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.

The final judgment has not been published in the Condliff case: this is the man whose PCT refused to let him have a gastric bypass, because he did not meet their standard criteria. He argued the human rights case of respect for his family and private life. The Court of Appeal agreed that it was clear that Mr Condliff’s family life was being adversely affected. The PCT’s IFR policy set the rules for making decisions in exceptional circumstances, but it did not allow non-clinical or social factors to be used. Social factors included ‘age, gender, ethnicity, employment status, parental status, marital status, religious/cultural factors’.

What the PCT was doing here was trying to be non-discriminatory in making its decisions. Therefore the court decided that Article 8 rights do not confer a right to have social factors wider than the directly relevant medical factors taken into account in service provision decisions.

Of course, it might be different in social services cases, where the whole raison d’être of funding decisions is social concerns. But it does suggest that social workers should focus on using their advocacy arguments with sympathetic professional colleagues, rather than trying to go to law.

But is this reasonable? Surely all decisions made by official bodies should properly take into account social factors, otherwise we cannot respond to inequalities.

Some more details at: http://www.lexology.com/library/detail.aspx?g=c73f5fe6-6952-45af-a4a9-baf5cbde2040&utm_source=Lexology+Daily+Newsfeed&utm_medium=HTML+email+-+Body+-+General+section&utm_campaign=Lexology+subscriber+daily+feed&utm_content=Lexology+Daily+Newsfeed+2011-08-12&utm_term=

Someone on LinkedIn asked about my new book, already out in the US, but coming out in the UK tomorrow (from Palgrave Macmillan: http://bit.ly/dTTf5M ). I thought readers of this blog might have an interest in the reply.

Perhaps the best thing to do to get a picture of the book is to read the excerpts on the American publisher’s website http://bit.ly/gEW2Hl. Here are some of the main points:

The book starts from the fact that we are human beings, working with human beings.

It tries to integrate four areas of knowledge about how human beings live in the world: humanism (in particular secular humanism), humanistic and transpersonal psychologies, human rights charters and the thinking that comes from them and microsociology.

From the importance it gives to human rights, it emphasises achieving social justice and responding in inequality as a major role of social work

It emphasises flexibility and dealing with complexity, whereas many systems of social work try to oversimplify human life into simple prescriptions.

It says we have an accountability for helping people use their personal skills and development in dealing with issues in their lives and also for helping people in their social context change to facilitate the personal movement that people are seeking.

Practice should incorporate artistic and creative understanding, and spirituality, as well as psychological and social knowledge.

We should be helping people to develop security and resilience in their lives.

A little while ago I posted about a evening experience with an organisation for homeless people in Bratislava, Slovakia. One of the young men I went out with that evening recently emailed a comment about homeless people dying on the streets: how little you can do, and how someone may die unexpectedly. Even though you provide all the care you can, people are still at a high risk of ill-health and death if they are homeless.

The National End-of-life Care Programme in the UK publishes a very good guide to good quality end-of-life care for homeless people; it mainly refers to hostels, but covers broader issues as well. You can get this on the internet:

http://www.endoflifecareforadults.nhs.uk/assets/downloads/RTS_Homeless___Final_draft___20101211.pdf

National End of Life Care Programme (2010) End of Life Care: Achieving Quality in Hostels and for Homeless People – a route to success. London: Department of Health.

Among the suggestions are getting homeless people to do some advance care planning, so that their wishes are known if they are found dead, and finding a way of memorialising their lives in a place that was important to them. A memorial event may allow people who knew them and staff in hostels or homelessness projects to deal with some of the upset they feel, having often tried so hard to help.

Volunteers working in homeless need training in helping people who are affected by families and friends of homeless people who die.

Projects also need to think about how they deal with reactions to people dying: openness if usually the best policy.

You’ll have seen all the flurry about the housing benefit changes, which may well lead to heavy losses in benefit for people occupying housing in expensive areas of the country, and average losses of £12.00 a week.  Palliative care and other social care colleagues might, however, have missed an element of the changes announced by the DWP. Here is its statement:

The Government is also responding to concerns that the criteria used to determine the size of property a customer requires only take account of people who live in the customer’s dwelling as their home. Therefore a paid carer who resides with the customer is reflected in the size criteria but no allowance is made for carers who provide overnight care but who normally live elsewhere.

In recent years, local authorities have increasingly been asking for advice as they have come under pressure to include an extra room for the use of non-resident carers. This has led to inconsistency in treatment of non-resident carers. In some areas, the additional cost of a sleep-over room has been met by social services. Elsewhere the local authority has met the cost through a Discretionary Housing Payment but, on other occasions, the customer has had to meet the shortfall themselves. The Budget measure to fund an additional bedroom for non-resident carers puts right this unacceptable position.

What a nice positive way of putting this change. It means that if your carer is a live-in carer, you are likely to lose money, especially in a high housing cost area, but if they only sleep over, an extra room is paid for under the housing benefit. So there is potentially a small goody here for patients and clients who have carers not living with them.

But…

Remembering the effects of the cohabitation rule on my clients in the past, I can’t help thinking that it won’t be long before the DWP is taking someone to court for fraud because they have made a (larger) claim for a sleeping-over carer when it should have been a (smaller) claim for a live-in carer. I look forward to the DWP definition of when you’re living in rather than sleeping over. Will it be like Blackpool landladies: you have to go out after breakfast and not come back until the evening? Or perhaps your bedroom will be examined to make sure it doesn’t have the appurtenances of living in (no home comforts, perhaps, no telly, book, kettle in evidence)? Or perhaps sleeping-over carers will not be allowed in the living room with other people in the household.

You can look at the DWP impact statement on who will be affected by size of house, area etc; it is instructive about the sums of money individuals will lose (although not necessarily a high proportion of the population), at least outside London:

http://www.dwp.gov.uk/local-authority-staff/housing-benefit/claims-processing/local-housing-allowance/impact-of-changes.shtml

Scroll down to click on the impact statement. People have criticised the DWP assessment, so don’t take it as gospel. You can look for how it will affect your area.

American palliative care and other websites are all of a flutter about a study that shows widespread disparities in end-of-life care across the US. Information about the study is on the Dartmouth Atlas website, and the picture is not unlike the map from the DH health atlas project I posted about last week: http://www.dartmouthatlas.org

There are various takes on this: for example the Wall Street Journal majors on variations in ‘aggressive’ medical treatment and efforts to get doctors to feel OK about not trying one more time. I know that many colleagues in UK palliative care will feel the same about some specialist cancer treatment centres; it’s also an issue in renal care.

One interesting American project is trying to help healthcare staff think about ‘closure’: http://www.closure.org

It has interesting ideas on ‘community conversations’. I think this is the right sort of approach. It is hard to make a ‘no-more-treatment’ decision when patients very much want to carry on, and it is not uncommon for relatives and patients to have conflicting views; even more difficult. Also problematic is the situation where acute care doctors fear they will be accused of assisted suicide if they do not treat aggressively.

But a lot of people do feel that they do not want, or cannot bear, yet another heavy treatment, and we should be careful to listen to this, although not give up if there genuinely is a real chance.

It all goes back to advance care planning. The community conversations approach means thinking early and widely among the networks supporting patients about what people really want, and helping families and communities to get behind patients’ views. These things really should not be thought about at the last minute.

Here are some of the American website comments:

Wall Street Journal (there are some very thoughtful reader comments to this report, including the fear of ‘death panels’, which seem to have infected the American psyche): http://blogs.wsj.com/health/2010/11/16/surprising-variations-in-end-of-life-care

A very good palliative care blog: http://palliativemedicine.blogspot.com/2010/12/staggering-gaps-in-late-life-care-makes.html

and my own blog on current policy, in which I make the point that social workers have a good record of working with patients and families to support them in making these sorts of decisions: http://malcolmpayne.amplify.com

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

I’ve rather neglected continuing care of late, but my colleagues are still struggling with the criteria and assessments. Of course, people receiving palliative care are usually good bets for a positive assessment. However a recent Telegraph article points up many of the issues that often arise, and that anyone involved in continuing care assessments will experience. The article mainly looks at solicitors’ experience of appealing. Here are a few quotations:

Given the costs involved, Ms Lipszyc [a solicitor] said she was appalled that some people were not even being assessed to see whether they qualified for continuing care.

This problem has been raised before by the Health Service Ombudsman. The Ombudsman has published a number of highly critical reports into this area over the past five years. This led to the establishment in 2008 of national eligibility criteria, which all local health authorities have to follow when assessing who should qualify for this care.

According to Age UK, the charity, the national guidelines have led to an increase in the number of people qualifying for continuing care. In the first quarter of this year a total of 52,176 people qualified for continuing care, according to the Office for National Statistics – a figure that has risen steadily over the past two years. But Age UK said these figures masked wide regional variations, which indicate that there is still a “postcode lottery” as to whether people get this help.

The differences between individual primary care trusts are…significant. Mid Essex Primary Care Trust (part of the East of England Strategic Health Authority) has just 12 continuing care cases per 50,000 population – one of the lowest rates in the country – whereas Lincolnshire Teaching Primary Care Trust, barely 100 miles further north, has 162 continuing care cases per 50,000 population. A spokesman for Age UK said this “massive regional variation” indicated that “all is not right” when it comes to assessing people’s eligibility for care.

It seems we should still be looking out for our patients and clients. There’s a distinct possibility that people whose medical condition deteriorates in care homes will become eligible, but will not be re-assessed to check.

On the web: http://www.telegraph.co.uk/finance/personalfinance/insurance/longtermcare/8161457/Councils-stop-elderly-from-getting-help.html

The recently-published NHS atlas of ‘variation’ in healthcare (variation is the new inequality-lite, approved by the present government) has had a lot of publicity, most of it on where in the country you’re likely to get good care (Daily Mail: NHS postcode lottery exposed: The shocking maps that let YOU know where you will get good treatment and where to avoid).

The Mail article and case studies: http://www.dailymail.co.uk/news/article-1332992/NHS-postcode-lottery-exposed-Maps-tell-you-good-treatment.html#ixzz16lzsSZ2j

An aspect of this is end-of-life care, which gets map 29, and is connected to poor integration in community services for older people. There is less vari-inequality (I like to remind the government of the old days when we worried about unfair inequality) in end-of-life care than some NHS actions, hence perhaps the lack of press comment (this is being generous; I realise that in general they don’t like to talk about end-of-life care, except to promote assisted dying – I wonder what the vari-inequality on that would be?). But here’s the comment from the DH report:

In 2006–08, 58% of all deaths in an area occurred in hospital. The variation among local authority areas was between 44% and 76%. In half of all local authorities, the proportion of deaths in hospital was either below 53% or above 61%. Thus, there is much variation among localities. This suggests that community-based services are not always available to support people where there would prefer to be cared for, leading to potentially inappropriate use of the acute sector. People should be admitted to hospital only on the basis of need, regardless of incidental factors such as age and frailty. Furthermore, hospitalisation should not be used as the default setting for care when it is clear that admission is medically unnecessary and contrary to someone’s expressed wishes.

Couldn’t have put it better myself.

Department of Health (2010) NHS Atlas of Variation in Healthcare: Reducing unwarranted variation to increase value and improve quality. London: DH.

(I’m not quite sure how to cite this document, because increasingly NHS web documents do not bother to tell you who is responsible for them, though I assume it must be the DH. But you may care to know that this is coming from something called Right Care NHS. Why no NHS fair care or NHS equal care or NHS moral care– who knows? This is connected with QIPP (They’re going to produce an NHS glossary soon, so I’ll wait until then to spell this out – why do we need an NHS glossary, why can’t they speak normal language?). More about right care later.

On the web: http://www.rightcare.nhs.uk/atlas/qipp_nhsAtlas-HIGH_261110c.pdf