I don’t know if you have ever talked to a woman who is approaching retirement with a reasonable salary but facing the prospect of an entirely inadequate pension; I find they are often in tears of frustration, anger and anxiety. This often arises because of the way the pension system has assumed women will rely on their breadwinning husbands, when for many people in the present generation long-term relationships that support a good pension just do not exist. It also happens because in the present and previous generations, and to a great extent still, women have usually borne the burden of child care responsibilities and other family caring, particularly for older relatives. A high proportion of women still get a lower basic state and second state pension than men in the same position, and this inequality will not be righted for some time, although the system is slowly moving towards equality.

I’m taken, therefore, by the detail of another House of Commons research report on Pension Contribution Conditions: sounds like a boring topic, but not to someone who is affected.

In particular, I think social workers should know that where people are doing more than 20 hours a week caring for children of other members of the family (even if there are breaks for respite care, holidays and hospital admissions), they can get a professional in health and social care to certify that they are careers and get National Insurance credits towards their pension. Anyone in health and social care can do this, carers do not have to be receiving some standard allowance. Have a look round the carers you’re working with and see if you can help them towards a better pension in the future. They might not be thinking about this, with all they have to do.

But their social worker should be thinking about it and doing something.

The report on the web here: http://www.parliament.uk/briefing-papers/SN03111. This also has stuff about other pensions changes and a current consultation on pension changes.

With all the talk about personalisation and direct payments, you might find it useful to look at a House of Commons Library report on the legal basis for direct payments, the things local authorities have discretion over (for example, employing relatives to help someone who is receiving direct payments), who is eligible, how much you can get and so on. It also (on the last page) has good links to further information. It’s only eight pages long. Presumably they write these things because MPs need help to deal with them.

It’s on the web, here: http://www.parliament.uk/briefing-papers/SN03735

You might find this interesting: it’s a case study of Madge, using a person-centred style of documentation about someone engaged in end-of-life care. My comment on it would be thatsome people might find this a useful format for asking questions that focus on what a person wants in their dying phase (and is a format for advance care planning, which usefully does not have too much of a focus on advance decisions, a failing of some of the palliative care based advance care planning processes). Helpful for family members (although I wonder if some family members who are less open might find it too personally critical, and therefore whether everyone would want to say some of the things that she does about what she wants and how she does/does not want to be treated).

Professionals might need to be more challenging than Madge wants them to be – that’s sometimes their job. but sometimes it isn’t. The extent to which the job is to challenge people’s preferences, particularly in end-of-life care, deserves some careful thought. Coming to the end of life is a new personal experience for everyone, but which many professionals have good knowledge and eexperience from the outside. The current orthodoxy that people should particpate and direct the serviecs that they receive runs the risk of becoming a tyranny that stops professionals from exercising critical judgement based on their professional knowledge and experience but which may challenge services uers’ beliefs. If a professional never challenges, what is the point of their professional role?

The case study: http://www.helensandersonassociates.co.uk/media/60834/madges%20story.pdf

An intriguing post from an American nursing home site: a list of what to pack to go into a nursing home, which lots of people involved institutional care might find a useful thought-provoker. You may wonder what Folgers is (I did): apparently it’s an American brand of coffee. Which raises a dignity question: do you need to take your quality coffee with you – as I suspect you have to if you care about coffee in any British care home or hospice? And therefore is your own cafetiere or coffee making machine also de rigeur in care homes now? And do all older persons wear tank tops nowadays? And have their own MP3 players?

The post here: http://www.nursinghomeinfo.org/packing-list-for-nursing-home/#.TjKff8RK24s.twitter

And the list:

The interesting online journal Music and Arts in Action, from the University of Exeter recently had a special issue on Music and the Arts in Health and Wellbeing. This inlcudes a long artucle on the St Christopher’s Schools Project, a public education project that helps children to be more in touch with death and dying; it also has a good piece on arts work with people with dementia.

http://musicandartsinaction.net/index.php/maia/index

The Nuffield Trust published an interesting study last year, which I’ve only just got around to. It looks at all the people who died in three local authority areas and compared their use of local-authority-funded social care and in-patient hospital care (about 20% of people fund their own care, so the study tells you nothing about them). It is also good at citing other similar studies, so it gives you an in to related material.

It finds that about 30% of people had some social care during the last year of their lives, rising to 40% for older people. The number of people using social care rises from 15% to 30% during the last year of care. Much of this average increase in the last year represents increasing use of (expensive) care homes. Of the people studied, 7.2 per cent used only social care, 49 per cent used hospital inpatient care and 23 per cent used both. Use of social care increased slowly over the last 12 months, inpatient care increased hugely, except for people who already had high social care costs (meaning they were in care homes). Above age 60, hospital costs at the end of life declined with increasing age, while social care costs increased. A crossover occurs in people aged 90 and above when estimated social care costs in the last year of life exceed the hospital inpatient costs.

People with a mental illness of any age used more costly social care than any other group; people with cancer used fewer social care services (possibly because they have access to special services for cancer sufferers, such as hospices, Macmillan and Marie Curie).

There are some caveats but, on the interaction of health and social care costs, the report concludes:

There is a subset of people accessing both social and hospital care who are associated with proportionately higher costs.

Social care costs in the last 12 months of life are most significant for older people. Increasing age is associated with higher social care costs and a broadly equivalent reduction in hospital inpatient costs.

The level of hospital inpatient costs is lower for people with high social care costs (people in care homes). This inverse relationship is observed at different age bands and is not solely linked with activity in the few final weeks of life.

A Canadian study has similar results. Possible explanations include:

Some people have health problems that are not amenable to hospital‐based treatment and the concentration of these may be greatest in the population in care homes.

Sometimes a hospital admission can be avoided by care in a residential setting – a substitution effect.

There may be some discrimination about offering hospital‐based treatment because the recipient is old and in a care home.

People within care homes may feel better able, or better supported, to cope outside of the hospital.

Interesting stuff.

Martin Bardsley, Theo Georghiou and Jennifer Dixon (2010) Social care and hospital use at the end of life. London: Nuffield Trust.

On the web: http://www.nuffieldtrust.org.uk/uploadedFiles/Publications/Social_care_and_hospital_use-full_report_061210.pdf

Frank Field’s report on what the government should do about poverty aims at intervention in early childhood development to try to achieve long-term impact. This connects very much to the Marmot report’s recommendations on combating health inequalities.

The Guardian’s summary of the recommendations are:

He proposes:

• parenting classes throughout school life, arguing that Britain believes parenting is learnt through osmosis;

• a new index of life chances that can be monitored annually;

• a focus on foundation years equal to primary and secondary schools;

• a rationalisation of children’s services, including post-natal work, from the womb to going to school;

• a working-class version of Mumsnet, the online forum for parents;

• kite marking children’s tv programmes to help speech development.

The issues:

1          inequality is too high for this to have impact

However, there are two main issues, one of them pointed up by a TUC comment on the BBC News website:

The TUC said the report understated the financial pressure on families having to live on the breadline.

“We remain a country with an exceptional level of economic inequality that needs significant fundamental structural change and government investment,” general secretary Brendan Barber said.

I think this means that increasingly all those middle class options are not available to many poor families; this was always the case, but it is worsening.

2          Influence needs personal, trusting relationships.

I call this the social work issue. As the Victorian moralising campaigners found (and Ian Hislop said on the telly this week), to influence someone in a highly personal area such as how they manage their families and their households, you have to build a personal trusting relationship so that they accept you are on their side. This means, as social workers have always found, you actually have to be on their side.

For example, why do we need a working class version of mumsnet? First, because most poor working class people have little access to the internet, and if they have they use it for things other than debating parenting. Second, because the world views of the mumsnet people are so distant from the life experience of poor working class people, that there is no true personal connection. So how will the ‘not-very-good-mumsnet’ actually influence their prospective members. I recommend bribes, the other story of the day. A hamper of food for your family if your child meets its targets?  Somehow, I think not.

So if you reorganise post-natal to five-year-old services, will there be finance to allow us to recruit enough health visitors to spend time to build the trusting relationship with working class mothers? Health visitors are icons of the fantasy that it will make a difference to have the odd visit and professional advice from a middle-class healthcare services perspective on how you should look after your child. I suspect there’s not going to be a lot of extra money. Also, if we are going to have regular testing to check up on whether you are doing the right things for your child every year, they are going to be even less trusted. Mothers will just stop going for health checks. Because, what are they going to do if the child is not meeting government targets? In the education sector, schools that don’t meet development targets get labelled failing: will that be true of health visitors too? Or will we be putting in more resources so that the ‘failing mums’ get more for their children. Or will they fear we will be taking their children away from them? I can just imagine the Daily Mail’s campaigns about that.

What has this to do with palliative care? Just think what they are going to be saying in ten years time about families not having the skills to look after their elderly relative properly. Schools will be told to provide training on caring for your grannies; more community nurse specialists will be visiting to make sure you are meeting your caring targets. We’re not going to have the money for services, but caring families are obviously going to need to be kept up to the mark.

The Marmot review on health inequalities: http://www.ucl.ac.uk/gheg/marmotreview

As I write the Field report is not yet available, I’ll provide a link later. News websites as follows:

http://www.bbc.co.uk/news/uk-politics-11903735 http://www.guardian.co.uk/politics/2010/dec/03/frank-field-welfare-sacred-cows

It hasn’t made it to the Telegraph yet, so no alternative political view.

The Daily Telegraph is warning that gas and electricity usage has shot up in the last few days. I for one am not surprised, since I’m at home burning gas because they’ve suspended rail travel on my journey to work for the last two days, when normally I’d be relying on St Christopher’s to keep me warm. Apparently demand for gas was up 25% yesterday in last year’s levels. Because gas and electricity prices are also shooting up (electricity up two-thirds since the beginning of winter according to the Telegraph), social care clients generally will be paying much more for keeping warm this quarter than they were paying last year at the same time (up perhaps 47% on last year if the cold weather continues – the Telegraph again). And palliative care clients even more, because a major illness, staying in and probably being fairly immobile almost certainly means you need higher heating. This is particularly significant because it will be an extra factor, and will have happened unexpectedly for many people.

So WARNING, be ready to make the case for sympathy from the fuel suppliers (and get MPs and Ofgem to bully them if they’re not sympathetic), keep the info about the cold now from the papers available for when you need to make the arguments in a few months time, and make sure medical and nursing colleagues give you the info about how important warmth is to combat immobility and illness. This will also help to get them onside, and make them realise the value of another of the jobs that social workers and their welfare rights teams do.

The Telegraph article: http://www.telegraph.co.uk/finance/personalfinance/consumertips/8174586/Fears-over-record-gas-bills-in-cold-weather.html

A Twitter message from Dementia UK alerts me to a service that specialises in providing beauty and massage therapies in a variety of older people’s homes, or through home visits. It includes, I see, a ‘gentlemans manicure’; not being a gentleman I wouldn’t know about this.

Happihands (they also do hand massage) is a commercial organisation, so you have to pay, but I think things like this should be a routine part of people’s lives in care homes. Research into the St Christopher’s complementary therapy services a couple of years ago by people at the health and social care faculty at Kingston University  showed that people really valued the sense of being given something special, with time and space away from their troubles offered by aromatherapy, massage, reflexology and the like. I’m sure it would be the same in any care home setting. I think we should be doing more of the ‘something special’ for lives that are often not special enough.

You can get the report on complementary therapies at St Christopher’s from the St Christopher’s bookshop http://www.stchristophers.org.uk/page.cfm/Link=109/t=m/goSection=7

The service: http://www.happihands.net/

I found out about this from: http://www.dementiauk.org

Some good Department of Health information leaflets about something they’re calling ‘personalised care planning’, which is what end-of-life care would call ‘advance care planning’ and the Scots are calling ‘anticipatory care planning’. This emphasises the point that advance care planning is not longer what doctors and nurses do with people who are dying, but everyone in care services everywhere should be doing with everyone who is receiving care services. Not even, pace this Department of Health project, just people who have ‘long-term conditions’

Stop doing things to people in categories, do it because it’s the human thing to do.

(But it’s good guidance: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_121603)