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)

With all the news about poor care for older people, we should all be thinking about the possibilities for housing that provides good care alongside it: the Department of Health website on independent living choices has a very rich compilation of tube videos, documents and guidance on every aspect of running extra care housing:

On the web: http://www.dhcarenetworks.org.uk/IndependentLivingChoices/Housing/

The Guardian reports on the Appeal Court case on the former leading ballerina, Elaine McDonald. She was assessed as needing a sleep-in carer to assist her with using a commode and some day-time help. Without a reassessment (that is, looking at the whole situation in the round), this was to be replaced with incontinence pads, although the Council (Kensington and Chelsea) relenting somewhat, the carer has been reduced to four days a week.

The judges are quoted by the Guardian as saying:

The evidence is that the use of pads in circumstances such as those which afflict Ms McDonald is a widespread, satisfactory and accepted practice. Although it does not suit Ms McDonald’s preferences, and it cannot make for perfection in a difficult situation, it provides safety and a large degree of independence and autonomy.

Well, to me, it may be widespread and accepted practice, but it is not satisfactory, where it is not provided within a human relationship. Respectful care is a human, interpersonal activity, in which a relationship is built up over a period. What this makes clear is that non-human provision is accepted because it is cheaper, and although we do not know the details from the Guardian report, it is clear that this was done in a way that did not respect Ms McDonald’s engagement in the process:

The court’s reserved judgment finds that the council was wrong to reduce the care in the way it did, but upholds its action in later reviewing McDonald’s case and concluding that she had a “more general” eligible need for night support that could be met by the provision of pads.

In social work, you interact and engage with the person you are working with; you do not make decisions on financial grounds, enact them and then when there is a protest defend what you did in court as ‘widespread and typical’. This is non-human, non-interpersonal and not respectful. Someone should not be treated as an unreasonable old lady when you started out by responding to her preferences and offering a human alternative. Once you’ve done that, you have to engage with her again to work through the need to provide an option that balances your financial responsibilities with your interpersonal repsonsibilities.

Yes, I think a human carer is better than incontinence pads. But I particularly think that if it is social work that provides the assessment and decision-making, it is core to the social work profession that the decision-making must also be human in the way that it works.

At least so I say much more extensively in my soon-to-appear book: Humanistic Social Work: Core Principles in Practice. (Chicago: Lyceum; Basingstoke: Palgrave Macmillan).

The Guardian report: http://www.guardian.co.uk/society/2010/nov/04/council-social-care-services-cuts?dm_i=4X7,AK7P,162Q9T,SZKN,1

Back from the Devon Dying Matters conference. Dying Matters is the ‘alliance’ that tries to focus minds on thinking about good care for dying and bereaved people and their families and communities.

I’m a bit doubtful about public relations style promotion of concern about social issues, because I think that people only really take a social issue into their minds when they come into contact with it in their everyday lives. You need a personal relationship to work on to push you into trying to get your mind round something. A bit of video with a weepy end does not do the business of finding out how you feel and how you are going to react. When you’ve got an older person in your family who needs care or a dying person to care for, you see pluses and minuses. Without that real contact, you get a sentimental ‘isn’t it awful, I’m glad that’s not me’ response. With real contact, you get a link from the present troubled time with past good and bad times, and you see people and their families and communities in the round, rather than as people with social care ‘issues’.

In fact, I hate the whole language of saying ‘I’ve got issues’ about something; it’s a vagueness about something that allows people to avoid saying why this is important to them, how they are trying to tackle it and what is happening as they are working on it.

However, you might find something useful on the Dying Matters website, which has well-presented information. It’s a bit medicalised, becuase the NCPC, which leads on this, is part of the healthcare world that doesn’t really think about dying and bereavement as social relationships, but as problems for healthcare professionals. In this case, they’ve selected  ‘getting people to plan their care in advance’ as the focus, and building up professional skills to talk about dying; these are both things you can do something about. But they’re still too stuck on advance care planning in the last few months, instead of seeing it as something that should be going on from later middle age onwards.

On the web: http://www.dyingmatters.org/

The national dementia strategy has been updated by the coalition ministers, and points to four priority outcomes:

- Good quality early diagnosis and intervention for all – Two thirds of people with dementia never receive a diagnosis; the UK is in the bottom third of countries in Europe for diagnosis and treatment of people with dementia; only a third of GPs feel they have adequate training in diagnosis of dementia.

- Improved quality of care in general hospitals – 40% of people in hospital have dementia; the excess cost is estimated to be £6m per annum in the average General Hospital; co-morbidity with general medical conditions is high, people with dementia stay longer in hospital.

- Living well with dementia in care homes – Two thirds of people in care homes have dementia; dependency is increasing; over half are poorly occupied; behavioural disturbances are highly prevalent and are often treated with antipsychotic drugs.

- Reduced use of antipsychotic medication – There are an estimated 180,000 people with dementia on antipsychotic drugs. In only about one third of these cases are the drugs having a beneficial effect and there are 1800 excess deaths per year as a result of their prescription.

This gives a good sense of priority and a focus on things that are really important. Otherwise is contains the usual whitter about what they’ve been doing and complicated diagrams about overarching etc objectives. A pity when the priorities set are so clear. Still, at least they’re continuing with an important part of the DH’s work.

Department of Health (2010) Quality outcomes for people with dementia: building on the work of the National Dementia Strategy. London: DH

On the internet at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119828.pdf

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

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.

There was also a moving account from something called Pearl (it means ‘positively enriching and enhancing residents lives’. Yuk – they should not have bothered with the words; this is a hotel company that also does care homes and it calls its hotels pearl; they could have done without this). And notice that they don’t know about apostrophes, when I’m a crabbit old service user, I shall be demanding that my provider is able to spell and puctuate their glossy brochures, as evidence that they take trouble over what they do.

However, now I’ve had the grouse, I thought this was a very good, non-unipart, way of motivating their staff to learn and develop both the systems and the skills of good care for people with dementia. Note, you management consultants: systems, skills and people – all together, all at once. That’s holism for you.

And truly convincing.

There’s a website but it’s not very informative: http://www.fshc.co.uk/elderly-care/dementia-care