported; and better services for those with dementia and Alzheimer’s so that every area of the country has access to psychological therapy, counselling and memory clinics.

There will be an end to the age discrimination that has too often seen older people disadvantaged in the provision of health services.

The section on communities (that is, local government) extends the NHS intention to get staff to run social enterprises to provide services. So social workers can run their own child protection teams and get the blame for everything even more directly than at present..

7:5 We will extend the right of public-sector workers to request that they deliver frontline services through a social enterprise. Public-sector workers in the NHS currently enjoy this right. We will extend this to more public services, including social care, with greater community involvement in their governance.

Right, on to the Conservatives.

Conservative Party (2010) Invitation to Join the Government of Britain: The Conservative Manifesto 2010. London: Conservative Party.

On the web: http://www.conservatives.com/Policy/Manifesto.aspx

The main emphasis of this Manifesto is the public involvement argument. It is a fairly thick (I don’t mean stupid, I mean long) document, like Labour’s, but with less on end-of-life and social care. However, the line is much the same. The main point on health also includes a mention of social care (demonstrating joined-up thinking) as follows:

45 Back the NHS

We will back the NHS. We will increase health spending every year. We will give patients more choice and free health professionals from the tangle of politically-motivated targets that get in the way of providing the best care. We will give patients better access to the treatments, services and information that improve and extend lives, boost the nation’s health, and reform social care.

Then we’re on to the public do-it-all-yourself theme, which leads on to a mention of personalisation and independent budgets, merging health and social care funding, although not the actual service as far as I can see. Is this possible? I doubt it, in which case, see below my comments on the LibDems and merging health and social care into a seamless service.  Note though the continuing commitment to cash for children’s hospices (before they’ve only said they’ll look at this, now they’re going for it). More important, they are proposing a per-patient payment for all hospice patients. Once the Treasury sees that it will probably disappear, although they don’t actually say they are going to pay all the costs of the patients, so they could just give voluntary hospices a penny per patient and meet their manifesto.  There’s also positive stuff on carers, as with all the main parties:

48 Take control of your care

Where possible we want to devolve control over health budgets to the lowest possible level, so people have more control over their health needs. For people with a chronic illness or a long-term condition, we will provide access to a single budget that combines their health and social care funding, which they can tailor to their own needs.

48 We will provide £10 million a year beyond 2011 to support children’s hospices in their vital work. And so that proper support for the most sick children and adults can continue in the setting of their choice, we will introduce a new per-patient funding system for all hospices and other providers of palliative care.

Then, on to social care: they’re pushing their rather stupid line about death tax, probably because they haven’t heard that this is already what happens when local authorities defer your care payments. However they slide from choice to a focus on (very cheap) help for carers, rather than (impossibly costly) doing something about the real costs of social care for older people.

48-9 We reject Labour’s plans for a compulsory ‘death tax’ on everyone to pay for social care, regardless of their needs. We want to create a system which is based on choice and which rewards the hundreds of thousands of people who care for an elderly relative full-time. So we will allow anyone to protect their home from being sold to fund residential care costs by paying a one-off insurance premium that is entirely voluntary. Independent experts suggest this should cost around £8,000. We will support older people to live independently at home and have access to the personal care they need. We will work to design a system where people can top up their premium – also voluntarily – to cover the costs of receiving care in their own home.

An interesting move is to focus on public health (presumably because they’ll be devolving and privatising all actual health services) although we also get an element of the Conservative view that it’s the unhealthy choices of the working classes that have to be put a stop to. So, instead of taking responsibility for educating people about healthy choices and stopping the food and drink manufacturers profiteering from marketing unhealthy choices, local communities who don’t become healthier will have their health budgets cut back. This ‘paid according to how successful they are in improving their residents’ health’ is inconsistent with the bulleted point that says they will spend most on the poorest areas.

A healthier nation

Lifestyle-linked health problems like obesity and smoking, an ageing population, and  the spread of infectious diseases are leading to soaring costs for the NH S. At the same time, the difference in male life expectancy between the richest and poorest areas in our country is now greater than during Victorian times. We will turn the Department of Health into a Department for Public Health so that the promotion of good health and prevention of illness get the attention they need. We will provide separate public health funding to local communities, which will be accountable for – and paid according to – how successful they are in improving their residents’ health. In addition, we will: introduce a health premium

– weighting public health funding towards the poorest areas with the worst health outcomes;

- enable welfare-to-work providers and employers to purchase services from Mental Health Trusts; and,

- increase access to effective ‘talking’ therapies

That’s the Conservatives; now moving on to party 3.

It’s easy to cover the LibDem manifesto, there’s not a lot to interest us, partly because they’ve gone for briefer and more focused; that is, don’t bother within anything so unimportant as end-of-life and social care. End-of-life and palliative care do not get a mention at all, neither does social work but social care comes up twice, one mention and one item about long-term care indexed to social care. Yes! Don’t faint, but they have an index and their indexer knew that long-term care was about social care.

However, perhaps you’d better practise fainting again, because they’re going to merge health and social care to provide a seamless service. Does that mean remerging children’s social care, too, as the Greens are proposing (see below)? I suspect they haven’t thought about that, because they’re thinking in current silos. Does that mean paying for a totally free social care service on the same basis as the NHS? If not, the differential will be hard to maintain. And does it mean that they don’t care about the interface between social care and housing, social security, criminal justice, youth work and a whole range of local council services which will be made more difficult because social care will then have to kow-tow to healthcare priorities (i.e. healthcare for individual patients and particularly their consultant physicians are god and getting people out of expensive hospitals is the most important thing in the world rather than the broad needs of families and communities)?

Liberal Democrat Party (2010) Liberal Democrat Manifesto 2010. London: Liberal Democrat Party.

On the web: http://www.libdems.org.uk/our_manifesto.aspx

41 Integrate health and social care to create a seamless service, ending bureaucratic barriers and saving money to allow people to stay in their homes for longer rather than going into hospital or longterm residential care.

53 There is a further, serious, long-term crisis facing older people: the sustainability of the systems for providing long-term care. It is unacceptable that this challenge has been treated as a political football. A Liberal Democrat Government would immediately establish an independent commission to develop future proposals for long-term care that will attract all-party support and so be sustainable. We believe that the eventual solution must be based on the principles of fairness, affordability and sustainability.

The Commission idea is like Labour’s proposal (and the LibDems are also into calling problems challenges), but a bit more instant – after all Labour has had commissions before, and they know that when you get the report, it’s harder work to pitch it into the long grass again, so they’re probably going to make sure it says what they want it to say before they start.

Now I’m on to the smaller parties. It’s worth looking at them because they often have clever ideas that the other parties will pick up. And if we get a hung Parliament, some of their better ideas may well get some traction.

Green Party (2010) Green Party General Election Manifesto 2010: fair is worth fighting for. London: Green Party

On the web: http://www.greenparty.org.uk/assets/files/resources/Manifesto_web_file.pdf

The first thing about the Greens is that they’re going for assisted death as a policy, but only if there’s the highest level of palliative care available, whatever that means. So that’s no assisted death in the near future, then. But it does reflect an awareness of what the socially-aware public actually think:

23 Provide the right to an assisted death within a rigorous framework of regulation, and in the context of the availability of the highest level of palliative care.

Then there’s a big section on social care, which is mainly sloppy kisses for carers, rather than applying their mind to what social care services should be about. However, they do suggest re-merging child and adult social care, which a lot of councils are actually doing. It’s a sensible move,because councils have found out that there’s no real symbiosis between the universal education service and highly selective children’s social care. That always was a silly idea. Also, the Greends have realised, as the Conservatives would if they really were thinking about families, that the 1970s reorganisation of social services was about creating a family service, because all sorts of people live in families, including mentally ill, disabled and older people, and you need to deal with the things that are challenging them (see, I’ve learned the modern term for problems) in a coordinated way that looks at the whole family, not sending a whole lot of different people along from different departments to deal with little bits of the family’s…challenges.

13-14  A fair deal for social carers

A vast proportion of social care in the UK is provided by unpaid family carers who  save the NHS £87bn a year. Carer’s Allowance (CA) is an income-capping straitjacket. CA paid to family carers aged 16 and over is the ‘Cinderella Benefit’: £53.10 for a 35-hour week minimum commitment is no real compensation. Child carers under the age of 16 receive nothing at all. They are perhaps our most vulnerable child labourers, often working very long hours and bearing emotional burdens far beyond their years. These children receive no financial support and in many cases work longer hours than their older counterparts. Their schooling and education are often compromised and some simply never have the chance to ‘play’.

The Green Party is committed to:

- A more generous Carer’s Allowance, increased by 50% to £80pw.

- Offering support to people who want to give care, recognising their pivotal position while increasing the amount of care available.

- Healing the rift between adults’ and children’s social services that was created by New Labour.

- Providing more short breaks to families, including disabled people or those with long-term illnesses. Such early intervention schemes have been shown to save money by preventing crises.

- Improving working conditions for professional staff at all levels, paying for preparation time and follow-through, as well as contact time, and providing more in-service training to help cope with the vast spectrum of service user requirements.

- Instituting workforce health checks as advocated by UNISON.

- Repealing the oppressive Welfare Reform Act (2009) as a prequel to supporting people through lifelong development for their own and the planet’s well-being.

- Cancelling the DWP benefit entitlement assessment contracts with private sector.

- Restoring the link between state benefits and earnings.

- Giving carers cheaper local travel on bus, trains, tube and trams.

Finally social care for older people is going to be free á l’Ecossaise (the Greens haven’t learned the correct jargon for ‘the elderly’ yet; or perhaps they realise that nobody else understands the correct jargon). Free social care is actually a very logical move because it means you don’t have to face up to all the boundary disputes about what is health and what is social. The problem is, it costs – a lot:

22  In particular, maintain the principle of a free NHS by implementing in England  and Wales the scheme that provides free social care to the elderly in Scotland. If the Scots can do it, so can the rest of us. This would be phased in, costing about £3bn in 2010 rising to £8bn pa, and could create 120,000 jobs.

United Kingdom Independence Party (2010) UKIP Manifesto: Empowering the people. London: UKIP.

On the web: http://www.ukip.org/media/policies/UKIPManifestoWeb.pdf

UKIP have a short and pithy manifesto, and none of my search terms came up. They major heavily on immigration. But they have two interesting and original proposals. Healthcare, is going to be run by elected ‘County Health Boards’ in their worldview. Perhaps this reflects the reality that they don’t expect to win any seats in the cities, where there aren’t any counties. But actually elected bodies running healthcare as part of, or closely connected to, local authorities, is not a bad idea and (whisper it quietly in their presence) quite a lot of the rest of Europe does it.  They are also proposing to roll all long-term pensions into one pension-type provision and all welfare benefits into one ‘basic cash benefit’ at the same level as jobseekers allowance or income support. This would cover a very wide field, including for example student grants (just welfare scroungers really, none of this nonsense about education). The argument for this is that they can get rid of a lot of bureaucrats (they’re very much a ‘bomb the bureaucrats’ party) because they wouldn’t have to differentiate between and means test for a lot of different benefits. Not a bad idea, although I think they might run into some problems with the Daily Mail and its readers, who still support the centuries-old maxim that the deserving should get more than the others, which means sorting out the sheep from the goats.

Plaid Cymru (2010) Think Different, Think Plaid: 2010 Westminster Manifesto Cardiff: Plaid Cymru.

On the web: http://www.plaidcymru.org/uploads/publications/467.pdf

This proclaims itself as different, because it’s the first one with a publisher’s address outside London. It’s also brief, with lots of big colour pictures and not a lot of text, so it’s the prettiest, but none of my searches came up. However there is one item on social care, which says it’s just nursing really. What I think about this is that we need to improve caring skills in the social care workforce. But I’d rather have a focus in adult residential care on deveoping social lives and family and community relationships, which I don’t think fits with mujrsing skills so well:

Plaid Cymru remains committed to free care provision for older and disabled people and we call for the transfer to the National Assembly of the necessary powers. We oppose means-tested allowances and we will campaign to abolish the distinction between nursing and personal care.

I’m not sure what they mean by means-tested allowances, presumably this does not refer to people paying for their own care, but all social security payments. Could be difficult financially and in gaining public support. However, they also want a ‘living pension’ for older people and others such as disabled people, so there seems to be a consistent view for an old style welfare state. Good heavens, Wales will be just like Sweden next..

I could not find a manifesto yet for the SNP or any of the Northern Ireland parties, although the DUP, Sinn Féin and SNP have a variety of policy statements on their website. If something turns up later, I’ll try to cover it.

Finally, http://www.general-election-2010.co.uk/votes/bnp-policies, a website of the UK Politics Forum, which is a good place to follow the election, says that there is not (yet) a British National Party manifesto, but you can look at policy statements on its website, too.

On the web:

BNP: http://bnp.org.uk

DUP: http://www.dup.org.uk/default.htm

Sinn Féin: http://www.sinnfein.ie

SNP: http://www.snp.org/home

A trip to Teesside University (the geographically challenged will find Middlesbrough on a map in the top right-hand corner of England about equidistant along the coast between Hull and Newcastle, but the local authority so named seems to have disappeared) to work on a project.

I find on arrival that Teesside University is trumpeting the fact that it is the Times Higher Education magazine’s university of the year, an award that I imagine must have put noses out of joint in some sniffier universities down south. Arriving in the evening, I find that the multi-coloured lighting that public buildings go in for nowadays (at what cost to the environment, I ask myself?) suggests that the X-files people should be called out to investigate a giant alien spaceship landed in the middle of a car park wasteland. The following morning, I realise that this prestige building sits in multiple buildings of more prosaic education architecture thrown up over the decades of administrative metamorphosis from technical and teacher training college to university of the year. The campus is, indeed, in its lack of beauty another challenge to the environmentally concerned.
They have been developing social and health care education in end-of-life care and there is a doctor, Edwin Pugh, who has produced an interesting paper, based on his professorial lecture, on achieving a good death (or what trendier sociologists are calling ‘dying well’). From this I am reminded that memento mori are medieval symbolic pictures of skulls and the like to remind us that fleeting and precious life will necessarily lead to death. And that ars moriendi refers to the art of dying well. I do like a bit of Latin in a blog.
Margaret Holloway, who writes the introduction to this paper suggests that we should see end-of-life care as delivering services ‘artfully’.
My grandmother would not have regarded being artful as a compliment; she saw it as deviousness. But I take the point that dealing with the complexities of the dying process in a family requires input from many arts, human and scientific. And the way today’s society is set up does not make it any easier.
The paper: Pugh, E. (2008) Memento Mori: Personal reflections on achieving a good death in today’s society. Middlesbrough: School of Health and Social Care, Teesside University. (Occasional Paper No 1.) available from Maria Morrissey, Project Officer (Enterprise), Senior Management Support Office, Teesside University, Middlesbrough, Tees Valley. TS1 3BA UK.
T: +44 (0)1642 738063; F: +44 (0)1642 384995

Last week’s post on the Law Commission is actually likely to be the most important long-term material on social care. But today’s announcement that the election is starting means that a lot of political debate will shift away from detailed policy considerations, and everything will be up for grabs again.

The debate about care costs

Parliament in going into its ‘wash-up’, getting through all the stuff that’s still hanging around, so I feel that I need to complete my own wash-up and pick up on the accumulation of materials on funding of long-term care. Most of the emphasis is on older people, the largest population group, and perhaps the one most of interest to people in palliative care, but of course whatever is decided will affect all groups who might use social care services. Perhaps the best general analysis of the issues is contained in the Select Committee on Health Report, originally an investigation of and response to the Green Paper. This is both informative and politically astute, because it explores political judgements alongside the usual policy stuff.  Paragraph 372 gets it right:

We would have liked to see all the political parties come together in that spirit to map out a programme of sustainable reform. Instead,  regrettably, the Government is hastily drafting a White Paper while also rushing through Parliament a hurriedly concocted Bill that cuts across its own Green Paper, in a febrile atmosphere of unedifying pre-election party-political squabbling and point-scoring.

The Select Committee on Health Social Care Report: http://www.publications.parliament.uk/pa/cm200910/cmselect/cmhealth/22/22.pdf

The social care green paper last year was about issues broader than the funding issue, but how to fund adult social care is the big political issue. No politician cares much, unfortunately, about the many issues about the quality and availability of social care. This is in part realistic, because it is development in social care practice and professional education that will have most impact here. Let’s hope that the proposals for taking on the Task Force recommendations on social work will make a contribution, but it’s hard to imagine this in view of the fuss about the least important of these, the College of Social Work. And also not a lot will happen because nobody much is going to spend money on social care or say a lot about it in the election. Even though some of the importance that people attach to health care is partly about how they or their parents are going to be cared for in their old age, government thinking treats this separately.

Getting personal care right, and the care deficit

The Green paper offered a number of options for funding adult social care, and primarily care for older people, which led to a great deal of political and media interest. To everyone’s astonishment, the government then came forward on 25^th November with a partial scheme for free care for older people in the Personal Care at Home Bill, at the same time publishing a consultation, which ended in late February, on regulations that would go with the Bill.

You can see the consultation at: http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_109139

And the report on the responses at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_113945.pdf

What they found, not surprisingly, is that most people and organisations involved supported the idea about making free care at home available to more people with the highest needs, but were worried about funding and organising it, particularly in short order. A significant feature of the proposals is an emphasis on promoting home care rather than residential care, and promoting re-ablement services, to help more with people who would be capable of a greater degree of self-care at home. You can’t disagree with this, and you can understand why the government is concerned that the funding debate, as so often before, does not degenerate into how you can fund more care home places, which on the whole are not the favoured option for many older or disabled people. This is a welcome focus on how we can use professional skills and an effective preventive service; just what I said I would like to see when talking about the development of professional social care above.

But…

The perception arises that this is another New Labour ‘stop relying on state care and taxes paying for it and get yourself together to care for yourself’ policy. Such policies are entirely reasonable in one way, because a lot more getting people towards independence would be possible than in our currently dependency-focused care services, and most older people would really like these independence and prevention priorities to be more important in social care. However, you can’t also avoid the impression that this is about trying to organise the services in such a way that the government can get out of paying for most of it, as with their policy on disabled people and single mothers – in fact anyone who is likely to be a significant drain on state resources for a longish time.

I think people just find this unacceptable: their experience of the NHS, and frankly their view of common humanity, leads them to expect that when they need care and it is absolutely clear that they need care, in addition to their own efforts and family support, they expect the state to rally round and do the business. There would be mixed views about how much they are prepared to contribute towards the cost. For most people the answer would be a fair bit if they could afford it probably, and most families would also expect to do their bit too.

But people actually expect the service to be there when they need it, and they don’t expect to be told to sort it out themselves. Neither do they expect to be punished by physiotherapy and aids and adaptations into coping at home with inadequate personal care when they’ve had their approved slice of re-ablement. Physiotherapy, aids and adaptations are valued, but they are not personal care.

The implication of this is that we need to get the personal bit of personal care right. At the moment most people, because of the ghastly stories they have heard, and with some truth, don’t believe their care will be personal and good. We all know, and it says in the Select Committee Report, that there is not enough money in the system currently for that to happen: it’s underfunded. Moreover, the country’s financial mess is likely to mean that for the foreseeable future it’s going to continue underfunded and probably get worse.

There’s a further stumbling block of all these policy statements: they assume that there is no ‘care deficit’. The care deficit is the concept that there is not and never has been in all of history enough care in the world to go round.

Do you share the following scenario? The care I want, when I’m really up against it, is my lovely wife. Unfortunately, there’s only one of her, and when I’m up against it, she will probably be older and in need of care herself. So what I really need is two people who will care for me just like her; actually what I want is for them to be just like her. In shifts, so that means four of her. For me, there aren’t four Margarets in the world. And she’s likely to be competent at it. If you ask her, she would probably say that she’d like me to be around when she’s up against it, but actually she’d like someone better than me at the hands-on personal care. In shifts, so that’s another four people as well as me. You only have to think about it to realise that the kind and quality of personal care that most people ideally want is not realistically likely to be available to them if their care needs are significant. Something more or less adequate most of the time is probably what most people expect and would put up with. But there is not enough pay and there are not enough people who want to do the job for the numbers we are talking about in twenty years time.

The BBC News account of issues about care costs (includes interviews with the main parties’ health spokesmen, a clip of a woman talking about the costs of her husband’s care and a link to the BBC’s good summary of the issues in Social Care Q & A): http://news.bbc.co.uk/1/hi/health/8593118.stm

Guardian news items: http://www.guardian.co.uk/society/social-care

The Personal Care at Home Bill

Meanwhile the Bill has been going through Parliament. I’m not going to go through this, because the debates represent the issues about paying for care looked at more generally in this post, and because I think the detail and  a lot of these actual politicians are going to be lost in the election. Time enough when something actually happens later on. If you want, you can see information about the Bill and read the latest version and explanatory notes at: http://services.parliament.uk/bills/2009-10/personalcareathome.html

I list below where you can read the main debates:

(House of Commons)

http://www.publications.parliament.uk/pa/cm200910/cmhansrd/cm091214/debtext/91214-0008.htm#0912147000001

http://www.publications.parliament.uk/pa/cm200910/cmhansrd/cm100112/debtext/100112-0005.htm#10011255000002

http://www.publications.parliament.uk/pa/cm200910/cmhansrd/cm100112/debtext/100112-0020.htm#100112103000002

(House of Lords)

http://www.publications.parliament.uk/pa/ld200910/ldhansrd/text/100201-0002.htm#1002012000311

http://www.publications.parliament.uk/pa/ld200910/ldhansrd/text/100222-0002.htm#1002222000313

http://www.publications.parliament.uk/pa/ld200910/ldhansrd/text/100301-0002.htm#1003011000638

http://www.publications.parliament.uk/pa/ld200910/ldhansrd/text/100317-0002.htm#10031747001048

(House of Commons considering the House of Lords amendments)

http://www.publications.parliament.uk/pa/cm200910/cmhansrd/cm100330/debtext/100330-0026.htm#10033137000007

Death tax or national care service?

There was a political fuss about all this when the three main English parties had meetings to see if they could arrive at a political consensus about how to fund adult care, which was blown apart by jockeying for the election. The Conservatives are keen to say that the option of a levy to pay care costs on people’s estates after they die is a ‘death tax’. Actually, it’s what goes on now if your local council agrees to defer its charges until after you die. So Labour came forward with a delaying White Paper, which, aside from helping people with the ‘highest needs’ with free-ish care now, puts off the decisions for a Parliament and funding for longer.

A good Guardian report about this, which gives links to some of the political shenanigans, is at: http://www.guardian.co.uk/politics/2010/mar/30/burnham-old-people-reforms-concessions

You can read the White Paper at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_114923.pdf

Citation: DH (2010) Building the National Care Service (CM7854) London: TSO.

The title refers to the policy wish to build a national care service that mirrors the NHS. This objective is understandable, because most people cannot understand the distinction between health and social care, and expects to see a similar approach. The aim is to achieve this by portability of assessment between local authorities which would continue to have autonomy about the care provision that they make. However, as the Law Commission consultation on adult care law, which I discussed in detail last week, makes clear, you cannot legislate for total portability because each local authority will vary in what it provides in response to an assessment brought from somewhere else. One point which politicians and policy wonks don’t seem to realise also is that a professional organising or providing a service to a vulnerable older person cannot take responsibility for a service unless they make their own assessment and judgment. So it’s not possible to give people the security that what they’ve got now in Dawlish they can get if they move to Daventry (that’s from one small town in Devon to another in Northamptonshire if you’re geographically challenged). It’s not even possible to ensure that their needs will be seen in the same way.

Another problem with this is thinking mainly about people with the ‘highest needs’, because focusing on this group ignores preventive work. Social care has never been resourced to do a lot of prevention, certainly adult social care – there’s been a bit more in child care on occasion. This plan virtually encourages not bothering with anyone until they, their carers or their family are really desperate. It’s not what people want because it does not provide that sense of security that the NHS provides: that give or take a bit of shambles from time to time, it will be there for them when they need it.

The Conservative option of a low-price voluntary insurance scheme with a one-off payment at retirement for care homes only also won’t work. As most of the comment has suggested, while some Conservative voters can probably afford it, poorer people probably can’t, so the state will end up paying for lots of care anyway. Also, most people will not pay insurance for needs that they can’t yet foresee and hope to avoid. That would be so even if they trusted the insurance companies, which because of their behaviour over the last two or three decades most people don’t. Insurance that everyone pays throughout their working life would probably be acceptable, as it is in Germany for example. However, our benighted level of political debate sees this as an unnecessary tax rather than a sensible collective provision, so this is probably not a runner. A practical problem with this Conservative proposal, like the Labour ‘highest needs’ one, is that it only focuses on a small part of the care system: most people will need home care, not a care home and this proposal will push them towards a care home.

(In parenthesis, if we’re going to get people to understand this we probably need to change the terminology, too: did you understand that last sentence? Of course you did, because you are in the system, but the distinction between care home and home care is likely to be lost on a lot of people.)

So this debate also comes back to the care deficit. There is not enough of the absolutely right personal care in the whole world. This would be so. even if you imported enough poor African and Asian women to do the rich world’s low-paid care and domestic work at the current low level of resources in the care system. Or you could export older and sick people to be cared for in situ in poor countries where the low-paid labour is available. I expect we will be doing a lot of that in future decades, in the same way that the well-off middle classes moved to the Mediterranean in the 1980s and ‘90s (and came back again when they got older without family support and the NHS).

No, what we need to do is to put enough preventive resources into the care system so that people can be helped to stagger on independently for as much of their increased time on this world as possible. Then, we need to resource services so that a reasonable proportion of them get good enough care for as much of the remainder of their time on earth as we can manage. It will not be wonderful; I don’t think anybody believes it will be. Nobody wants the experience of growing older, becoming heavily dependent on others, needing masses of personal help just to get through the day and not being able to do very much interesting with their time. So drop the rhetoric about quality of care and personal development in our third age. Right at the end of our third age, just about coping more or less adequately is about what most people expect. If people hope and plan for better many of them might well be lucky. Really demanding care needs arenot universal,  so quite a lot of people will  be happy with how it goes. Quite a lot of people will also make plans to leave this earth if an adequate experience in their later life is not available.

In a way, I think the Labour approach has actually been realistic. We can probably stagger on with the present system until the early baby boomers are in their mid-seventies – that’s the early-mid 2020s. By that time, let’s hope the economy and political will can ante up enough resources and caring competence to do a reasonable job for them. That reasonable job will be more preventive, more making the world older person-friendly – we can start on that now. And it will also be a mixture of state, personal and family finance and action. All of those contributors will be paying for care services through insurance and commercial services as well as state provision. All are going to have to do more and better than they currently can. This means better professional training in a whole range of professions, more family care and support (I’d better start improving my skills up towards my wife’s likely expectations) and more taxpayer money and effective state, private and voluntary sector service management and provision. That will be hard to do, but we still have a decade to get better before the real crunch comes.