Social care and social work are important in end-of-life care.
Malcolm Payne's blog focuses on developments in social care and social work that affect palliative and end-of-life care. It is part of the information work of St Christopher's Hospice, London.
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
I always think it’s a bit unfair that sometimes there’s a comment in other places that readers of the blog only may not get to see. So I reprint here a series of exchanges on Twitter (cutting out all the Twitter technology so that you can see the comments more clearly and spelling out the Twittering abbreviations and missing words – indicated by [ ]). I was abroad for some of this time, so I don’t know I’ve seen all the points people made; in any case, unless you are continually on Twitter, you’re quite likely to miss some of what people say.
The debate here is about perceptions of a ‘local government social work’. Is it an over-generalisation to say that social work in local government is all bad? I didn’t say that, but I think an important issue is being raised. Should we be critical of the impact of the local government environment on social work practice? And is social work in a specialist environment, such as palliative care, always better?
The conversation on Twitter was about this post on April 25th, 2011: Palliative social work damaged by child protection controversy. You can read it in the archive.
Monstertalk retweeted one of my tweets drawing attention to the post.
Itsmotherswork saw this and commented to me and Monstertalk: [I’m] not at all comfortable with sideswipe at the end towards local government social work – as though it’s all bad.
Monstertalk re-read the post and could see the point that Itsmotherswork was making. I thought this was about a different post and tweet and, rather on the hoof, replied: Local government social services: [the] evidence (and my experience) is in general that many [people in local government social services] need to skill up on end-of-life care.
I made this point since it is a crucial element of the Social Care Framework document of the National End-of-life Care Programme; I was on the advisory group that contributed to this document, so I endorse its contents, although not uncritically. When I came back to a computer, I realised that Itsmotherswork was not tweeting about the social care framework, so I commented: [I] now realise you commented on a different post. No criticism of local government social work [intended]; all social work needs to get support from all specialisms.
Itsmotherswork then helpfully tweeted the part of the original post of concern and explained the critique of it: It was this remark: ‘…and one could only wish that social workers in local government children and adult social care would look to the social work specialisms for evidence that social work can very easily be seen as a good thing, if you work at achieving a very high standard of practice in all that you do.’ …which seemed to imply that local government social workers of all types (it didn’t specify) don’t work hard at achieving good practice. That’s a bit sweeping!
There was then an exchange between Itsmotherswork and Memma_pie; I think I have not found all of this in my Twitter feed, but Memma_pie obviously asked about what Itsmotherswork was saying and there was this exchange between them:
Itsmotherswork said: That’s how I read it, but in fairness, it sounds as though it’s not how Malcolm meant it. I’ll retweet the original. Memma_pie then replied: It feels a little disparaging having read it in full, but I understand the gist and agree. Sadly.
I think this is a really important and worthwhile exchange of views; so, now I’m back at my computer, I’d like to extend the discussion a little to talk about the connections between local government and others locations for social work practice, with particular reference to palliative social work, which is what I’m supposed to deal with in this blog.
The most important point to make is that, in most European countries, local government is the main location of social care services and therefore of social work practice. Therefore, the responsibilities and organisation of local government has a significant impact on the form of social work in any particular country. In many countries, and this is certainly true in the UK, social work is very much defined by the kinds of social work practised in local government.
The peculiar characteristics of local government, as it is everywhere, therefore have a significant impact on how social work is practised everywhere. I work in a number of European countries, and wherever I go I find social workers complaining about stifling rule-bound requirements of practice in local government, compared with the freedom and flexibility of ideas about how social work should be practised. They also talk about how they are burdened by excessive workloads because their local government services are under-resourced to meet the requirements laid upon them by imaginative and forward-looking legislation. I was recently asked to give a lecture on ‘Social work: vision and reality’ the keynote topic of a conference in Slovakia. Talking about the topic to people at the conference, it is clear that the difference between vision and reality for them was just this distinction: between the vision of an empowering therapeutic social work and the reality of a constricting local government system.
In UK local authority adult social care the constriction is about workload and the highly tick-box oriented assessment part of the care management system and in children’s social care it’s about workload and the highly defensive practice promoted by media and political pressures around risk in child protection. I think everyone accepts that the focus on child protection has deviated much children’s social care from what used to be a child and family care service. You can exaggerate this, of course, because you can see a lot of very positive achievements in fostering and adoption work, in family support and work with children in family centres and in the community, in children’s residential care and in working with children in child and adolescent mental health services.
Equally, as I talk to people in any country, I come across practitioners who describe how they are doing imaginative and empowering social work with clients and community groups. Sometimes the way they have achieved that is by setting up a specialised agency that provides help for a restricted user group; sometimes it is by developing the skill and self-confidence to practise in an empowering way with their excessive caseload in a local government agency.
The same is true in the UK. I talked to a patient at the Hospice who told me that they had a wonderful care manager in the local authority, who really helped them to come to terms with the change of family lifestyle caused by dealing with their elderly mother’s increasing frailty. It quite changed their fantasy views, garnered from the gutter press, about what social work is and how it can help. That’s not the only example I have come across, I regularly meet people who sing the praises of their local authority social worker.
The problem is that I also come across a lot of care managers who tell me (just like all those other social workers across Europe) that their local authority is so controlling that all they can do is fill in the forms they have been given within the time limits required, and the extremely restrictive computer system that ties them to their desk.
By the way, this fantasy that social workers once went out and spent most of their time with their clients is just that: a fantasy. All the research that has ever been done on social workers’ workloads, going back to a study I remember but can’t now cite on child care officers in the 1960s, shows that most of the time always was taken up by meetings and paperwork (and, you hear less mention of this but it was always true, travelling to get to home visits). It’s self evident, if you think about it. An hour’s visit means at least the equivalent in travel, a further hour again in making notes and phone calls in following up, and if the agency has to be run, a further hour in meetings, coordination, cover for absent colleagues and training averaged out over the client contact you did that week. Twenty percent of your time in contact with clients is probably about average in any kind of people working.
I was involved in the introduction of care management and wrote a book about it and its possibilities (Social Work and Community Care, Macmillan, 1995) which to my astonishment is translated into other languages and still sells in the UK sixteen years later. Back in the late 1980s, care management was the personalisation of the age: it was going to lead to flexibility, imaginative creative practice and was going to be the foundation of a new adult social work (which was always the inferior branch compared with child care and family work). Just like personalisation now: forgive me for being a bit doubtful about fantasies that this will lead to a sea change in social work.
Well, adult services care management has led to a new adult social work; it has institutionalised social work assessment and service coordination skills as an integral part of the care system in this country. And well done, as it sometimes is, it can be life-enhancing to people in very difficult situations. I believe it has made a major difference particularly for people with learning disabilities, but also for other client groups. Even routinely done, as it often is, it enables a wide range of services to be provided and coordinated to a lot of people who really need and benefit from them. We all do the routine much of the time. For most of my practice career, I have done the job and provided the services as required. At any time, there have been a few families who have been at the point where I have something to offer them and you see a major shift in their lives.
When we comment on local government social work in any country, therefore, we have to be clear that the backbone of any service is doing the everyday job adequately. It is important also to be clear that there is always the chance if we can take time and space in the everyday job when there is a need, when there is a possibility, when people are ripe for it to make an extraordinary impact on people’s lives. I don’t think that is the difference between a ‘good’ local authority or practitioner or a ‘bad’ one. Whatever the setting there is always a chance to step up to doing a wow in a particular instance. The best practitioners are always looking for occasions when they can do this.
But we also have to accept that local government in general is over-burdened with responsibilities and under-resourced. It is also burdened with a management system that is primarily about rationing resources. Generally, throughout Europe, this is done by tight administrative controls that practitioners complain about. It also means that UK central and local government has chosen an administrative form of care management that international research has shown is not particularly effective at making a significant difference in the lives of vulnerable people, whereas there are other forms of care management that have a history of being much more successful at having an impact, but they are more expensive of money and staff resources. If you want that greater success, government, you have to pay for it. And if you want to connect with that research and my commentary on it, try my very well-reviewed book: Social Care Practice in Context (Palgrave Macmillan, 2009).
There are just such tight administrative controls on practice in specialist settings such a palliative care social work, or in forensic social work, another specialist area where I have been involved in the past. However, most of these services have fairly limited caseloads and an opportunity to use social work more fully, more broadly, more of the time as part of the everyday job. Many of these services are also part of healthcare, which is generally much better funded than social care in the UK (and elsewhere). So the expectations of professional colleagues in nursing and medicine are of a higher standard of everyday practice, because they have the resources to achieve it more often. High expectations tend to lead to stronger achievements. It ill behoves people working in these specialised services to complain about the everyday ‘good-enough’ standards of the more resource-constrained backbone local government social care, because it does provide the backbone, without which specialised services are likely to be flimsy in their achievements.
But what I was saying in my post was two things. First, specialist social work operates in settings that mean it has to develop credibility with colleagues in other professions. By meeting their expectations of good practice and using their generally better resources, social work can demonstrate to the world that social work can be and often is widely valued by other professions, service users and the managers and policy-makers who develop services. That demonstration of the value of social work in at least some settings should enable us as a profession to say in relation to local government social work: ‘Hey, this social work stuff can be a really good thing for people and as part of services generally’. We can say it to buoy ourselves up in our down moments and to show other people that social work does not have to be minimalist as under-resourced local government forces us to be. Second, it enables people in local government to point to valued social work and say: ‘Give us the resources and we can do more of that too.’
I come across palliative social workers who moan about what it was like when they were adult services or children’s social care social workers and say how pleased they were to work somewhere like a hospice and do ‘real social work’ or they complain about the bureaucratised attitudes of the care managers that they deal with who aren’t doing ‘real social work’.
Let’s be clear: ‘real social work’ is the local authority backbone of adult services care management and children’s social care. Because of the massive number of people that local government provides services to, the everyday backbone job makes a crucial difference to the generality of people’s lives in this country and elsewhere. And the times when there’s a chance to do a really good job in that setting means that a lot of people have really good experiences of social work in those settings too. Specialised social work settings, like palliative social work, provide the opportunity to add into that a social work that is relevant to the particular needs of people with very special needs. Because of the special needs, that kind of social work is different again.
I’ve stopped talking about social work, instead I talk about ‘social works’ of all different kinds, relevant to the setting and the role. That’s true when you talk about social works that we in the UK are not familiar with, like social development practice, or social pedagogy, or cultural social work; these are all well-established practices in some countries. It’s also true about the different social works practised in the UK. None is a ‘real social work’; all are a social work.
An interesting article by Jonathan Walters on an American children’s safeguarding case in which social workers have actually been threatened with prosecution for manslaughter for failure to protect children has taken my interest:
Read it here: http://www.governing.com/topics/health-human-services/punishing-social-workers.html?nlid=h110412
I’m intrigued by a certain amount of American social work anguish about this, because it so happens I’m writing a paper about the effect of thirty years of criticism of social work in child protection cases for a for a conference on parenting in Poland at the moment, and this post is based partly on a comment on American discussion on LinkedIn. You tend to think of palliative care social work as about social work with adults, but I think one of the things about palliative care is that you find yourself dealing with the issues that are facing a whole family, most of which are not about the fact that someone’s dying. So palliative social work is actually just as generic as social work used to be in generic social services departments were in the 1970s, when we were trying to deal with all sorts of social work issues.
High public concern on child protection is of course justified (or as the jargon seeking a positive spin has it nowadays ‘safeguarding children’). Anyone ought to be concerned about abuse or neglect of children by adults and thinking through what we should do about it is an important concern of the public. Social workers have experienced opprobrium on child protection for thirty years, since the case of Maria Colwell in the early 1970s; Maria was killed by her stepfather in 1973 when being supervised at home by a social worker, and this has been damaging to the whole image of social work in the UK.
Since then, there have been many cases that have led to public scandals about child protection issues, including the Cleveland cases, when the public found out about the extent of child sexual abuse for the first time and the recent Victoria Climbie and Baby P cases. At least after Baby Peter, there has been a serious effort in government, maintained by the present coalition, to think carefully about what kind of social work we actually want rather than knee-jerk vituperation. Some thoughtful work is being done by the Munro Review, which alongside the Social Work Reform Board developments (a continuation of the Task Force) and perhaps the hopes for a College of Social Work might well help. Some links at the end to websites on this issue.
The main damaging result of justified public concern about child protection has been a naive proceduralisation of social work in the UK, to formalise and manage communication between agencies, to incentivise effective action by professionals and to share decision-making (and blame) among the agencies involved. It is as though if you tick boxes properly damaged human and social relationships can be This has led to a system in which child protection and the surveillance of parents is more important than providing good child care services and family support.
And public attitudes towards parental rights and responsibilities have also swung to and fro. The historical position was that parents had the right to bring up and discipline their children and nobody, least of all the state, should interfere with that. Over the last thirty years the law and public opinion has shifted towards a position that with that right goes responsibility for doing it well. But that hasn’t always meant that people feel that the state should interfere, and certainly there has been doubt about social workers doing that, not least because they have lost credibility because of child protection failings.
So social workers have continued to be the main target of criticism. This is partly because, in the UK system, children’s social care services are usually the agency with legal responsibility for taking action, so the police, doctors and nurses are inevitably less responsible.
But I believe it is also because of a political view among right-wing political parties, such as our Conservatives, US Republicans and German Christian Democrats, that people ought to be competent to manage their own lives and look after their children, and the state should not have to pay for a social work service to help them. So when people cannot look after their children, the political and media reaction is punitive to the parents and then also, when cases go wrong, to social workers for not intervening decisively enough and for being supportive and kindly to parents instead of representing a punitive public morality about parental responsibility.
So the criticism of social workers is also a frustration on the political right about the need for state intervention in family life. By setting themselves up as a profession that can help families deal with their problems, social workers have put themselves in the firing line.
The frustration for palliative social workers is that they have actually done a good job of convincing colleague professionals that they make a worthwhile contribution to multiprofessional practice in our field, but malking progress on this is held back by the continuing damage to the reputation of social workers by this semi-political issue about child protection. It;s important to keep plugging away about the positives, and one could only wish that social workers in local government children and adult social care would look to the social work specialisms for evidence that social work can very easily be seen as a good thing, if you work at achieving a very high standard of practice in all that you do.
The Munro Review website here: http://www.education.gov.uk/munroreview
The Reform Board website: http://www.education.gov.uk/swrb
The College of Social Work website: http://www.collegeofsocialwork.org
You’ll be aware perhaps from previous posts that BASW is, somewhat ludicrously, trying to claim the credibility to run the College of Social Work itself, rather than cooperating with everyone else; this is its website, but to get a balanced view of the issue, look at others as well: http://www.basw.co.uk
Another day, another book.
This is about some aspects of adult services in the EU; there are two articles specifically on palliative care, both from the UK. There’s also, among the general papers, a really good brief analysis of social policy affecting social services from a Czech perspective and a very nice paper with a private sector view on care home development in the UK – it’s gives a commercial perspective on decision-making you don’t often see.
More broadly, many of the authors (it’s a collection of conference papers) are from central Europe, so you get a picture of social services in a part of the world that most of us don’t know a lot about. There’s facinating paper in projects working with Roma communities and two comprehensive-looking papers on unemployment policy and disability policy all referring to Poland. There’s stuff on older people’s needs, on family problems and on community punishment in Slovakia (which gives a comparative perspective on their view of other countries’ developments), homelessness in Denmark and chronic drug addicts in Germany.
There are two facinating papers, with some interesting history on social work with families, on the problems with finding adults who will provide foster care and with transition to adulthood of young people in care in Poland. With a UK perspective, you tend to think of that as ‘child care’ rather than adult services, but actually these papers are about adult responsibility for young people and the transition to adulthood.
Another bit of a surprise is a comprehensive paper on university of the third age as a community development activity with populations of older people in Poland; it shows you an immense amount of social development you can do with older people.
Some practice skills papers give you a picture of how people in central Europe are thinking about skills issues.
I helped with the editing in English, and did a paper on where personalisation is at, but the book comes from Opole University in Poland.
It’s published by College Publications in London: http://www.collegepublications.co.uk/other/?00018
and you can find it on Amazon UK or US by searching for the title: Social Work in Adult Services in the European Union. Selected Issues and Experiences
This is my third discussion of current policy fads and fashions and their consequences for health and social care, and in particular end-of-life care: this time the focus is on Bog Society policy. In it, I argue that Big Society policy is underdeveloped, but reveals important features of Conservative thinking about society, in particular the wish to move away from public service approaches to service provision towards service provision that reflects the asumed ‘enterprise’ of the private sector.
Like most people, I’ve spent a bit of time struggling with BigSoc (this is what I call it), and you can see my struggle represented in my BigSoc blog (http://bigsoccommsw.blogspot.com/). I keep this separate from my St Christopher’s blog, partly because it deals more directly with party political issues (which is a no-no for St C’s). Also, it includes a lot of detail unrelated to end-of-life care and blogs need to stay with one main subject, so that people know what they’re getting. Hence the separation. However, struggling with BigSoc elsewhere does mean that I have a stash of material to ground my thinking in relation to palliative care. That’s what I’m doing in this post.
Why is BigSoc a struggle? For two main reasons. One is because its political focus and objectives are claimed to be unclear, by political commentators in the press. My stance in my BigSoc blog is ‘details tell all’: that is, if you dig around in what people actually say and do in some detail, you can get a picture of the whole, because what they are doing in practice informs you about the big ideas behind it. The picture reflects Conservative ways of thinking: they want a more private sector ethos in public services.
The other reason is that the BigSoc idea seems attractive to those of us who have always been committed to community work. Community work is the practice (sometimes it’s an element of social work and sometimes broader) which seeks to facilitate people from communities, both local communities and communities of people who share interests, to come together, work collectively on issues that they share and create solutions that they put into action themselves. BigSoc seems to want to encourage this; groups of local people are encouraged to find their own solutions.However, the engagement with people at the grass-roots that is typical of community workdoes not usually produce the kinds of initiatives and engagements that can be presented as colourful, imaginative developments demonstrating an important political idea likfe BigSoc. Consequently, activities selected to represent BigSoc, in order to promote the policy, are often quite untypical of what is actually done in community work and of what local government will achieve by decentralising and localising decision-making.
Therefore, contradictions seem to grow out of how the ConDem coalition has tried to implement BigSoc. I have pointed out before in this blog and elsewhere that the history of attempts to encourage community endeavour through government action is littered with government finding out that community action often leads very rapidly to protest about what government is doing, and rapid squashing of what communities want. It often also leads to communities creating responses that government does not expect. Governments (or the politicians in them) tend to think that their political views are widely shared, whereas they are often only shared by the people those politicians meet. The people who come together to share views and work on things together often find that their views and what they want to do about them differ from the political assumptions. Their public response is often protest or resistance, rather than imaginative development, or development of local services which do not offer a lot of zip-zap for someone who wants to promote a new BigSoc policy.
BigSoc seems to have two main drivers. One is a conception that government is too big. There are at least two elements to this: one is that it is too large as part of the UK economic system, and that if you reduced its economic role, it would leave space for non-government sectors of the economy to be creative, expand and get us out of economic problems. The second element is that government looms too large in people’s minds as the solution to social problems and that if you reduced its role in providing services and responding to social issues, people would sort out answers on their own. These are broad objectives for cultural change, based in broad political philosophies. Can encouraging local engagement in quite prosaic local government decisions or developing responses to small-scale local issues achieve such change?
The first concern driving the policy is that government is too big in the economy, leads to an economic policy which reduces government expenditure and tax, and associated political policies such as the ‘bonfire of the quangos’ and the ‘bonfire of red tape’, with the aim of reducing the burden that government places on the economic capacity of other sectors of the economy to innovate and expand.
The second driver, people should be enabled to become more active in resolving social issues, rather than relying on government, leads to attempts to reduce the role that government takes in providing many services and encouraging citizen activism.
Both these diagnoses and prescriptions might be questioned in serious economics and sociology, but I leave that aside. Also, critics from the left would say that these are just new formulations of a conventional liberal position, which argues on economic grounds for a small state. I’m leaving that on one side, too. The ConDem government has given these ideas importance in BigSoc, and so that is what we are playing with. In ConDem policy they are connected because reducing government expenditure and activity inevitably means present services or activities disappearing altogether, or being replaced by something less extensive. Making space for non-government enterprise at the level of the whole economy can also mean making space for individual activism in responding to social issues.
In a speech reported by the BBC, David Cameron, the UK Prime Minister, connects these two things: ‘My mission is social recovery as well as economic recovery’.
The BBC report, including a clip of Cameron speaking: http://www.bbc.co.uk/news/uk-politics-12443396
Another good political report from the BBC looks more comprehensively at the concept: http://www.bbc.co.uk/news/uk-politics-12163624 , and includes a lot of comments from viewers and listeners.
As this report makes clear, virtually anything that has to do with activism, such as volunteering or people demonstrating commitment to and involvement in their locality or some other social interest, may be seen as BigSoc. Since in the UK a lot of such activism goes on, the government might be able to claim wide support for its concept and the press might be able to identify lots of BigSoc activity. In one of my BigSoc blog posts, I looked at the claimed evidence for ‘broken Britain’ and the need for greater volunteering, and came to the conclusion that the government was overstating its case: a lot of community involvement and volunteering goes on, more than the government claims. This post is at: http://bigsoccommsw.blogspot.com/2011/03/good-evidence-exists-for-strong.html
Similarly, an earlier post looking at stated Conservative Party policy on BigSoc found that this rather naively seemed to be unaware of a lot that goes on in local community activity:
http://bigsoccommsw.blogspot.com/2011/03/bigsoc-minnie-mouse-policy-minimal-and.html.
The problem with this approach to BigSoc is twofold. First, it demonstrates a general ignorance and naivety or, alternatively, complete denial about what valuable things are going on in local communities and suggests that the policy is based on ignorance and denial. Second, it will allow Conservatives to claim all sorts of activities as the product of its policy initiative, when they were there anyway.
Palliative care organisations such as hospices fall into this category: they are there, they are successful, they substantially fund themselves. They are therefore a good example of what BigSoc policy might achieve. However, as I argue below, hospices are rather unusual voluntary organisations, and their size and funding cannot transfer all that easily to other comunity activties. So people in hospices should not be too forward in claiming either that what they do can be replicated elsewhere, or that they are some wonderful example to others: that is calculated to irritate lots of local government and the voluntary sector, who do not have the same advantages.
Claims that BigSoc is everywhere are already happening. In another BigSoc blog post, I examined all the projects that had received a BigSoc award from the Cabinet Office, at the time twelve, although the details of one of these was missing from the Cabinet Office website http://bigsoccommsw.blogspot.com/2011/03/details-tell-all-analysis-of-number-10.html. There were, of course, a variety. But an interesting feature was that many of them were for really rather ordinary community activities, carried out with pizzazz. In my later post, I listed the top ten words for putting into your applications for a BigSoc award, things like inspiration, passion, life-changing: the whole list here: http://bigsoccommsw.blogspot.com/2011/03/top-10-words-for-getting-number-10.html.
In many respects then, the government is treating BigSoc as a marketing tool for things that it wants to encourage. You’ll have gathered from many comments in this blog that I’m unhappy about marketing as an approach to health and social care. In another BigSoc blog post (http://bigsoccommsw.blogspot.com/2011/02/bigsoc-is-not-pr-message-it-demands.html), I pointed to a PR wonk’s take on BigSoc; she was saying that people in government were treating it as a way of conveying a warm friendly image, in the face of criticism about cuts.
I connect this with Steve Burghardt’s recently published book on macro social work (Macro Practice in Social Wokr for the 21st Century Los Angeles, Sage, 2011), in which he describes community work as being ‘chutzpah meets humility’. The point is: if you are going to facilitate people to come together and make their own decisions, you have to take a step back out of the limelight and help them to work things through in their own way. One the other hand, you also have to have a certain amount of zip-a-dee-doo-dah to promote new ideas, get people engaged and push things along. It’s a difficult balance to achieve, and one of the skills of community work is achieving this.
I think the Conservatives understand the chutzpah bit, but not the humility. You can see this in the kinds of things that they support as BigSoc.
So what is BigSoc as the government sees it? Cameron has made a number of attempts to describe this.
The first general presentation of the ideas is the Hugo Young lecture in 2009: http://www.conservatives.com/News/Speeches/2009/11/David_Cameron_The_Big_Society.aspx
The conclusion of my analysis on this in the BigSoc blog (http://bit.ly/i3pD3L) is as follows.
To sum up the argument, Cameron is arguing that the size of the state leeches away personal and shared social responsibility. BigSoc policy aims to provide government to action to reverse that. Subsidiarity is the thing, giving responsibility to the lowest possible level in society. They will try to give individuals the responsibility and capacity for helping themselves, through family, education and welfare reforms. Where that is inappropriate, they will encourage shared action in neighbourhoods, and when that is not possible they will make the lowest level of government, local government responsible, and make it more transparent, accessible and responsive to active citizens.
In an article in the Observer, after some criticism of BigSoc, he says:
The big society is about changing the way our country is run. No more of a government treating everyone like children who are incapable of taking their own decisions. Instead, let’s treat adults like adults and give them more responsibility over their lives. That’s why, in reality, this is quite different from what politicians have offered in the past.
This is not another government initiative – it’s about giving you the initiative to take control of your life and work with those around you to improve things. It has the power to transform our country. That’s why the big society is here to stay.
The article here: http://www.guardian.co.uk/commentisfree/2011/feb/12/david-cameron-big-society-good
An article in the Observer recently claimed that some of Cameron’s ideas are from Schumacher’s famous book of the 1970s, ‘Small is Beautiful’. Quoting extensively from the book, I argued in the BigSoc blog http://bit.ly/dN1rvU , that, if so, it is a complete misunderstanding of Schumacher’s point. He is arguing that a policy of pursuing economic growth to achieve larger economies, with larger economic units consuming larger finite natural resources, is unsustainable. The outcomes of this growth model are the increasing use of finite natural resources to achieve merely transitory consumption. Present Conservative policies clearly aim at this kind of economic growth, which Schumacher criticises. Conservative BigSoc policy is completely antithetical to Schumacher’s position. It seeks to reduce constraints on big business in order to achieve higher economic growth. It sees the main constraint as big government, and so it wants to remove big government in favour of localism, because it thinks this will release economic growth. Schumacher does not talk about localism so much as the small and the human.
In his Observer article, Cameron notes, fairly accurately, the criticism of the concept, and these are his answers:
It’s too vague: he rejects this because he is against creating one central design
It’s a cover for cuts: he says supporting social responsibility is a different matter and he has supported that for a long time; anyway, greater social responsibility will benefit society.
It will work in rich areas, but not where there are no resources: he rejects this because there is evidence of activism in poor communities.
It’s not new: yes, but he wants to encourage more of it.
Voluntary bodies are being squeezed: no, they will be restructured because the Conservatives will open up opportunities for voluntary bodies to bid for contracts for public sector activities. (To the extent, I would say, that they demonstrate emterprise thinking and chutzpah.)
Polly Toynbee and a range of commentators on her article cover most of the issues about cuts to voluntary groups. She distinguishes between small very local social groups and the organisations providing services, often under contract from the government already, although it may limit their preparedness to criticise government. The fact that small groups fund themselves is irrelevant to support for that part of the voluntary sector that provide useful serviecs. She also criticises the concept of the BigSoc bank, providing development loans at commercial rates to help voluntary organisations compete for government contracts as part of her argument that government support is central to succesfsul voluntary endeavour.
http://www.guardian.co.uk/commentisfree/2011/feb/14/david-cameron-big-society-charities?intcmp=239
Similarly, a Jackie Ashley article sums up well the critics who say you cannot achieve BigSoc if you simultaneously cut funding to charities and voluntary organisations, because they are the major existing aspect of BigSoc. If you cut local government, those cuts will have a disproportionate effect on voluntary organisations, since local government will priorities its own staff and services.
http://www.guardian.co.uk/commentisfree/2011/feb/13/big-society-destruction-david-cameron?intcmp=239
So what does BigSoc seem to involve in practice? To work that out I looked at a number of policies and practices, and you can follow the detail in the following BigSoc blog posts.
What’s happening in the three continuing BigSoc ‘vanguard’ local authorities (one, Liverpool, gave up in a shower of sparks because local government cuts was preventing it from developing BigSoc policies and had reducing funding for voluntary sector BigSoc activities):
Sutton, in south London: http://bigsoccommsw.blogspot.com/2011/02/suttons-bigsoc-vanguard-tells-us-what.html
Windsor and Maidenhead, to the west of London: http://bigsoccommsw.blogspot.com/2011/02/details-tell-all-windsor-maidenhead.html
Eden, in the Lake District: http://bigsoccommsw.blogspot.com/2011/02/details-tell-all-windsor-maidenhead.html
Overall, what is going on in local government is not very impressive and not very imaginative – no chutzpah there. First, most of what they were doing they were doing anyway, they were just relabelling it BigSoc. sometimes openly. Second, many of the initiatives were about local involvement in planning; nice, but probably they should have been doing that anyway. The problem with participation in decision-making is that it is not very attractive to local politicians, because they feel they have been elected to make decisions and achieve their political objectives, not have them questioned by every Tom, Dick and Harry that turns up to public meetings. Third, there were meetings with local citizens or with voluntary organisations to discuss what BigSoc might mean. These seemed to be part of getting more volunteers for things, especially if it meant reduced local council costs.
Another important aspect of BigSoc policy is what I call ‘enterprise’ thinking, and I have sometimes called it ‘businessification’, following John Harris’s critique of treating social work as though it was a business activity. In many Conservative eyes, an important objective of BigSoc is that it is a local arm of the government’s aim to encourage the private sector to be engaged in what is now public sector activity; this is inherent in many of the government’s policies. Part of the reasoning for this is an opposition to bureaucratisation, by which Conservatives often mean unimaginative thinking which opposes change of the kind that Conservative politians would like to achieve. The answer to this is being enterprising, imaginative, creative and all these traits are assumed to be associated with the private sector, rather than the public sector. To the extent that voluntary organisations emulate that, they are good and not part of the public sector. To the extent that they just take government money for providing government services, they are bad, and just another aspect of the public sector.
It’s back to chutzpah again. Conservatives like to see community activity that demonstrates chutzpah; humility and participation are not enterprising; they do not understand why you would need it. So only particular kinds of community activity are required, therefore, and activities such as continuing to build and provide end-of-life care through professional integrated community services (to give one example) do not have it.
Much of the rest of my blog has been about the debate on voluntary organisations. Here, the pattern is quite clear. Conservative commentary is anti the ‘establishment’ of the voluntary sector, which receives government money for providing services (http://bigsoccommsw.blogspot.com/2011/03/tories-reject-establishment-charities.html) they are really hoping for radical, enterprise oriented voluntary organisations with right-leaning policies enabling disabled people and single mothers into employment, for example. And chutzpah. A ‘society of the second chance’ is an Iain Duncan Smith phrase which seems to mean forcing people to take whatever second chances they can get, instead of staying comfortably on social security benefits.
What does all this mean for palliative care? It’s a complicated picture. Most palliative care is in hospices in the UK, whereas a lot of non-specialist end-of-life care is with GPs and general health and social care services and BigSoc policy is different in these two areas.
Hospices are talked up by the Conservatives, including Cameron. I have commented before in this blog that this seems to be for two reasons. First, hospices raise a high proportion of their own funding, so they are not ‘establishment’ charities, in the sense that the government supports all their activities. However, they are not enterprising; they do not have chutzpah. The need for chutzpah if you want to appeal to the government is the reason for the success of organisations such as Marie Curie and Macmillan: they employ high-profile senior staff who trumpet successes in a glossy, businesslike way with lots of advertising and image. Solid service provision from your local hospice is a lesser priority.
Second, there is a sentimentality about end-of-life care, which politicians pick up from general public attitudes. Most people have little to do with the end of life, don’t like to think about it and support organisations that make them feel that it’s all going to be handled very nicely and kept out of their way.
On these two counts, BigSoc will have little impact on hospices, for so long as they are able to continue raising their own funding and put up some people with chutzpah. This means that the government does not actually have to make clear decisions about the extent to which they support end-of-life care as against other priorities, and it all sounds jolly good. I suspect that if they did have to think about it, they might not be so supportive, and might in particular want to see a reduction in the high costs of quality palliative care. The distance means that everyone can feel a warm glow of doing something nice with a little bit of funding and expressing support.
End-of-life care is not much involved in local authority and voluntary sector funding cuts, so it neither irritates government supporters by whingeing about cuts nor engages with the problems of local health and social care organisations. That will last until local service changes begin to affect hospices’ capacity to achieve home care.
Another factor is that most hospices, although theoretically voluntary organisations, and locally committed, are really part of the health service, and BigSoc does not talk a lot about the NHS. Health promotion and well-being are good things, but actual services are part of the public sector bureaucracy. Hospices do not generally have a lot to do with the local voluntary sector establishment, or with local government, and are much more affected by NHS policy. The more generous funding of the health sector tends to insulate them from the debates about BigSoc, at the same time as being a potentially desirable element of BigSoc.
So BigSoc is not a big deal for palliative care yet, but BigSoc policy is going to permeate lots of thinking about public services. This will have a particular impact on palliative care as the health and social care reforms that I discussed on Tuesday begin to affect palliative care. My next post will try to bring together health and social care reform, BigSoc thinking and end-of-life care.
This is the second of my posts looking at the whole situation in health and social care at the moment and its impact on end-of-life and palliative care.
It is clear that the government proposals on NHS and (to some degree) social care reform are in trouble. What will this mean and what will it mean for end-of-life care?
I did some detailed stuff on the proposals and what’s in the Bill in previous posts: search for ‘Health and Social Care Bill’; there are several posts in January 2011.
However, if you want a good summary of the characteristics and political impact of the proposals, look at the BBC news website, in its Q&A on the reforms:
http://www.bbc.co.uk/news/health-12177084 (this also has a nice diagram of the changes).
and its summary of views for and against them:
http://www.bbc.co.uk/news/health-12750695.
A more complex account of the issues may be found on the King’s Fund website:
http://www.kingsfund.org.uk/topics/governance_regulation_and_accountability/index.html#keypoints (start at the keypoints, then go on the background tab and the comment and analysis. Anna Dixon’s blog post on the ‘paradoxes’ in the reforms is worth a read, and so are some of the comments: the readers of the Fund’s blogs are better informed than a lot of comments in newspapers).
The fact that the Health Secretary, Andrew Lansley has said that there is still room to amend the reforms suggests that they are: the Telegraph report on that here (I use the Telegraph to report on government views because it is a broadly government-supporting newspaper, so I can’t be accused of selecting press that might put a negative slant on things):
The reforms are in trouble for three main reasons.
One of the reasons is not privatisation through marketisation (that is, reducing the public sector element of NHS provision, by strengthening that aspect of NHS care that is provided through a managed market). Of course, the usual suspects have said ‘Tories – get your thieving private sector friends’ mitts off our NHS’. The two main suspicions are (1) that American and other big healthcare companies hope to get in on running local commissioning and (2) that the ‘any willing provider’ policy integral to the reforms is likely to increase private sector participation.
The main concern there is cherry-picking. Private sector providers like nice cheap easy, repeatable procedures to carry out (hip and knee replacements, cataract operations like the two I have just had, and so on). If you take these out of the NHS, you leave the more difficult stuff for the NHS to do. As a consequence, they have to deal with the more complicated and expensive stuff and over time can be made to look even more unrealistically expensive than they are now. Also, they cannot train up their surgeons on the easy stuff, so they are going to be less skilled on the difficult stuff. Faced with these criticisms, the government has introduced some concessions to meet these concerns. Lansley says in an interview (link below) that this means any willing qualified provider, so the local commissioners will decide; they can choose to avoid excessive private sector provision if they want to maintain their local hospitals.
Also, patients can say they want their local hospital and I expect a lot of them will. After all, we all know that if there is any problem in a private hospital, they can’t cope and the patient is blue-lighted to the nearest NHS hospital. It’s only really naive believers in the private sector that are unaware of this. Also, things like palliative care just don’t happen in the private sector and since the main increases in service demands are going to be among older people with long-term problems, they’re not going to find really good care in the private sector of healthcare. Private sector domiciliary and community care is far more likely to stay directly commissioned from the public sector, even if providers are increasingly private or social enterprise organisations.
Is there any evidence that private sector companies are trying use the reforms to get into the NHS? Yes, of course; any private sector organisation is going to look for expansion opportunities, just like any energetic public sector manager. Try having a look at the website of the private sector consultants, Binley’s: they’re charging a lot of money for people who want to get up-to-date news on changes, NHS changes are the top of their list of ‘products’ enabling private sector organisations to ‘track’ the NHS reforms; they say they have 30 researchers doing nothing else. Yes, there is big money in prospect for the private sector:
http://www.binleys.com/Products.asp?CatID=13
Not including, it has to be said, the official opposition, Labour. As with the cuts campaigning that I covered yesterday, they are somewhat stymied by the reality that many of the reforms explicitly build on their own policies, and they might well have wanted to do something similar.
No, the three main reasons why the reforms are in trouble are mainly other professional and political opposition.
The first is that the people who are intended to be major players in the reforms, the GPs, have turned out to be mostly opposed to it. There are supporters in the GP camp, mainly people who have been making GP involvement in commissioning work in, mainly rural, areas where the Conservative MPs come from. A few of these people can be (and have been) characterised as venal doctors keen on supporting a privatised NHS so that they can get rich(er); possibly because some of them really are like that. Consultants have also called for the Bill to be withdrawn, it seems because it may endanger the importance of the major local hospitals through fragmentation and privatisation, and therefore their influence. They have been trying to whip up concern about local hospital closures. See the Telegraph report of their concerns, for example. This presents a mish-mash of claimed concern for the NHS and their patients and complaints that they are not respected by politicians, who promised to leave the NHS alone: http://www.telegraph.co.uk/health/healthnews/8400872/Doctors-call-for-industrial-action-over-devastating-NHS-reforms.html
However, they are still negotiating on pay and conditions (like other public sector employees, their pay has been frozen, fancy the consultants being treated like the lower orders), so perhaps the government will be able to buy them off. Governments have been doing that since Aneurin Bevan, the Labour health minister in the 1940s.
Also, lots of people concerned about the management of the NHS are doubtful that GP consortia being responsible for commissioning the majority of services can be made to work. This is partly because GPs are considered to be mainly interested in treating their patients (although GPs I know are also scathing about the management of commissioning on behalf of their patients and it’s important to recognise that being able to refer your patients to the right treatment is an really important aspect of the role of GPs), but also because this will lead to further fragmentation in planning and management. Some others are concerned that it will let private sector healthcare companies in to help them manage it. If you think pct bureaucrats are the worst kind of management to have, wait until you see a management consultant: incompetence is miles better than financially motivated rapacity.
The second major reason for the trouble that the reforms are in is that the LibDem party, in coalition with the Conservatives who have dreamed up the plans, have now come out opposed to them. There will have to be concessions. The Telegraph report contains a video of Nick Clegg, the LibDem leader, distancing himself from the reforms:
http://www.telegraph.co.uk/health/8378143/Nick-Clegg-faces-crisis-over-NHS-reforms.html
Another account of the LibDem debate here:
An important influence in this has been the intervention by Lady Williams, Shirley Williams an ageing national political treasure on the left: interviewed by Simon Hattenstone in the Guardian, she said:
“I’m very worried about health. I’m a passionate believer in the health service, I’ve never used private medicine in my whole life.” She believes the NHS is “by and large wonderful” and the proposed restructuring is as unnecessary as it is dangerous. “We looked at [Andrew] Lansley’s white paper, and it’s got a lot of holes in it. For example, what happens if a foundation hospital has a deficit or a surplus, where does the money go, to whom is it accountable? There’s no system of accountability of a democratic kind, except for the bit the Liberal Democrats have put in, which is not very strong, but all credit to our guy for doing it.”
Williams is aware that critics argue this is a preliminary step towards privatisation of the NHS. And yes, she is fearful. “What I do know is that if there was any sign we were moving towards privatisation of the NHS, a lot of Liberal Democrats would not put up with that.” Would Nick Clegg? After all, power is pretty intoxicating, isn’t it? “Oh to be fair to the man, I think he would feel this was a red line.”
The full interview at: http://www.guardian.co.uk/theguardian/2010/aug/14/shirely-williams-saturday-interview
The third major reason, also political, is that while the reforms are likely to get through the House of Commons, they will be under much more pressure in the House of Lords. Lady Williams and her friends are clearly calling up a storm. Again, probably some more concessions.
There’s a good LibDem document which is perhaps the best available political statement in favour of the reforms – it’s significant that Appleby, providing a critique in the British Medical Journal, cites this, rather than the white paper or any Conservative statement; it’s just such a good explanation of the political case:
This is worth reading to get an idea of the arguments against the ‘Tories red in tooth and claw’ critique you get from left-leaning sources.
The government makes two main points. It argues, first, that reform is needed because UK health outcomes are not as good as in Europe. This point has been subjected to a statistical analysis in the British Medical Journal by Professor John Appleby of the authoritative King’s Fund: http://www.bmj.com/content/342/bmj.d566.full
He argues that UK outcomes on cancer and heart deaths are worse than some countries in Europe, but are coming down faster, so we’ll be better soon, that in other illnesses the UK does better and that much of the difference is down to how the data are collected and analysed, rather than actual differences.
In a later article, Appleby points to the British Social Attitudes survey results, which show increasing public support for the NHS, and evidence that the public thinks it’s improving. A link to Appleby’s article: http://www.bmj.com/content/342/bmj.d1836.full
And to a summary of the British Attitudes survey (actually co-authored by Appleby, so it appears his BMJ article is in the nature of an advert for his work – what an academic would call effective dissemination):
http://www.natcen.ac.uk/media/606952/nat%20british%20social%20attitudes%20survey%20summary%204.pdf
This report says:
- The largest increases [in positive views of the NHS] have been among those with traditionally low levels of satisfaction. These include 18-34 year olds (up 32 percentage points since 1996, compared with an increase of 24 points among those aged 65 and over) and better-off households in the top two income quartiles (up 31 and 36 percentage points respectively since 1996, compared with an increase of 25 points among the lowest income quartile).
- While satisfaction with the NHS among Conservative supporters fell initially when Labour came to power, it rose 12 percentage points between 1996 and 2009, reaching a high of 61% in 2009.
So actually it seems that people mainly like the NHS as it is. We know this, of course, because satisfaction surveys are not the most sophisticated way of measuring effective healthcare outcomes and most people could not imagine how it might be better if they’ve had (or they’ve heard that other people they know had) a broadly good experience. But all this does not add up to an overwhelming case for a very disruptive reform in most people’s eyes.
The second, and more important, point the government makes is that the NHS will have to cope with escalating demand and need and these reforms empower people in the NHS to transform the way they work to meet that demand.
You can of course go back to the horse’s mouth. Andrew Lansley gives an extended 42-minute interview on a doctor’s website at:
http://healthandcare.dh.gov.uk/andrew-lansley-talks-to-doctors-net-about-modernisation
(unfortunately, you have to sign up for other things – make sure you set your preferences); if you think 42 minutes is too long, set it going and do other things on your computer while it’s running; don’t do this at night, it’s very soporific. For example, he argues that cherry-picking will not be possible because if GPs set up an integrated care pathway, private sector companies can’t pick off individual procedures. The journo who interviews him puts serious criticisms (from doctors) to him, for example from specialist doctors who say they have studied to acquire the knowledge about what is effective, so how can GPs make these decisions, and, for example again, if things don’t work out, what are they going to do? He, of course, sounds eminently reasonable, and the interview doesn’t really put him under Paxman-like pressure, but it does give you a picture of what he thinks.
Overall, the picture is that it’s future population and medical cost pressures on the NHS that he has to reorganise to cope with, and if there’s not going to be much money, it’s clear that doing things better is the major way of dealing with those problems. The critics would say, of course, stop spending the money on silly things like maintaining an unrealistically significant place on the international scene, settle for being a little country with not much international power but a really good lifestyle for citizens. Then you might have more money again, and you might give priority to citizens’ healthcare.
The Department of Health is keen to say that GP involvement in commissioning has been very effective. If so, there’s not a lot of evidence on its website. One case study is trumpeted as showing how it will work, but is about a group of GPs who decided they wanted to get more counselling for their patients with personality and eating disorders and worked with a local voluntary organisation to provide it, which eventually got the contract. Here is the link:
http://healthandcare.dh.gov.uk/case-study-integrated-care-commissioning
There’s another case study based in my home town, Sutton, where Care Minister Paul Burstow has his base. This is about local authority and GP commissioning. In this case, the GPs and local councils worked together to keep patients at home rather than admitting them to hospital for three conditions. ‘A six-month pilot, based on just three medical conditions and a trial area of only 25,000 patients, reduced PCT admissions by 29 patients with long-term, high risk conditions and saved approximately £322,000.’ It is now being extended to two more conditions. Again, this is a small-scale project, rather than mass commissioning.
GP commissioning is not the only aspect of the reforms. A much greater welcome, across the political spectrum, has been extended to the arrangements for better integration with local authorities. And of course, if you are going to make things work better for an ageing population and a country that can’t afford medical developments, this is one important route to achieving it. One of the pluses is that better integration with local authorities will connect up health and social care services much better, and it builds on long-term attempts to improve relationships and joint work and planning. The minus is that this has been going on for forty years, and conflict and competition is still rife on the ground. One simple reason for this is lack of resources; both sides try to pass the buck as much as they can.
A more high-flown point about the failure to integrate, is that all integration efforts assume that NHS illness care is the most important thing. However, we are not talking about illness, we are talking about long-term care for people with complex social and health care needs as they age. And the NHS has withdrawn from all that, but still demands all the resources for its acute services, starving the much more important long-term care needs of resources.
As a result, healthcare (and DH generally) twists social care into being the mere servant of healthcare priorities. Remember that social work is about promoting social solidarity, resilience and cohesion so that a population can cope with the social pressure on it more effectively. Public health sits well with those priorities, but the NHS is about illness care, not wellbeing. Attempts to merge NHS concerns with public health and wellbeing are prone to disaster because the imperative to treat sick people twists all other social objectives out of kilter. This runs a serious risk of prioritising massive treatment problems instead of equally massive but rather more distant problems of health inequality and social cohesion.
I think of it as rather like the Japanese and their nuclear power industry. The Japanese don’t have reserves of fossil fuel, so if they want to run an advanced industrial society, they have to have lots of nuclear power. However, they also occupy a mountainous set of islands, with minimal coastal plains in which people can live, be industrious and build their nuclear power station, alongside a major geological fault on the earth’s surface which creates large earthquakes and tsunamis. So they keep quiet about the problems, and minimise the difficulties. The recent earthquake and tsunami has found them out.
Because people’s free health care is so important to them, what the DH does, like the Japanese on nucelar power, is run everything they do as subservient to the NHS, and just ignore or keep quiet about any other priorities that might interfere with it. That is why the DH is so bad for social work and social care. It also runs everything as though important care services such as end-of-life care is the same as but less important that acute care in hospitals, so that acute care always seems more important. That is why the DH is so bad for end-of-life care (but seems alright for palliative care, which is really only what the doctors and nurses want to do, and the less important doctors and nurses too, because they’re not concentrating on curing people). It is important not to forget these eternal verities about health care in the UK. Actually, what is more important is mutual social support, prevention and quality care in the long-term that affect everyone as they age. As I said yesterday, we should be aiming to love quality care, but theNHS is set up to love expensive acute care; they love money for treatment rather than less money for quality of life. The whole NHS healthcare system is set up to twist everything so that it fits the fantasy medicine of high-level surgery and heroic medical care.
In some ways, these are points made by the experienced civil servant, social services director and former Labour health minister Lord Warner, in a book: http://www.guardian.co.uk/society/2011/mar/22/nhs-reforms-essential-lord-warner
He argues, according to the Guardian, that Labour failed to ‘…achieve effective commissioning of healthcare, allowing an excessive expansion of the workforce, thus worsening productivity, and ducking the challenge of replacing seriously underperforming and unsustainable hospitals and other care providers.’ He is focused here on the way in which local campaigning often emphasises acute hospital care and the closure of acute hospitals rather than boosting the far more important provision of long-term care in the community.
The reforms aim to use enforced collaboration with local authorities to achieve this. I’m not hopeful, because as I’ve said, it never has achieved any change in the ‘acute-is-best’ NHS scenario yet. The DH trumpets ‘early adopters’ of health and wellbeing boards; these are 132 areas where they have set up shadow boards: http://healthandcare.dh.gov.uk/early-implementers-of-health-and-wellbeing-boards-announced
But if you look carefully, they haven’t actually done much. The DH general statement says:
Many local authorities already have projects in place to integrate services, including:
- combining health and social care support for dementia suffers (sic) to reduce hospital readmissions
- improved communication between health and social care professionals to enhanced the support package offered to vulnerable members of the community
- fast-tracking learning by integrated public health teams in local authorities.
Notice that this is not a brave new world; it talks about local authority projects. I wonder how genuinely collaborative they have been and whether they have been directed to social objectives and health prevention aims, instead of NHS treatment priorities. Notice that the leading achievement is to reduce hospital admissions for dementia sufferers (as I think they meant in their website); this is, it means hospitals don’t have their acute care priorities twisted by actually having to care for people with long-term problems.
This overall impression is supported by another entry on the DH website, the example of effective health and wellbeing board shadowing in Leicestershire: http://healthandcare.dh.gov.uk/leicestershire Again, this is in special project territory, with the aim of getting more health checks for people with learning disabilities. Nice, for example ‘supporting people with learning disabilities to interview Trust Board members about progress’ but not exactly mass commissioning of the full range of NHS services. It’s an important aspect of service, which you would hope to see developing, but a small development project involving a local voluntary organisation for a limited range of patients who are unserved at present is a million miles from commissioning the whole range NHS services. When the big boys of private health want a slice of the action over something that’s important to them, it’s unlikely that a little local group will get a look in, and the GPs would find it hard to resist the pressures of the big professionals.
The website also has a filmed interview with someone described as an early implementer. This is an accolade I’ve often been tempted to seek, and always discretion proved the better part of ambition. You really wonder why the DH decided this innocuous film of someone saying they’ve got an shadow health and wellbeing board was worth putting on their website. The interview is apparently conducted against the background of a conference, no doubt to make it stunningly as of the moment, in that artistic way that only Channel 4 news can really achieve. It features a pink-bespectacled NHS bureaucrat, now working for a County Council. I thought of not bothering to give you the link, since it’s one of the most pointless uses of internet technology I’ve ever seen, but I’ve decided to offer it as a good example of how to say absolutely nothing in 38 seconds – it was edited too, so she was obviously irrelevant to anything important for even longer. Don’t show it to any Tories: this is exactly the sort of unnecessary bureaucracy that they’re keen on killing off and she seems quite nice really: http://healthandcare.dh.gov.uk/early-implementer-cheryl-davenport-nhs-leicestershire-county-and-rutland.
This has a lesson for palliative care. Existing palliative care organisations which are providing services on the ground are quite likely to get their provision supported under the new system. But if extensive developments in palliative care are required in local hospitals, is this going to get priority when they’re fighting tooth and nail with big private providers for more major areas of acute care? Will it fall by the wayside because the big health providers will not be interested? This is likely, because exemplary care for amorphous things like the end of life is not what the big private providers are about. It works in America, I hear you say? Yes, but only because everything is private in the US, so there are financial mechanisms for all sorts of values-based bits of healthcare, and of course, unlike the NHS, they do not have to be responsible for a substantial slice of the population that presents social problems and does not have any personal, family or community resources.
To add to the more neutral stuff mentioned above (good old BBC), the Guardian’s page on the reforms covers the main points on the reforms well as they were published in January:
http://www.guardian.co.uk/society/2011/jan/19/nhs-health-reforms-unveiled
(with a nice Steve Bell cartoon in which surgeon Lansley bloodily extracts the innards of the NHS:
Why are they in trouble, then? The Guardian account of the BMA meeting which rejected the reforms of behalf of GPs, who are the main protagonists in the new system, is instructive:
http://www.guardian.co.uk/society/2011/mar/15/bma-meeting-rejects-nhs-reforms?INTCMP=ILCNETTXT3487
However, there has been something of a media war and the government tried to put the positive side. The Guardian also reported on GP supporters of the scheme who turned up at a reception at No 10:
http://www.guardian.co.uk/society/2011/mar/15/nhs-reforms-doctors-accountants
and there was a subsequent exchange of letters, mainly representing opponents of marketisation, in which ‘fantasy economics’ had a part to play:
What about comment other than in the left-leaning Guardian. I turn to the Telegraph.
A Tory MP and GP says that the reforms will change the NHS ‘beyond recognition’:
Her criticism is that it’s good to get rid of a middle tier of NHS bureaucrats, but NHS planning should not be done by an unelected regulator (Monitor, the much-expanded financial regulator in the plans) and local GPs have too much to do treating their patients. Also, stripping out two tiers of management is really top down, and the Tories are not supposed to be being top down.
If you want to see Conservative official policy on health, this is the link to the election manifesto, which says ‘where we stand’:
http://www.conservatives.com/Policy/Where_we_stand/Health.aspx
But I searched for ‘NHS Reforms’ on the Conservative Party website and in the total returns found only one passing mention by George Osbourne in a party speech in 2011; most of the entries are much earlier. The Party obviously does not keep its website up to date, or else it’s keeping quiet on NHS reforms.
You can’t search the Labour website, I’ve said before that they don’t like you to find out anything they don’t want to tell you (although it is easier to read than when I last assessed it – but I suppose that may be because the NHS has renewed my eyes). They don’t really talk about policy there, but there are one or two items telling you how David Cameron has broken his promises to protect the NHS, but not a lot of detail. I worked hard to find these by ploughing through the site map, so here they are:
http://www.campaignengineroom.org.uk/frontline-nhs
I’ve already mentioned the very good LibDem statement explaining the case for the reforms, but here’s the link again:
These are the positives that the critics have to argue against.
The Social Enterprise Coalition, whose sector is one of the intended beneficiaries of the reforms enabling non-public providers a chance of getting involved, focused on a concern that NHS staff would find it easiest to go for privatisation because they didn’t know enough about social enterprise to use it properly.
http://www.charitytimes.com/ct/NHS_reforms_must_shield_against_privatisation.php
This is a thoughtful point, and the palliative care sector, along with many voluntary organisations, could draw on their own experience to support this. Most NHS commissioning is done from the perspective of people who mainly only know about the NHS and do not have the time or knowledge to build alliances with small local organisations, or to support them to develop. Privatisation may come about by default.
A good realistic website, which usually contains links to the latest news, is the Royal College of General Practitioners’ commissioning website. They are trying to improve GPs’ skills in commissioning and getting feedback from their members about what’s happening on the ground, so this is a really good site for understanding how GP commissioning is going to work:
http://www.rcgp.org.uk/centre_for_commissioning.aspx?gclid=CJrznKuW9KcCFY0hfAodphr3bQ
This is the daily news update for today:
General practice must embrace change to improve quality of patient care
GP reforms’ leaders on boards of private firms
Why the NHS needs to be reformed
Private firms set to join NHS Board
Consortia must save £4bn by 2014
There could be no better evidence of the likelihood of serious privatisation and reductions of funding than these headlines from just one day.
And here is a broadly supportive comment from a blog, and some of the supportive or critical comments received:
http://bellagerens.com/2011/03/13/those-nhs-reforms
Among the points made are comments that many people involved in health and social care would agree with, that neither central government nor PCT commissioning has been particularly effective, and improvements in effectiveness are certainly needed. There are also some ways in which these reforms might help; whether they do will depend on how they are implemented.
Writing a conclusion sounds a bit like finishing off a student essay, but I feel I should get to some sort of summary of what I think, having looked at this stuff. In a few sentences, it’s this.
It’s clear that reforms of NHS provision are needed, to cope with demographic and medical developments.
I have probably also made it clear over the years of this blog that I yield to nobody in doubting NHS commissioning, which I think is very distant from the priorities of patients and the communities they live in; I have never seen any genuine engagement in the community from NHS commissioners, but I’ve seen a lot of worries about the budget and relationships with big providers; hence I am also doubtful about the value of PCTs as at present constituted. So I’m up for reform, but I want to make sure it improves things and I think the general opinion is that this might not be the right way to go.Evidence of successful local collaboration is of small-scale projects with limited service user groups, rather than extensive broad service commissioning. This is likely to continue. It’s good to see, but it’s no evidence that GP commsisioning will work for everything.
It looks as though proposals for universal GP commissioning are over-optimistic, but greater bottom-up professional engagement, and not only from GPs but other professionals and from social care and local government, would probably deliver a better system.Campaigning by critics of privatisation have already achieved some concessions, but it is clear that marketisation will go ahead, because the Conservatives have a majority and believe in it and most people (like me) are not convinced by NHS bureaucracy and are happy to see some change. In this way, I think NHS bureaucrats are a bit like child protection social workers – they have the kind of job where something is bound to go wrong and they’re bound to be blamed for it.
While there are many opportunities for private sector input, there is everything to play for in defending local services against excessive cherry-picking and disruption by private sector companies.
There is broad support for collaboration with local health and wellbeing boards, and some good joint projects: there will have to be a better focus on long-term care, prevention and care policy and away from over-emphasis on local acute hospital provision.
To achieve better end-of-life care, we need to put effort into supporting better integrated long-term care, especially for older people and in dementia services, because that is where most end-of-life care happens, and therefore we need to support the shift from acute hospital care to better community care, more effectively integrated with good palliative care in hospitals so that people’s end-of-life care needs are better met wherever they are.
I think we should replace the rhetoric about ‘cuts’, from the government as well as from its critics, with something more sensible. In this first post of a series on the Big Society and health and social care reforms and budgets, I argue that we must change the culture of our society away from the love of money (by big government, big finance and big anti-cuts campaigns) and towards the love of providing quality services.
After the weekend of the large TUC-organised anti-cuts march in London, I suppose I should say that I am not an enthusiast for the ‘cuts’ rhetoric. This starts up in the press, among right-wing enthusiasts for the small state and among people with genuine concerns about public provision whenever an international financial crisis leads to our government retrenching on its financing of public services. I sympathise, but I think we have to look at the bigger picture.
The bigger picture is, first, to understand the role of the economy in balancing the public and private sectors in health and social care provision. Second, the bigger picture involves understanding and achieving the complex balance of professional standards, regulation and economic drivers that maintain good quality care. I’ve said before in the blog that, for me, if I’m up against it, no organised care can ever possibly replace my lovely wife’s care, and this will not be available 24 hours for weeks or years ahead, no matter how hard she tries. So the reality is that all care is not the best we would want. The problem is to make sure that it’s good enough.
Look, for example, at Southern Cross, the private sector nursing and care home organisation that has been in trouble for some months. It’s in the news again today, with the chief executive having achieved the honour or ignominy of being interviewed about his troubles on the Today programme, although he was treated very kindly.
What’s the problem here? There are two points, according to the Financial Times. One is that during the good times, they have agreed high rents with their landlords, which they now can’t afford, and are having to renegotiate them. The CEO was sanguine about this on the radio: it’s in the landlords’ interest that Southern Cross doesn’t go bust, so they’ll have to do a deal. His relaxed style on this was probably a bit of show for his worried investors, but nonetheless what you are seeing here is the impact of economic drivers on a private sector company. They did not drive hard bargains in the good times, but they’re now being forced to do so. The FT suggests that good quality providers might replace Southern Cross in some of these homes, if they can make the maths work, so in some cases quality for the residents might actually improve.
You can see a fairly comprehensive diagnosis in the FT: http://www.ft.com/cms/s/0/d550d81c-4e82-11e0-98eb-00144feab49a.html#axzz1HBYad3p9
The second problem is that one of the reasons why the high rents don’t stack up is that local authorities and health trusts have been cutting back on their placements and cutting back on the charges they are prepared to pay. There are also some good points about this. First, it’s the economic drivers again. The public sector commissioners of care did not drive hard enough bargains in the good times, now they’re doing so. Both they and Southern Cross are being forced into doing the job for the minimum possible expenditure.
Second, one of the things the health and social care commissioners are probably doing is providing alternative packages in people’s own homes, rather than shoving people who don’t need it into care homes. Everyone, including the people being cared for, would agree that this is a good outcome. However, there’s a ‘but’ there, which I’m coming to.
There are also some negatives that we should factor in. Ask the question why Southern Cross is in this mess. Some of its troubles have to do with the fact that for several decades running care homes has primarily been a property-oriented business. A lot of money has been made from the properties, rather than giving priority to care. Because of this, it has now hit the buffers as the property bubble has collapsed. If everyone involved (including the landlords) were less concerned with extracting money from the property and more on giving an absolutely first class care service, you can’t help feeling they would not have lumbered themselves with inappropriate property costs, and instead would be focused on how they can provide the best care.
I think of the Railtrack debacle, when the privatised providers of railway track came a cropper because they spent their time extracting money from the property rather than focusing on running a safe railway. Or the numerous high street shops that have gone west because their private equity fund owners were extracting so much money from buying and selling companies and properties that they took on big loans and property costs that, with a retail downturn, they cannot afford. Perfectly good chains of shops have disappeared because of this.
And the lesson from this is not, as our anarchist rioters would have us believe, the evil of capitalism, or at least not directly. The problem is that the people who are doing capitalism these days think it’s only about making money for themselves, instead of the boring old job of running a good service. They get the money to run good shops and care homes, not to line their pockets. I feel I have to mention in passing bankers’ bonuses: there’s another lot of people who think it’s about making money for themselves instead of making the economy run properly by doing their job.
People I know who run businesses, but do not get big bonuses, work very hard to provide a good service. It’s these businesses that people go back to and will survive and build from the recession. But once they are big enough to get into the hands of the money men, their job becomes making money instead of providing a good service. Wrong priorities immediately result. One of my friends who was running an expanding business decided to reduce his expansion so that he didn’t need to get any loans from the banks, because the bank started getting too interested in telling him what he should be doing instead of leaving it to him. Sitting back with no bank loan, he’s living well enough, and nobody interferes with him.
What this tells me is that an overweaning interest in making money is actually a negative in providing all kinds of services, and also I suspect in manufacturing as well.
It’s a bit like Colonel Gadafy, also in the news this week. I can’t help thinking that if he decided to do a really good job of running Libya over the last 40 years, instead of lining his pockets and the pockets of his relatives, he would be generally regarded as an all round good egg and nobody would be wanting to rebel or bomb him.
As the Bible (or at least 1 Timothy 6:10) says: the love of money is the root of all evil. So it is in health and social care. It’s not the economic drivers, but the love of the money that economic drivers bring, that is the problem.
The other negative we should think about is that the downside of pressure from economic drivers, even if they have positive effects, is sometimes to drive down quality. Of course, Southern Cross will have to drive down the rent it pays, but it may also be forced to drive down the quality or amount of care it provides. The people on the streets this weekend, who are concerned about the use of economic drivers in public care, are the most concerned about that and rightly so.
Of course, it does not have to be. You only have to look at John Lewis to realise that people will pay more and flock to an organisation that focuses on providing a reasonable service rather than just the minimum. The problem is that care service users often do not have enough money to go to the John Lewis of care provision. Instead they have to use Poundland health and social care. I go to Poundland a lot, for a look round. It’s efficient at what it does, but a lot of the goods it provides (once you go beyond the small packets of big name goods at the front) are tat; they look glittery and something like what John Lewis offers, but in their manufacture and ingredients, they are cheaper and nastier. I do not want Poundland health and social care. Neither do I want Curry’s health and social care; their products are as good as in John Lewis, but the staff are so ignorant or unpleasant that you positively want to avoid the place.
Quality of care, then, is about the product – in care, the environment and the care processes – but it’s also about the attitude of the people providing the product. These two aspects interact, in a complex way. Economic drivers do not deal with that complexity: you need other factors.
One problem with economic drivers in the complexity of care is that the people who pay, local health and social care commissioners, are not the people receiving the service, so they have no economic interest in good quality service. That comes from the professional standards of the people providing the service, but the split between commissioner and service provider in health and social care also splits the people who pay from the people who provide the quality. Previous governments have so twisted the organisation of health and social care that ‘effective commissioning’ and similar clap-trap, has become the marker of professional standards in health and social care management rather than the best service. The end product of ‘effective commissioning’ is Poundland health and social care, good if you’re lucky but tat that only looks like good care if you’re not.
The second reason for the difficulty over economic drivers in health and social care is that people worry that the definition of quality is too bound up with the personal interests of the professionals. I’m in favour of discretion in applying professional standards for deciding what good care provision ought to be like, because in the end having high professional standards is the only way of ensuring good services in every detail. That has to be alongside genuine rights to decision-making by service users, so that services can be clear what they want and are driven by their choices. However, back to the anti-cuts march this weekend, it is hard to avoid the accusation that trade unions are using the ‘good standards of care’ banner mainly to support good pickings for health and social care staff. I’m one myself, and I think it’s right for us to be paid a fair salary and to have good conditions of work. This ultimately benefits the people we serve, and I’m happy for trade unions to work for improvements.
The problem is that nobody, but nobody (and including me), will believe that focusing on the wish to employ more public sector staff, pay them better and give them good conditions of employment will necessarily lead to improved quality of provision. Lots of very good people aim to provide the best services for service users work in health and social care. In the long run, history shows that if you run down pay and conditions in the public sector as compared with the private sector demoralisation results. People who can will make their exit, while people who can go elsewhere before getting involved in health and socila care never work for the public sector in the first place. But as we’ve seen, there are economic drivers, and they do prodce some benefits. The problem is to mitigate the downside of using economic drivers and boost the upsides.
Several friends where I live have elderly parents in a local care home – we’re all that age. They were all worried a little while ago when a new manager was appointed and the standards slipped – they all became quite anxious about the safety and quality of life of their parents. The economic drivers didn’t change, the overall management didn’t change. What changed was the skill and professional ability of the manager. Being middle class, they applied pressure. The regulator seemed suddenly interested. The external management took action, the manager was replaced, standards shot up again. Economic drivers didn’t change, the overall management didn’t change. Checks and balances led to improvements.
You could say this was an example of the Big Society in action. At least, it’s an example of the John Lewis contingent in action. But in Poundland health and social care, services can’t afford enough good people to maintain quality; you get what there is, mostly it’s okish cheap and cheerful, sometimes it’s less good, now and then you’re lucky and it’s great. Economic drivers don’t work because the people who are affected (isolated older people or inexperienced or inarticulate relatives) are not well involved in making caring choices and so don’t have the power of their active engagement in the services.
Would personal budgets make a difference? They are not a good economic driver, because they are about minimalist provision. The aim of introducing personal budgets is to provide the basic; you add to it, if you want a reasonable standard. You cannot use a personal budget to get improvements from an unsatisfactory care home unless you can assess quality of life, negotiate for improvements, and have the self-confidence and choices to move your budget elsewhere. There is just not that much choice in care homes at the lower end of the market, so unless you are rich enough and middle-class enough to add to the basic amount and get extras or you have good negotiating skills, you cannot get improvement or change.
We need to change the culture of our care systems. The only thing that provides good quality care is good quality people trying to achieve the best possible professional standard, well-regulated and, yes, encouraged to be as economical as possible by the economic drivers, because in the end that means more service for more people. And with social workers advocating on behalf of the people who cannot get what they need. Getting the balance between all these factors right is complex, but it’s twisted by an emphasis on economic drivers, because that encourages people to focus on loving money rather than quality. And that’s why cuts rhetoric is also wrong. It also focuses on financial rewards instead of quality of service.
Love quality not money. That will be the basis for my prescription for good palliative health and social care during this week’s series of posts.
Today: replacing the cuts rhetoric. This week I am going to post every day about some aspect of the Big Society policy, NHS reform and palliative care. The topics to be covered are too vast and complex to be dealt with in one post; but I will put them all together at the end on my Scribd website, where you can see past documents from this website and past publications, together with information about me.
Malcolm Payne’s Scribd website: http://www.scribd.com/m_payne5153
If you’re not used to Scribd, when the page comes up, click on ‘Shelf’ then on ‘+ See All’ for a complete listing of the papers and publications available.
Congratulations to Trinity Hospice on its 120th birthday, and getting Huw Edwards and Jack Dee to come and celebrate it for them. Unfortunately, their local newspaper can’t spell Clapham, but there you go.
On the web at:
http://www.wandsworthguardian.co.uk/news/8832177.Celebrities_celebrate_charity_s_120th_anniversary/
A well-made American television film about the medicalisation of death and dying
http://video.pbs.org/video/1639625115/
Ranged along the bottom of the picture are the various chapters: chapter 4 is about having the discussions about ‘do not resuscitate’. Below the video are some interesting comments from doctors and family members about those conveersations.