The government’s green (consultation) paper on ‘Giving’ is frou-frou (see the end of the post for a definition if you need to); even so I am going to spend quite a bit of space on it. This is because it gives us an important clue and direction sign to how the ConDems understand the idea of the ‘big society’ and how they are going to implement it. It also has considerable implications for how end-of-life care is going to be supported and funded by the present government, since most of it is charitable.

The paper is on the internet at:

http://www.cabinetoffice.gov.uk/sites/default/files/resources/Giving-Green-Paper.pdf

So you see that it comes from the Cabinet Office and is a document that applies across government and implements the government’s philosophy, rather than just being about a particular department’s interets. It is, therefore, an important general signal about what the government is trying to do.

Starting point

The government’s Green Paper on Giving is mainly white, but has shifted to a new yeuchy-yellowish-green theme colour. I presume their marketing people think this is cool; I think it’s like vomit.

Green papers are theoretically consultations about policy. However, do not be misled. You are not being consulted about the policy; you are being asked to come up with more ideas than the government has come up with to do what it has decided to do. What you cannot do (or you can but they obviously won’t take any notice) is say: ‘Well actually I wouldn’t mind paying a smidgeon more tax to help provide state services, if everyone is going to pay according to their wealth and income, and especially if bankers are going to stop leaching off the country and pay their own way’. No, instead you can have ideas about how they can arrange to get money and more volunteers to support the services they’re not going to provide, through your donations or money and time to charities and similar organisations, provided they’re run like businesses. Not, God forbid, to the state.

A good way, according to them, is to take a slice of your money every time you use your bank’s hole in the wall to pay presumably to a few charities that the government has selected to do the things that it won’t be doing. I wonder what the banks are going to charge for that? Presumably proportionately more than the Inland Revenue (sorry Her Majesty’s Revenue and Customs) would cost for adding the same amount on to my tax bill. Well, don’t worry, because on principle I, along with everyone else I know, will not be cooperating with this in any way at all, so the banks are not going to be overcharging me for that as well. This is a worrying politicisation of giving to charity, which is going to turn a lot of people off, certainly a lot of people I know.

The real weakness of this document is that it is written by people who are in marketing and believe in it. Frou_frou.com will lead you to a heaven in which cool, computer-linked , computer-kinked all-sharing people who have lots of frou-frous that don’t matter too much to them will contribute their frou-frous that you didn’t know you needed and improve your community custard tart.

I repeat what I’ve often said on this blog: the voluntary sector is created by what people, voluntarily, themselves want to do. It would not be created for what the government wants to do; if the government wants it done, it should do it. In a small way, the voluntary sector sometimes gets money from the government to provide some of its services. Most voluntary organisations don’t do this. Those that do, like hospices, get a fairly small proportion of their income from government. A few (usually noisy) voluntary organisations get most of their money from government. They have to be noisy because they have to influence policy to make sure they continue to get that support. But as soon as the government sees the main purpose of voluntary activity as providing what it wants to provide, then it ceases to be voluntary, because it ceases to be free to decide on how and what it is going to help.

The government seems to think that by setting up lots of local community organisations, social enterprises and supporting voluntary organisations, they will be able to have a flock of providers keen to reduce the monolithic character of government health, social care and other things. But the problem is that independent organisations do not necessarily do what you want them to; the government cannot implement their policies by telling independent organisations what to do. The history of edgy NHS relationships with GPs (whose practices are small social enterprises that have been in existence for more than 60 years) should tell them this. And then, of course, all these little local organisations may sell out to big multinationals. Or big multinationals may be preferred providers because they’re less trouble to contract with. But they also, of course, have considerable power to do what they like. Then, like banks, if they are providing most of your services, you can’t let them go bust. I see 2035 as the date for the bailout of the health and social care multinationals.

You’ll have gathered that I don’t come to this Green Paper very enthusiastically, but I have nerved myself up to it, because as major providers of excellent services to the public, palliative care organisations and hospices, not to mention other voluntary sector organisations have a very real interest in how the government is going to go about this. And our patients and everyone else has an interest in how they think they are going to make the ‘big society’ work.

The context: a culture change

The Introduction to ‘Giving’ (it’s not just money, it’s your energy and commitment) puts this bit of their policy in context; this is helpful direction-setting, trying to identify the network of footpaths that will lead to the big society. The aim is:

-        Empowering communities – policies and actions to encourage or allow local communities to do things for themselves.

-        Opening up public services – allowing (in this order) charities, social enterprises, private companies, employee cooperatives to take on running public services

-        Encouraging social action – encouraging people to give time, money, assets, knowledge and skills ‘to support good causes and make life better for all’.

They will do this through:

-        a localism bill, giving people the power to change their local community

-        public service reform, allowing people more involvement in local services.

The main values expressed are to ‘acknowledge the limits of government’, emphasising ‘the role of reciprocity’ and to use technology, particularly ‘social media’ (things like Facebook and Twitter). There is a big emphasis on culture change, the assumption being that we don’t do enough collectively for other people. They hope to get local communities to play an important role and businesses to provide ‘support’ by enabling their employees to do more.

On ‘community’, the sociologist in me comments that this is all about local communities rather than communities of interest (people who share similar interests) or, indeed, online communities, which sociologists have recently begun to recognise. Bearing in mind their interest in using new technology for many of the things in this paper, it ’s rather surprising the paper seems to miss out on this; to a ConDem obviously only ‘local’ counts as community. This is fifty years behind the sociological times.

There is also nothing in this about families and carers. Not, I think, that they are against family and carer support, but the emphasis in this interpretation of ‘giving’ is on organised support outside the family. I wonder why this is, since all the research shows that people are more likely to offer support to relatives than neighbours and more distant members of their community. I also don’t think that localism necessarily generates mutuality and shared interest; we get more support from people with shared interests, wherever they are. Social networking connects with this: some people make their connections in ways that do not slot in to localism. It also fails to tell you how all this new giving is going to interact with families and carers; it’s too busy pulling together examples of cool things that it wants to do to think and plan about how it fits in with the most important forms of support in our communities. Alongside families and carers all this sort of thing is frou-frou.

On the other hand, social networking has to be taken a step further than computer or mobile or Twitter communication; it requires real human interaction to cement it into a group of people prepared to take action in some way. I think we have to be more thoughtful about how we turn technological social networking into interpersonal social networking. That transfer from networking to action cannot be taken for granted. Some of that reciprocity has also to be there and it has to be planned for and worked at.

And, on top of all that, I go back to the government getting what they want. The whole principle of any kind of giving is that givers choose what they give, how they give it and what they give it for. The whole history of social action is littered with examples of governments encouraging community participation and then finding that what the communities want from their participation is something the government doesn’t like. As a result, participation gets taken away pretty smartly. That is going to happen here too, if the frou-frou social marketing-speak ever gets taken towards anything real on the ground.

The people I talk to are saying fairly clearly that the government is not going to get what it’s looking for from these initiatives. First of all, people won’t give if they believe the government is giving up. Second, it takes a lot of hard work to create community initiatives and people are not going to do it for objectives that they don’t agree with and that don’t really benefit them. A local community organiser said to me a couple of weeks ago that she wasn’t doing newsletters and trekking round the streets in her estate just to do something that she wasn’t interested in and that the government should be doing anyway. Looking at the recent social care ‘vision’ document, I commented on the idea that dealing with adult safeguarding (stopping granny-bashing in normal-speak) through a neighbourhood watch model will not work. People are just not going to sit in the front rooms and check up on neighbours who neglect their elderly relatives. They expect to be able to report it to officialdom and for there to be a lot of well-trained officials to do something about it.

The main actions

To achieve its desired culture change, this sections tells us what the government is going to do. Perhaps you won’t see this in the typography, so I’ll point it out; it comes as an acronym or possibly a nemonic: GIVES. This kind of cutesy stuff turns me off government documents. It makes it more marketing frou-frou than an effort at engaging me, and I do not like to be marketed at; I don’t know a lot of people who do.

Here it is:

-        Great opportunities, so it’s exciting and convenient to do giving;

-        Information, so we know how to go about it;

-        Visibility, so we see other people giving and do more ourselves. This is a sort of ‘keep up with the Jones-Smythes’ on the giving front, obviously we’ll all want to do what our friends are doing.

-        Exchange and reciprocity, so we all see the benefits of giving much more.

-        Support communities and charities to take on more responsibility and scale up what they’re doing.

Great opportunities

You’ve seen the press comment on easy giving using new technology. Examples are; every time you click on the internet, every time you get money from the hole in the wall, rounding up to a pound every time you make a card payment, easier donations through the internet, on your mobile phone, volunteering slivers of time from home through the internet. Yes, come on, offer your sliver of time via your computer to the person dying in the next bed to me; I’m sure the highly qualified nurse will find it very useful. Volunteering is real people in real places when required, not an exciting marketing concept. And real professionals have to provide the services, and not spend all their time organising slivers of time from people on their computers at home.

Other ideas are creating ‘trigger moments’ that catch people’s attention, getting civil servants and local government officers to volunteer, for example providing training. Dying as a trigger moment might get a lot of people’s interest, but I happen to think a service providing for people’s needs during dying and bereavement is demeaned by seeing it as a ‘trigger moment’ in a marketing campaign for increased giving to charity.

From the point of view of an ordinary, possibly donating, member of the public and from the point of view of the common or garden hospice in their local community, I’d like to know how I choose who I’m donating to. Will it be some government-selected charities that they like, perhaps those that are helping them fill in for their cuts in services? Or will I be able to select any of the thousands of local charities for my slivers of money and time so conveniently donated? I can see that every local bank might be able to offer a choice of, say, a local community fund as well as three or four national charities to choose from in the fourth pages of my hole in the wall process (which already has too many buttons to press to get my cash), but how is that fund going to choose the organisations that get the money locally?

We’d all better start buttering up the bank managers who design what charities are on the front page of the bank machines, or fund organisers who decide on the local grants. I’ve actually done that job for a local fund years ago, and what it led to is a few thousand a year at most, more often just a hundred of two, for many local charities. And anyone who’s worked for a grant-giving charity (or government department) will tell you they spend much of their lives with people pitching clever re-designs of their organisation to meet the latest cool criteria that teh fund-gier has come up with so that they can market their exciting grant-giving to the outside world and the trustees. And it always leads to grants given for projects, in the same way that foundations provide now. This is not the way the provide funding for solid continuing local care services. It’s likely to be no good at all to your local hospice spending a few million a year on supporting dying and bereaved people with a consistent service.

Then on to volunteering. The offensive paragraph about volunteering is apparently drawn from the Commission on the Future of Volunteering; did this really say that volunteers provide ‘a personal, human touch that staff might be prevented from providing, making services feel genuinely caring’? Obviously, nurses, doctors, chaplains and social workers can’t provide genuine human caring according to the Commission. Or at least the way some ignorant marketing professional working for the government has re-written it. Neither can they provide ‘innovation and a fresh perspective’ and ‘a source of local and other knowledge’. Not too knowledgeable all these qualified staff, and of course our nurses and health care assistants doing shifts all day and night must be living miles away from the hospice and have no local knowledge at all. In case you didn’t realise, that sentence was ironic. Perhaps the staff will be so driven because of all the cuts in services that only volunteers will be able to do anything human. I’m sure that sentence was ironic too. And perhaps that one was.

One of the laughable examples is how another of the government’s green papers aims to stimulate people into local social action in providing effective punishment, rehabilitation and sentencing of offenders. I must make a note to read that document, because my lifetime’s experience (I was working in offender services forty years ago was on the board of one more recently and retain a concern) is that people do not want to get engaged in voluntary working with the nasties in life. The number of people wanting to help punish, rehabilitate or sentence offenders through local community action is likely to be infinitesimal (except in the local teenager castration clinic, but probably the government is not going to want to go that far). I can see that loads of people might enjoy being a volunteer for the Olympics (another example). It’s time-limited, it’s nice, it’s in the summer, so they’ve had a lot of applications. And, yes, hospices might be OK because although people do tend to say that they can’t imagine working in a place where a lot of people die, when they’ve experienced the services, they find it interesting and worthwhile. But there are not going to be a mass of volunteers to work with middle-aged alcoholics, or twenty-something druggies or prostitutes.

And I’d forgotten we’re going to have ‘National Citizen Service’ for over 16s to give their time. I’m sure lots of them will, particularly since so many are going to be unemployed and not going to university or getting education maintenance grants: but are we really going to run the country on this basis? Apparently so, because there’s going to be some funny money to support ‘a volunteer infrastructure programme’ for organisations that are recruiting, training and supporting volunteers. That’s presumably to make up for all the local authority grants that are going to be withdrawn from local volunteer centres that have been doing this job for decades (I ran one in the 1980s and there are several very good ones in the St Christopher’s area, that have been imaginative in supporting volunteers with special needs) Of course, the government knows about these organisations, but presumably also knows that it needs to come up with some realistic financial support for volunteering, because it’s not cheap, it involves a lot of people to support and train volunteers effectively. The problem is, I think, that training and support is best done close to the service that the volunteers are working in; on the hospice ward, in the hospice home care services, in the day centre or chaplaincy. Some generic support agency does not really have the expertise in the job to be done. Of course, I’d forgotten that only volunteers have knowledge and the human touch, so it’ll be all right; sorry.

Information

One of the ways slivers of time and money is going to work, apparently, is to have websites set up for volunteers to apply through and for charities to show what they’re doing and for donors to track the impact of their contributions. I’m sure there’ll be funny money to support this initiative too, so what this means is that there’s going to be lots of jobs for redundant local authority workers organising local charities to provide information about how all this money and time is being used, and they’ll need even more volunteers, because the staff are going to be run ragged providing all this evidence of impact. My job’s safe: there’ll be many more audits to persecute doctors, nurses and social workers with so we can feed information to these websites to demonstrate to everyone what they’re doing.

Here’s an interesting point; ‘There’s much that we can do as government to make sure the right information exists’ (p 12). What can this mean? Is there loads of information existing that’s not right, and the government’s going to correct it? Or is it: ‘Ve haf vays to ensure zat your information fits vat ve vant it to be’. Here’s the answer: ‘The volunteering initiative ‘Work Together’ was launched earlier this year to encourage all unemployed people to consider volunteering and to ensure that people have access to the information they need to find local opportunities’ Ah, so it’s: ‘Ve haf vays for you scroungers to find out how voluntary arbeit mach frei’.

And then there’s transparency. Apparently, people are not concentrating on the ‘right metrics’ (p 12) in deciding who they are going to donate to and support. Ah, so it really is: ‘Ve haf vays of making sure zat your information fits vat ve vant you to sink’.

Visibility

Logically, if you’re going to make everything transparent (see above), you’re going to have problems with visibility. This section is about making sure people are aware through social and traditional media that it’s OK to give time and money to charity, and that all their friends are doing it too. And celebrities that they’ve heard of. Delia will be tweeting every time she buys her eggs: ‘I’ve rounded up the price and given the money to the anti-obesity project for community cooks’. In case you hadn’t counted that’s only 78 characters, so there’s plenty of space for the donation website URL. But I suppose Delia, while trusted, may not be exactly cool with the younger set: Cheryl Cole, then, but while she may be supporting anti-obesity, it probably won’t be community cooks.

But don’t worry, the government is going to lead by example. That’s actually a sub-section heading; I have to quote this in its entirety:

Government has the opportunity to encourage its employees to lead by example, and in so doing help build new social norms. Plans are already underway to develop a ‘civic service’, whereby civil servants are encouraged to contribute to their communities. Our aim is to provide civil servants with opportunities to use their skills to support civil society organisations and to play their part in growing the Big Society. We will do this by promoting social action as a means of professional development for civil servants, and providing better recognition for those giving their time.

Phew, that’s all right then, the government is not going to lead by example: George (Gideon Oliver, Wikipedia tells me) Osborne is not going to be at my bedside to provide that human touch as I shuffle off this mortal coil, they’re only going to encourage their employees to do it. I thought there weren’t going to be any surplus civil servants, so how are they going to be building new social norms from their central London base in Whitehall? And if there were, they don’t have any worthwhile skills, do they? According to the government, skills only come from business.

Are they including all the hospital nurses and doctors alongside the local jobcentre clerks among their employees? The NHS as a really big government employer is obviously going to be a big target for this sort of project; not really worth it to get volunteers for the London area from the comparatively few pen-pushers (sorry, keep up to date Malcolm: keyboard-tappers) they have in Whitehall. Might be good to have nationwide civil servants from the NHS, though – judging by Casualty, I’m sure local hospital doctors and nurses could all fit in an extra shift at the local hospice once they’ve completed their undemanding day jobs. And all those unemployed PCT civil servants too.

They’re also going to promote the charities they work with on government websites – yes, Nick Clegg and his civil servants want to tell you that their favourite charity ‘Keep your word at any cost’ is a really top-notch place to volunteer and donate your hard-earned slivers of money. No, on second thoughts, it will have to be like cigarette packets. They discovered that the only way to give credibility was to say: ‘The Chief Medical Officer says smoking kills’ (I’ve never seen a cigarette packet in recent years so I don’t actually know what it says, but the point is it was definitely a no-no to send a message from the government). Being approved of by a government in decline (in three or four years time, of course) is going to be even less of a recommendation.

I also just have to quote the next one:

Finally, we want to consider whether we should be trying to establish social norms directly. For instance, some have advocated that we aim to make giving one per cent of income a social norm – but others would say that the level should be far higher, as much as ten per cent, which is in line with tithing levels. And there are similar questions about levels of giving of time. The government can play a role in creating the choice architecture and entrenching norms for giving… (p 15, emphasis original)

Well if giving 10% should be the social norm, it’s all right to put taxes up by 10% to pay for government services, isn’t it? But I agree I don’t want to pay it to the government. I’d happily pay it to my local council or the local NHS though, because they provide really useful direct services.

And ‘choice architecture’? Did anyone tell them about meaningless business jargon being a real turn-off. Either they all speak like this, or nobody with any connection with the real world read this before they published it.

Exchange and reciprocity

We’re nearing the end now. Here we go again, a quotation:

While powerful motivators in many situations, the prospect of feeling good about ourselves, making new friends or gaining experience, are not enough on their own to encourage us to give in new ways, to new causes or for non-givers to start.

So making a contribution to good in the world is not a relevant motivator then; bit inconsistnt with the rest of the document perhaps? Therefore:

Peer-to-peer lending and financing platforms like Zopa, IndiGoGo and Sponsume allow people to give money to individuals or projects who post requests for funding online. They enable a clear sense of connection between sponsors and those needing funds, and allow for reciprocity – in the form of benefits in kind, or a real financial return on money invested.

So sponsor St Soandso’s Hospice and we’ll reserve a bed for your wife when she’s dying. That won’t work because nobody thinks that they or their wife is going to die and she might not die for ages yet. And are only the donors going to get the beds? ‘I’d better get a quick donation in now my wife’s got cancer’. Working for a hospice, I have met some people who think this way, but it’s not the way I want end-of-life care provided in this country. The government shulds realise that this form of reciprocity is just not a realistic approach for many of the activities that charities provide for.

Then there is a list of organisations like freecycle that have come up with a good and useful idea (for those who don’t know, it’s an e-bay-like website where you give away things you don’t need to other people who do ). I know young people for whom this has been a godsend to find free furniture and household items; it’s a mutual Salvation Army clothing and furniture store on the internet without the SA as an intermediary. The government would like to encourage more of this. But such ideas are round the edges of life. I want to give away some palliative care books, but it doesn’t seem to have worked: perhpas death and dying freecycle could pass them on to someone who can use them. If you’re dying or bereaved, you want a coherent, consistent service available from trusted people. Yes, it’s supportive to get reliable information from the internet, but at the centre of the service there need to be well-qualified competent people; you know, those human being types that we used to see around so much.

Finally, support

People in communities will be encouraged to ‘step up’ to take on responsibilities. This business motivational jargon implies that they wouldn’t be able to and they’re not prepared to.  In forty years of being involved with voluntary organisations, I’ve seen people prepared to ‘step up’ to massive responsibilities if it connects with them and they believe in it. Let’s be clear that nobody is going to ‘step up’ to do what they think the government should be doing. People are not all failures in community commitment, in fact most people are very committed to helping others around them, but on a human-to-human basis with people they know and about issues that they feel connected to and believe they can make a contribution with.

So, here comes the funny money; since this is all about marketing, I’m going to start calling it funny munny.

Funny munny 1: a ‘community first’ programme will provide grants to help local people implement projects and plans (and employ all those unemployed people on short-term contracts until the project is up-and-running, when they can move on to the next project).

Funny munny 2: £50m of ‘matched funding’ to support community endowments. Matched with what? Local business is going down the tubes, self-interested banks won’t lend, so they certainly won’t donate (how can they justify it to their shareholders across our globalised world?) and more people are going to be cautious because they’re more likely to be unemployed. And endowments don’t lead to immediate projects, that people can’t use the internet to track their slivers of time and other contributions so that they can see that they’re ‘making a difference’. They imply a build-up of funds over decades, so the banks and financial services can invest it to produce income for the future. So, is this really a goody for the banks? If it is, let’s remember that investments are not earning real rates on interest at the moment, and stocks and shares have not increased in value for quite a while. There will be no community endowment, because endowments don’t grow in the present economic climate.

Funny munny 3: A ‘community organisers’ programme to train 5,000 people to ‘galvanise’ (p 17) people around them to be more active. What this will be is more money to employ unemployed community work lecturers or support courses in universities and colleges which are struggling because nobody is funded to do adult and further education. On short-term training projects, rather than building up solid, long-term education courses.

Then there’s ‘Every Business Commits’. This was a Cameron announcement at the Business in the Community AGM in December, so you may have missed it through not being focused on community development in the run-up to Christmas, which is the time most people make donations to charities, so I can see you’ll have been busy. It appears on their website: http://www.bitc.org.uk/business_and_the_big_society/business_commits/index.html as a series of recommendations by Bitc that all businesses should pursue; the government seems to have taken it up. The five main points are:

-        Reduce carbon and protect the environment

-        Support your community

-        Improve skills and help create jobs

-        Improve quality of life and well being

-        Support small and medium-sized enterprises

Alongside gems like ‘pay suppliers on time’ which funnily enough over decades no one has been able to get government organisations or big businesses to do, the supporting your community stuff is what the Giving green paper covers; these proposals are all circular. To improve quality of life and well-being, the following clear and concrete proposals are:

-        Make your workplace more family-friendly and offer flexible working wherever possible

-        Take further steps to improve the health and well-being of your workforce

-        Support diversity in the workplace.

This is the equivalent of: ‘Now I do hope you chappies are going to do jolly nice things in the future’.

But don’t worry, it’s not just business they’re supporting. There’s going to be more funny munny to help charities and social enterprises encourage volunteering:

Funny munny 4: The volunteering match fund of £10m to match private donations that support volunteering projects. I can already see voluntary organisations redesigning their accounts and talking to donors to prove they’ve got donations coming in to support volunteering. This is just another wheeze to take some money from state services and claim they’re supporting voluntary effort.

Funny munny 5: A Volunteering Infrastructure Programme of £42.4m (that is £10m a year again; you’ll remember I mentioned this above) to provide brokerage and ‘front-line’ support to volunteers that organise and manage them. This is another job creation programme for unemployed people to shift from public sector employment to supporting volunteering.

Funny munny 6: They’ve already announced a Big Society Bank that will ‘capitalise the market’ (p. 18) for social investment. If this is like Chris Huhne’s similar project supporting eco-friendly  projects, I presume the Treasury will stamp on it in case it overspends and nobody ever repays its loans, so it will not become a genuine bank that can borrow money and support social projects, but will be another grant-making scheme to help ‘social enterprises’. So I count this as more funny munny. This is not for charities because of course they are not real businesses, even if they provide useful services, and so therefore cannot be capitalised. I suspect there might be a bit of corporate redesign among the aspects of charities that can turn part of themselves into social enterprises.

Funny munny 7: A Transition Fund of £100m to help charities hit by local authority voluntary sector cuts over the next financial year, until the massive growth in business and community support for voluntary organisations in the new Big Society replaces it (you may think that was another ironic comment, but it’s actually not far from what the document assumes to be the truth). Since they say that local authorities should not be cutting stuff because they should be more efficient, it’s not quite clear to me how they’re going to allocate this. Hence, I designate this too as funny munny. But I presume at the end of the year, the big society won’t have arrived yet (just slightly delayed of course) so I anticipate an outcry at the withdrawal of this support which will embarrass the government, leading to the ‘transitional support’ becoming ‘pro-transitional’ and in later years ‘post-transitional’. Another wait and see there.

Finally, there is the suggestion (they are consulting on this; you may have a view) that they will make foundations pay out a minimum every year. So this is the new free choice Britain: ‘Ve haf vays of making you pay, even if you don’t vant to’. There no suggestion of a problem with this limitation on the freedom of decision-making of foundations. Apparently some other countries do it; I’d like to know where and I’d be interested to know how it works, because my long experience of people who make donations to charities is that they really, really want to support things that mean something to them, and they don’t like being told what to do by government.

But I wonder how the government thinks they’re going to do it, since they haven’t managed to get the much richer banks to lend, or even reduce their bonuses. Of course, foundations are much less powerful in the economy, when bankers won’t make ‘yes’ as an answer, so perhaps it’s easier to bully them.

And another aspect of free choice is venture philanthropy: get a grant from our tame foundation stacked full of businessmen and management consultants who are no longer employable because the government is cutting back on business consultants, and they will interfere with your objectives and management because being a real business they will have much better management skills than your pygmies. Many of their staff probably come from banks and financial services companies for example, real examples of entrepreneurial skill. Sorry, that’s another ironic comment; I must stop this. Perhaps some charities might go for this, because it might be better than having local government and NHS bureaucrats interfering with their objectives and management on grounds not of ability but democratic accountability for their grant-aid.

Now you mention it, there’s not been much so far about democratic accountability in this green paper. Of course, you don’t need that if everyone is building the big society outside government; nobody has to be democratically accountable to anyone. Except that I suspect the government is going to continue to take a very close interest in the big society doing what it wants, not what people in the big society want. This is because I don’t think they can quite imagine that some people don’t think like them, so it will be quite a shock when quite of lot of people start creating a big society that disagrees with the government. It’s happened with every other community development initiative in the world.

The supporting evidence

This account covers about half the pagination of the green paper. So what about the rest? The next big section offers the evidence in support of the proposals. This can be summarised as evidence that there is wide variation in giving across the population, and a lot of them simply aren’t asked, so if you can get at more people they will give more money and time. Also, as NCVO has said in one of its reports, if you make the ‘ask’ clear and attractive, you will get better support. Then there is a comparison between the UK and other countries: the UK already does better than most developed countries in getting people to give  to charity and 70% of people volunteer in some way. The US does a lot better, but has a completely different culture; presumably the government’s culture change is designed to emulate that culture.

However, there are a string of statistics here which show that many people don’t give money (or time but most of this section is about money and shows where the government’s main emphasis is) and there is mention of making it easier to make tax reclaims, to give larger sums, to engage a wider range of corporate donors and so on. All of this is predicated on the evidence that some people (or corporations) give, but more people (or corporations) don’t. The paper therefore makes the assumption that more people and corporations would give if giving was marketed to them better. Marketing rules OK.

I think it might have something to do with how rich the potential corporate donors are (I notice manufacturing and media companies are not big givers and I suspect this is because they are under the competition cosh, so can’t afford it) or what they can achieve by donations (I notice financial services give a lot, possibly to try to improve their seriously tarnished image, and they and other retail companies need to gain public approval and charitable giving is a useful marketing device to this end).

Consultation

At the end, there are several pages of consultation questions. These are more about how they can do what they intend to do, so mostly are not worth answering if you don’t accept the basic premises of the way they talk. I don’t, so I’m not going to bother with them.

The government believes that they can get community involvement through stronger marketing of their opinion that everything would be better if everything was run like a business but not by government. My view is that community work is a longstanding and well-established profession, with a long history of achievement across the world. It has demonstrated again and again that to engage people in community and mutual support you have to make a personal and human connection with them and get them involved in things they believe in and can make a personal commitment to through social relationships with like-minded people. Marketing is not going to work. And social networking has to develop an interpersonal interface to extend its reach into real community support.

On frou-frou

You may be wondering what frou-frou is. My internet dictionary says: 1. Fussy or showy dress or ornamentation. 2. A rustling sound, as of silk.

Yes; that’s what I think of the thinking behind this document.

My bit at the Devon Dying Matters conference was about ‘engaging communities in end-of-life care’, following up on Allan Kellehear’s work. He argues that health promotion (the Dying Matters public relations approach) almost says you will never die if you only have a healthy lifestyle, while palliative care focuses on just a few people whom happen to have some major illness at the end of their lives.

This is my argument with the NCPC/Help the Hospices view of the world, and indeed the approach of many hospices. Palliative care sells itself as providing this really caring service for dying people, when most dying people do not have a nice clear illness that doctors can manage the symptoms of and nurses can provide oodles of loving care for. Instead, most people become increasingly frail with all sorts of things that leave them with a dreary and restricted life, which needs developing social relationships to give them a bit more brightness. They never get near palliative care because they’ve got no clear symptoms to manage or care for.

Kellehear says we should improve everyone’s skills in human relationships with dying people, because this deals with the reality that we have an ageing population and not a lot of care services, so we’re going to need everyone to cope better with death and bereavement, which a lot of people find tough at the moment. Unfortunately for the healthcare world, this does not mean paying lots more doctors and nurses to do lots more medical and nursing interesting things, so it’s a bit of a struggle to focus on engaging communities.

The other problem of ‘engaging communities’, which community workers have been saying for decades, and have to say very strongly again whenever a Conservative government gains power, is that the whole point about communities is that they have their own shared priorities, and these are very often different from what governments want to achieve (which is cheaper or no services, especially if you’re Conservative).

It doesn’t work like this with communities, in exactly the same way that it doesn’t work like this with volunteering. Look at the dictionary. A community has shared interests; volunteers choose what they want to do. They cannot be commissioning by NHS administrators to do things that are not in what they perceive to be their shared interests, or relevant to their choice of activity.

You can certainly build communities, you can certainly recruit volunteers. But be prepared for disappointment, because you can’t build or recruit them to do what you want, you have to build and recruit them to develop greater solidarity and mutuality and then you can hope that some of them will grow an interest in what you want to do.

It’s the same with dying matters. If you strengthen communities generally, some of them will be engaged in real relationships around death and bereavement, so they’ll be wanting to use their developing solidarity to make dying and bereavement better. But the Dying Matters coalition (or the local GP consortium) cannot tell them to do this; it has to arise from the greater solidarity and we have to build this before we get the outcomes that interest us. As new governments find this out, they usually give up on engaging communities; I’ve not doubt it will be the same with this one too.

When you go to hear politicians, the announcements are often bland and sketchy; you go to hear the subsonics about how they’re thinking about what should happen. Here’s a classic from Lord Freud, now the Minister for Welfare Reform; he’s the guy that’s advised both Labour and now the LibComs on cutting budgets. With a name like that, you’ve just got to look at the subconscious.

Obviously he’s got the lordship and the ministerial role to achieve quick results (for results read cuts). He made this speech to organisations interested in getting people off social security benefits. There’s a new bit of jargon for you ‘off-flows’ – the flow of people off benefits and into work that doesn’t cost the government so much.

What he’s saying here is that they’re going to be looking for organisations to help people off benefits: what sort of organisations will they be and how should they work? Listening to this, can the same principles be applied across government to other voluntary sector charities, say in palliative care of social work?

Here’s a bit of what he said:

To keep up the pace of progress we envisage, we will need well-capitalised and well-resourced groups that are prepared to take up the challenge of competition in this area. Given the greater off-flows we expect to see through migration from Incapacity Benefit to ESA (Employment and Support Allowance) under the new Work Capability Assessment, we will need companies with the scale to make an impact. And in view of the difficulties that we are all familiar with in targeting support to some of the hardest to reach, we will also need groups that already have – or can co-opt into consortia – the skills and expertise needed to provide real change to people’s lives. Consortia formation, financing and management will, I am convinced, lie at the heart of the successful operation of the sector. So if you represent a medium or larger organisation, you might want to accelerate your thinking about how you can work with partners with resources in other areas or locations. Many of you, I know, have already elaborated strategies in this area.

In other words, if you are a voluntary sector organisation wanting to get resources to do things on behalf of government, get big. Small local organisations, local contacts, representation may be truly lovely, but they want results, so big means easier to cope with for the government and more likely to bring widespace results. If you’re small and local with existing local connections this is gives feel-good, but get in a consortium with others so that you can get big.

Hospice managements: now apply this to yourselves. How are you going to get big and help with the government’s off-flows?

Want to see more of the speech: http://www.dwp.gov.uk/newsroom/ministers-speeches/2010/02-06-10.shtml

Not to be St C’s-focused about it, there are two other honours that mention palliative care, MBEs, in the Queen’s birthday honours list:

Dr Constance Ada Mary LLEWELLYN-MORGAN

Chair of Trustees, Ty Bryngwyn Hospice,
Llanelli. For services to Palliative Care in
Carmarthenshire.

Professor Edwin John PUGH

Consultant in Palliative Medicine, North
Tees and Hartlepool NHS Foundation Trust.
For services to Medicine.

Who gets honours then and is it appropriate? Leaving aside the remnants of empire in the British system, all countries honour people who make a particular contribution Legion d’Honneur in France and congressional medals in the US, presumably following their own cultural criteria. For the UK, here is of course a committee that advises about who should get one, and anyone can put someone up for an honour, but my ercxperience of the voluntary sector suggests that many organisations plan this rather carefully to assure their recognition. Some people reject one or ask not to be put up of course. Senior civil servants also get a good whack, more or less routinely: you can tell who blotted their copybook or did a specially acceptable job by looking at the levelof what they got.

Even so, should it be quite so bound up in political and policy considerations? The head teacher who became a dame would have been less likely before Labour decided a while ago to honour contributions to teaching at the grassroots. Should it be entwined with political decision-making?  And, looking at a field such as palliative care, or social work, one wonders who keeps an overview. Since charitable activity is an important part of a field such as palliative care, people seem to receive honours for chartiable activity which in a way is a bit of a extra to their professional role: does that mean that palliative care gets a higher proportion than other health and social care specialties? If so, it might be because charities think about these things mroe carefully as a strategy in the fund-raising, reputational game.

Of course, one asks the same question abot royal patrons; again this is a routine part of the British charitable system, and other countries have their equivalents. but have we really looked at how far we want royalty entwined with charity?

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

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

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

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

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

Then, mentions of social care:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The challenge for Britain

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

The next stage of national renewal

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

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

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

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

- Access to psychological therapy for those who need it.

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

The challenge for Britain

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

The next stage of national renewal

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Right, on to the Conservatives.

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

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

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

45 Back the NHS

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

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

48 Take control of your care

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

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

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

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

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

A healthier nation

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

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

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

- increase access to effective ‘talking’ therapies

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

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

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

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

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

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

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

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

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

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

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

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

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

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

13-14  A fair deal for social carers

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

The Green Party is committed to:

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

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

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

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

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

- Instituting workforce health checks as advocated by UNISON.

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

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

- Restoring the link between state benefits and earnings.

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

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

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

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

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

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

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

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

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

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

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

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

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

On the web:

BNP: http://bnp.org.uk

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

Sinn Féin: http://www.sinnfein.ie

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

Introduction

I return to last month’s Law Commission consultation on changing the law on adult social care; you have to reply by July 1^st if you’re going to say anything. Do not rely on my account below to reply: you need to have the question numbers and look at the detailed argument to comment appropriately.

You can see the consultation document on the internet at: http://www.lawcom.gov.uk/docs/cp192.pdf

The aim of this post is to give you an idea (if you didn’t know this) of how complicated it is and the main areas covered. It’s very comprehensive, so this is one of my longer posts. To summarise a 200 page document, I collapse many of the sections and do not go into the detailed argument for and against many of the proposals; instead I try to give you an idea of what the debate is about and then what the Commission proposes to do about it. I have tried to make clear where I am expressing a view, where the Commission is making proposals or recommendations or where I am simply giving you information about what they say.

This introduction aims to sum up the approach for you in advance of reading (or avoiding) the detail. The Commission proposes that there should be some statutory principles, to establish the general aims and direction of the legislation. They then debate the main approach to the law, and conclude that they should establish the processes that are involved in adult social care, rather than specifying particular client groups or services. Process means things like assessment, eligibility and care planning. This means that you can then establish controls on how the process works, either in law or, for more detailed matters, through regulation. Social workers may worry about this, because it legislates for an important emphasis on assessment, rather than a care and treatment function, for this important service within social work.

The Commission’s consultation document is incredibly informative; after more than forty years of working on this stuff, I learned quite a lot about the problems in how the detail of the law works; and actually how the detail of all law works. If you know social care law, it’s well worth reading simply for an education in how legal matters arise and are dealt with in general. Generally, I thought the proposals were well-thought-out and sensible. They would certainly resolve a lot of uncertainties and lack of clarity.

Now for the problems. The Commission’s remit does not include political decisions, so they cannot deal with matters that require a political resolution, such as how much money we are prepared to spend on social care and what quality and level of services you can provide. This cannot be resolved legally, although the framework the Commission proposes would allow this to be settled to some degree through government regulation and guidance. However, it tells you nothing about what level of services are going to be provided, and offers no real rights to service. Because it is clear that social care is and will remain discretionary salami-slicing services for budgetary reasons is a real problem in social care generally. I think everyone accepts that it is massively underfunded now and that will be worse in the future. Unlike the NHS legislation, which gives the secretary of state a duty to provide for all reasonable needs, the social care legislation remains very much more open to cutbacks, particularly also because the local authority responsibility does not put the problems at the secretary of state’s door. People compare this with the approach in the NHS, for all its faults, and they feel they’re not getting the real deal from social care. This will continue to be a problem. We can see this in the (completely unmentioned in this consultation) lack of clarity between NHS continuing care and local authority community care. My view is that it does not adequately define or regulate the boundary between NHS community and primary care provision.

For us end-of-life care people, this is a topic that is not really covered, although the line would be that this would be covered by statutory instruments or (more likely) government guidance. This is an example of why the process approach produces potential problems, because it sets no line about who should receive what. That may be legally appropriate, they make a good case that it is, but I think that there is a question about whether it is socially appropriate. So I want to pick up some of their ideas that they ask for comments about and make it clear that there should be clear aims set in the statutory principles for social care, and additional principles such as responsibility to ensure people’s well-being in making assessments and a duty to make afrter-care arrangements on discharge from in-patient services (and prison).

You can tell how important the proposals are because the main pieces of legislation go back more than sixty years and the main topic areas covered are:

- Statutory principles – should there be some to provide overall direction
- Community care assessments
- Carers’ assessments
- Eligibility for services
- The main provisions in the main pieces of legislation
- Ordinary residence and portability
- Scope of adult social care services
- Delivery of services
- Joint working
- Safeguarding adults at risk
- Strategic planning

If they’re going to legislate on these topics, it’s going to be life-changing for most people in adult social care. So I’ll cover each of these in turn.

The aims of the review: I think service users should have the protection of rights to social care

Adult social care services are important to most people at some point in their lives, not only because of their own care needs (in the end most of us will have them) but because people in our families and communities will have care needs that we will have to help deal with. For some people, care will be an important aspect of their lives. The present legislation is a patchwork of Acts going back a long way. The Review covers England and Wales, although there are some differences in Wales. The proposals aim to be resource-neutral because the Law Commission is given a brief to reform a lump of legislation as it is, not make political proposals for how it should be changed.

Among the current policy issues identified that may have an impact on the review are the introduction of personalisation policy, and in particular direct payments or independent budgets, the government’s wish to switch to a more preventive approach , rather than concentrating resources on people with high needs and the current reviews of the funding of personal care services mainly for older people.

Should there be a single piece of legislation covering adult social care? I say ‘yes’, because it would clarify and bring together a confusing mixture of legislation with different aims and concerns.

What should the structure of legislation be: the Act should specify the responsibilities of local authorities, statutory instruments should be used to expand on or define these and directions from the Secretaries of State (plural because it covers England and Wales governments) should be used for guidance seeking to achieve changing policy and practice. The consultation asks whether there should be a code of practice to bring together the guidance. This seems sensible to me, and we’re used to this way of proceeding. The Code would often change with governments or after major policy changes.

The Review makes the point that legal definitions have not been very influential; they are not clear enough, while process guidance, such as the Fair Access to Care Services guidance FACS) which sets out how priority decisions should be made, have more of an impact on how the system works. Their main approach, therefore, is to use the legislation to establish tightly-defined processes for determining whether someone should have community care services, rather than trying to define these in advance. My view is that in principle this approach  allows for greater flexibility and creativity in providing services; the problem with it is that it does not provide many rights to services, only the right to be assessed. It is a recipe for constant salami-slicing of the quality and extent of services that people receive.

At a meeting I was at recently, someone gave the example of an assessment that provided two carers periodically to assist a disabled woman take a bath. On review, this fairly minimal care was replaced by a sponge on a stick, on the grounds that because the person could stand if they held on to their washbasin, this would enhance their independence and they could use it as often as they liked, rather than having scheduled visits from carers. Cheap cheap cheap: such is the approach to dignity and respect in social care. We desperately need some rights for social care service users, or this is what is going to happen in these budget conscious times. The review proposes, however, to have legislation with a list of exclusions (to define the interface with the NHS), a list of services included in community care and a list of principles which would specify how services would go about making decisions. I don’t think this is enough to protect service users.

Statutory principles: I think we should go for stating principles of service in the law.

The document moves on to look at this list of principles, which would be the basis of the services. Principles can either say what should be the most important thing. An example is primacy as in the child care legislation: the child’s interests should be paramount. Alternatively, they can direct decision-makers to take particular points into account, for example the principle of the least restrictive alternative in the Mental Capacity Act. Finally, principles might list assumptions, such as the unwisdom provision in the Mental Capacity Act that people should not be assumed to have no capacity to make decisions merely because they are making decisions that the professionals think are unwise. So how might this work out in social care law?

The proposed principles are:

- maximise the choice and control of service users
– person-centred planning
– needs should be viewed broadly
– remove or reduce future need
– the concept of independent living
– an assumption of home-based living
– dignity in care
– the need to safeguard adults at risk from abuse and neglect

Pros and cons are stated for each of these; are they too vague (viewed broadly), or just a current fad (person-centred planning), confusing (dignity, where there already are legal principles and the idea can usually support any number of opposing views)? On the other hand, they do express a direction over issues which many people think are important: things like a priority o home-based living and a duty to safeguard. These things are worth stating. It may be that some of the vaguer things are also worth including because they would force people to think about them, or worry that someone will zap them with a court case on ‘take a broad view of my needs’ and that might be a good thing. However, it does mean going to law: people have been prepared to do that for continuing care in the NHS because it’s about money: will they do that over granny’s right to choice? More doubtful I think.

What do you think? They’re asking, we should be telling.

Community care assessment

There are six main areas for proposals in this complicated part of the system:

- there should be a duty to undertake a community care assessment in our future adult social care statute, triggered where a person appears to the local authority to have social care needs that can be met by the provision of community care services (including a direct payment in lieu of services) and where a local authority has a legal power to provide or arrange for the provision of community care services (or a direct payment) to the person.
– a right to have an assessment on request
– the focus of the community care assessment duty should be an assessment of a person’s social care needs and the outcomes they wish to achieve, and should not focus on the person’s suitability for a particular service
– recognise coproduced self-assessments as a lawful form of assessment and/or allow for a pure self-assessment for certain people or groups of people
place a duty on the Secretary of State and Welsh Ministers to make regulations which prescribe details of the assessment process and specify the areas which these regulations must cover
– local authorities should retain the ability to provide temporary services in urgent cases

The three main points of debate are about whether you should have to ask for an assessment and, if the local authority can decide to do one off its own bat, on what grounds they should be able to do so. The aim of these proposals is to get away from a service-based definition; that is, they should not limit their assessments to situations in which they have services to provide. This is needs-led, but it includes the possibility of looking at outcomes. The right to request an assessment is there for those people who might be excluded for some reason. For example, some authorities might not be too keen to do assessments on people with large needs because of stigmatised conditions, such as HIV/AIDS or drug abuse.

There is an interesting discussion of self-assessments. One of the points made is that you can’t have self-assessments for a statutory duty, because local authorities can’t delegate statutory duties. Therefore, any legislation needs to say that it is appropriate for local authorities to work together with service users to produce their own assessments.

The last two points make it clear that the ministers should say clearly what they want done in assessments, so they cannot blame the local authorities for everything that goes wrong, and temporary services in emergencies can still be provided pending an assessment. This might be important in end-of-life care, because you often get the situation where local authorities say they cannot do an assessment for weeks or months and they then don’t do anything, in the meantime the patient dies. Such provision might give a lever to a palliative care service. I’m very much for that, at least partly because the whole local authority system is geared to the long-term, and they are not as accustomed as healthcare professionals to dealing with urgent matters. I also think this provision is needed for, and perhaps should be specifically connected to, safeguarding responsibilities.

Carers assessments: these need to be straightened out and coordinated with community care assessments

The proposals in this area deal with a very complex aspect of social care law, which has grown up over the last fifteen years. There are six proposals again:

- there should be a duty to undertake a carer’s assessment
– the duty to assess a carer should apply to all carers who are providing or intend to provide care to another person, not just those providing a substantial amount of care on a regular basis
– the duty to assess a carer should not be triggered by the carer making a request, but should be triggered where a carer appears to have, or will have upon commencing the caring role, needs that could be met either by the provision of carers’ services or by the provision of services to the cared-for person
– the following carers are not excluded from the definition of a carer for the purposes of a carer’s assessment:

1. a previously unpaid carer who now receives payment for their services through direct payments received by the cared-for person;
2. a carer who is paid for some but not all of the care they provide; and
3. a carer where the local authority believes the caring relationship is not principally a commercial one

- encourage a more unified assessment process for carers and cared-for people
- the carers’ assessment duty should be merged with the community care assessment duty

The first two proposals consolidate the duty to undertake a carers assessment, removing the limit that this responsibility applies only to those who provide substantial and regular care, because these are so hard to define. The third proposal means that the local authority should do an assessment on the same basis as it would decide to do a community care assessment, if it sees need that its services would meet. However – the rights point again – we need to make sure that this does not mean local authorities deciding that they don’t have the services or the money to provide them, so there isn’t a need there to have them.

The last three deal with some of the complexities of carers assessments. The fourth makes provision for the situation where a service user gets a direct payment and then employs an existing unpaid carer, a relative or neighbour for example, or pays for some of the time that they spend and gives the local authority a catch-all flexibility if other non-commercial arrangements exist. The last two are alternatives, and the Commission does not fancy the last, because the interests of carers and cared-for people may be so much at odds. However, some carers have their own needs, and it is difficult to disentangle needs that come from being a carer from your own care needs, and there may also be an issue about who pays when carers and cared-for people live in different local authorities. Only encouraging a more unified assessment may be weak or give a local authority a get-out from doing anything, although the aim would mainly be to require ministers to give appropriate guidance on things like cooperative working.

Most of these ideas are sensible and clear up a very confusing pile of legislation.

Eligibility for services

The Commission points to the confusion that arises from the duty to provide services alongside a discretion to decide whether or not the needs their assessment has identified call for them to provide services. The ministerial guidance allows them to take into account various factors, including resources, but they cannot only take the decision on the basis of resources. In particular, they must take account of duties under the Human Rights Act and Disability Discrimination Act, among other pieces of legislation and specific duties set out in particular pieces of social care legislation. The various guidance, like Fair Access to Care Services, seems to say that local authorities should provide services when they have assessed that someone is in need, but then allows them various discretionary get-outs by using eligibility criteria The legal problem appears to be that local authorities have powers but not duties to provide some services, so if you have a need for them, the local authority can decide it won’t provide them and do something else to meet them – the sponge on a stick problem (see above), even if you are eligible to receive them according to its assessment.

The Law Commission says that under the current legislation local authorities cannot do this; they have to look at the original powers. If they have a duty, they cannot use the eligibility criteria to get out of it, once they have determined that someone needs the service; if they only have a power, it depends on how the legislation specified that power. This is useful guidance for social workers in looking at helping individuals. The Commission usefully makes an analogy with children’s legislation and legal decisions on it.

The proposal to deal with this is as follows:

- a duty on local authorities to:

1. determine whether a person’s social care needs are eligible needs, using eligibility criteria; and
2. provide or arrange community care services (including a direct payment in lieu of services) to meet all eligible needs

How then would you decide on eligibility? The proposal identifies two issues that the ministers should give guidance about:

- a duty on the Secretary of State and Welsh Ministers to make regulations prescribing the risks to independence that will call for the provision of services

- and the objectives that are to be achieved by the provision of services

This fits with the proposals on statutory principles above: people would be eligible for services if there was a risk to their independence (social workers would assess the extent of that risk) and the aims of provision (for example, social workers would assess whether it would prevent further deterioration).

The Commission then looks at personalisation and shows that this is a legal shambles (the Commission is politer than I am about this): it’s not clear that some arrangements for personal budgets are lawful. It’s certainly clear that local authorities cannot tell if they are meeting eligible needs when they allocate a personal budget, because they are not in control of how it’s spent. This is a widely recognised issue in personalisation policy. If you give people choice, you cannot at the same time have a legal duty to provide services. This is one of the problems in providing personal budgets in healthcare, where the Secretary of State has a legal duty to provide all necessary services to meet a health need (see my resource document on continuing care). Since personal budgets for all are politically the in thing, the Commission says that there should be ministerial regulation that complies with the legislation. This is the proposal:

- the Secretary of State or Welsh Ministers may by regulations require that a local authority must allocate a personal budget in fulfilling the duty to meet all needs that are eligible

Services for carers are also a legal and administrative shambles. Again, the Commission is very polite, unlike me, but it’s not clear whether local authorities are using eligibility criteria, or whether if they do or don’t either course of action is lawful in a particular instance. The Commission thinks that probably if a carer had a critical need there would be a legal duty to provide for it. To clear this confusion up, the proposal is:

- there be a mandatory national eligibility framework which local authorities must use to decide whether or not to provide services to carers, and a duty to meet the eligible needs of carers

Legal duties

The Commission then addresses to two main pieces of legislation that confer rights to services. The first is the National Assistance Act 1948, which confers a rights to residential accommodation to people in need of care and attention not otherwise available. Local authority eligibility criteria do not apply here, and this right puts pressure on the system to provide accommodation as a fall-back if care needs cannot be met in other ways, for example by adequate housing and community care services. The complicated legal argument in the Review suggests that because if a statutory eligibility framework is introduced as proposed in the earlier part of the review, local authorities would have to take into account present and future needs, and so they could be forced in law to meet people’s reasonable needs, either by providing accommodation or otherwise. So the proposal is:

- section 21 of the National Assistance Act 1948 should be repealed and that the Government should ensure a proper scheme for the provision of residential accommodation to those people who might lose their entitlement

The Commission is looking for comments about what would happen and who would lose entitlement. My concern about this is that the proposed eligibility scheme allows a fair element of discretion about levels of service, so that over time an underfunded social care service will inevitably tighten up, and there is no pressure to provide services if the local authority is strapped for cash. Again, people may not lose rights, but a rights-based element of the system would reduce the political pressure to avoid responsibility for needs.

The second bit of rights-based legislation is the Chronically Sick and Disabled Persons Act. The same arguments are made and the proposal is:

– section 2(1)of the Chronically Sick and Disabled Persons Act 1970 should be removed from adult social care legislation

It’s phrased in this way because there are some implications for disabled children, so this provision may need to be retained for them. Again a rights-based approach gives way to an eligibility-based approach.

Ordinary residence and portability: my view is that it needs to be more certain what you are going to get and how, particularly if you move

Because they are local, adult social care services are usually provided by the local authority where the service user is ordinarily resident. That is often a duty, and the local authority may also have powers to provide services to others, such as people who are transient for some reason. However, the rules are confusing and inconsistent, so the proposal is:

- the local authority be placed under a duty to provide services for people ordinarily resident in their area and have the power to provide services for people who are not ordinarily resident in their area. In cases of urgent need of residential accommodation, there should be a duty to provide accommodation to those people not ordinarily resident in the authority’s area. Assessments of need and the provision of temporary urgent services should not be limited by the ordinary residence rules.
- the local authority in which the cared-for person lives should be given responsibility for providing carers’ services
- the introduction of: an enhanced duty to co-operate when service users move areas; and if these policies are implemented, a national portable needs assessment and national eligibility criteria

The aim of these proposals is to improve continuity in service provision for people who move. It is not clear whether they would help people to be certain what would happen when they move, because the same needs under the same eligibility criteria could well lead to different service provision. The aim of the duty to cooperate is to require local authorities to plan in advance when someone expresses a clear intention to move. I think this would be hard to enforce. One of the issues is the discretionary nature of social services provision and the low level of social care funding, compared with the NHS. This tends to lead all local authorities to try to hold off from making any commitments for as long as possible. This then creates uncertainty for people who might want to move. In effect, what you have to do is move and then persuade the local authorities to sort themselves out, which they will probably do, but you have to take all the risk.

Defining community care services

If the system will be organised through eligibility criteria, what services will people be eligible for? Should this be specified in detail? This might limit flexibility and innovation, but if it is only set out very broadly, it does not confer much by way of rights to services. The Commission argues this out and comes down on the side of short and broad: its suggested list is:

- residential accommodation;
- assistance and facilities in the home;
- social work service and support and advice;
- centres or other facilities in the community; and
- social, leisure, communication, education and training activities.

At least, this covers the main points and includes social work. And if someone has needs and the only way they might be met is by one of these, then that confers a right to the service. It also confers a right to a package that might substitute for one of these, if it is not available. Being short and generalised, it can also be put into the legislation, rather than a regulation which can be salami-sliced away. So the proposal is:

- community care services should be defined by a short and broad list of services
- the list of community care services should be set out on the face of our future adult social care statute

The Commission goes on to discuss whether community care services should be left undefined. This might increase flexibility and innovation, but would leave local authorities unable to argue with NHS or housing bodies that sought to say that local authorities should pay for housing of health services. It would also mean that members of the public, councillors or the managers of agencies are not clear about what sort of thing should be available.

The next bit looks at whether there should be a list of client groups in the legislation and how this can be structured. It is difficult to define particular categories legally, without restricting eligibility at quite a high level. An alternative might be referring to people who have a current need for services, have had a need in the past and/or need services to prevent a need arising; but this might be too vague. Similarly, carers’ services are hard to define. On the other hand, it looks at shared living schemes, what used to be called adult placements. This is where people live other people’s homes, rather like fostering for people who are frail or have disabilities. It’s not clear whether these are residential accommodation or not, but they may have to be subsidised in adult social care, to get carers to provide the facilities. In the end, the Commission says:

- we do not propose that our future adult social care statute should include a central definition of a disabled person or service user.
- carers’ services should remain undefined
- allow for regulations to be issued that are capable of defining Shared Lives schemes as being non-residential services in all cases

Maintaining the distinction between healthcare and social care is important so that the political commitment to a free health service can be retained. Similarly, adult social care provides a lot of accommodation in order to provide care, but it is excluded from providing accommodation that should be provided under other legislation. So the proposal is to retain the legal prohibition on social services providing healthcare services, if there is a duty under the NHS or housing legislation:

- local authorities would be prohibited from:
providing residential accommodation, if this is authorised or required to be provided under the NHS Acts 2006 any non-residential services that are required to be provided under the NHS Acts 2006; and
nursing care which is required to be provided by a registered nurse.
- social services authorities should continue to be prohibited from providing ordinary housing and connected services, if these services are authorised or required to be provided by or under other legislation.

Immigration law prevents adult social care from provide its usual services to destitute people if they are asylum seekers and refugees. Since this is government policy outside the scope of this review, the Commission simply asks for views on the likely consequences of continuing with this position.

Delivery of services

Since the Commission is moving towards a process view of adult social care legislation, that is, the law says how the services should be provided, rather than what should be provided to whom, it points out that care plans are a crucial part of this process. This is because it is the care plan rather than the assessment that says precisely what the local authority will provide. Even if this is then covered by a direct payment, this step is still a crucial part of the process, even if it needs to changed somewhat. The Commission therefore proposes flexible provision for adult social care services to say, in effect, ‘this is what we are going to provide’; this can then be disputed in law if the service user disagrees. The proposal is:

- a duty on local authorities to produce a care plan for people who have assessed eligible needs. This would be supported by a duty placed on the Secretary of State and Welsh Ministers to make regulations concerning the form and content that the care plan must take.

There is then an issue about accommodation. People who get direct payments, increasingly intended to be the majority, can choose and manage their own services. However, if they are assessed as needing residential care, the local authority has to manage the service, although the service user has the right to choose where they go and pay more than the local authority will pay if that is what the user prefers. Government policy is against simply giving people direct payments and allowing them to organise their own accommodation. This seems contrary to the direction of personalisation policy. The government makes the distinction because, they say, they want to retain the focus of direct payments supporting home care. The Commission asks for views about this.

I have my doubts about what the government is saying. I can understand one aspect of it, because back in the 1980s, when social security payments were available for residential care but not for home care, this encouraged people contrary to community care policy, to switch into residential care, and the costs took off like a rocket. Not leaving local authorities in control of residential care placements means that people might not put up with the hassle of organising home care, and go for the easy option of what would in effect be a subsidy of residential care. In turn, this would be an incentive for a burgeoning of residential care and probably care home operators in a more generous market increasing their charges. I suspect the government’s policy is less about avoiding a perverse incentive to people to switch from home care into residential care, but more that it would release pent-up demand, increase overall costs and reduce the financial incentives for people to set up private sector community care services.

The Commission seems to think that it would be more logical if direct payments also provided for residential care. But since the government will not do this, it proposes that the present ministerial direction that people should have the choice of their accommodation if they are assessed as needing it, should be written into statute. On the other hand, direct payments are made subject to various limitations, which might alter from time to time, so it proposes keeping the flexibility of the current regulation approach, rather than enshrining the limitations in law:

- the choice of accommodation directions should be placed in statute law and that the additional payments regulations should be retained in secondary legislation
- direct payment provisions should be retained in their existing form

Requirements on charging vary between England and Wales, and policy on charging may well change, so the Commission proposes leaving it to ministers to decide on charging arrangements:

- a regulation-making power to enable the Secretary of State or Welsh Ministers to require or authorise local authorities to charge for residential and non-residential services
- the existing regulation-making power, which enables certain community care services to be provided free of charge, should be retained. All services that must be provided for free should be listed in the regulations

Joint working

Aside from the limitations which mean that the NHS is divided from adult social care, there are various other transitional problems. Where children, particularly those with disabilities, transfer to from children’s to adult social care, the proposal is to make a clear dividing line at 18, but allow flexibility to facilitate transfer:

- future adult social care statute should apply to those aged 18 and above, and the Children Act 1989 (and the CSDPA 1970) should apply to those aged 17 and below
- local authorities should have a power to assess 16 and 17 year olds under our proposed adult social care statute and young people aged 16 and 17 (and their  parents on their behalf) would have a right to request such an assessment

Then, the Commission has a problem that if adult social care only applies to people over 18, young carers cannot be provided for under this legislation, but they currently have a right to receive assessments and services. Therefore, the Commission proposes:

- the [relevant legislation]  should be retained and amended so that they only apply to young carers
- parent carers should continue to be eligible for a carer’s assessment under the [relevant legislation]… [w]here a young person aged 16 and 17 is being assessed under our proposed adult social care statute, parent carers should also be given a carer’s assessment under this statute

Adult carers and parent carers whose children were assessed under the transitional arrangements would then be provided for in the adult social care legislation. This seems cumbersome to me; but there might be advantages in have separate legislation that referred to young carers, because it might get them a better deal than the rather poor services that most carers get if they are adults.

The well-being power

I have commented before in this blog on the well-being power that local authorities have to do anything that is for the general well-being of their communities. The Commission asks whether we should get rid of specific adult social care legislation and simply use this power, or, for a less total change, add a well-being responsibility into the adult social care legislation; they’ve had something similar in Scotland for many years. My view in principle is that greater autonomy to local government to do what it wants would be usefully more European in its approach – most local government in Europe has more power to do things that it thinks are beneficial, but they also have more independent income, whereas most British government funding is highly centralised. How it would work here, then is problematic however, desirable it would be.

The Commission points out, however, that in law the well-being power is a fill-in where it’s not clear that legal powers to do something desirable exist. It could be used to provide social care, particularly if it were off-the-wall, something a bit unusual that it wasn’t clear is covered by the present legislation. However, there are limits: the expenditure has to be proportionate to the gain, the local council can’t do anything that Parliament has forbidden or restricted in some way and the aim is not to regulate a well-established service. So you cannot enforce social care provision using a well-being power, although it does give you discretion to do interesting things that the law has not thought of. If you linked it to community care assessments, you could set up the system for assessment, and also require the assessment to show that the outcome produced well-being. Would that be for the community in general (the aim of the present well-being power) or for individuals? The Commission asks for views about this.

I’m for well-being as one of the statutory principles, because I think there should be a test of how good a service is to a community in general, and how good it is for individuals.

Delayed discharges

The delayed discharges legislation allows a hospital so say they’re ready to discharge someone from one of their beds, and local authorities have to scurry round and get them out, or be fined for failing to do so. Not in Wales, the Commission points out (which raises the question of why it is so necessary in England). And, I would add, not in palliative care, because it doesn’t apply to independent hospices; our experience at St Christopher’s is that there are signs that local authorities are getting to the point where this makes a difference. They and the DH started off by saying it wouldn’t, and this was generally true, and I believe is still generally true. But with things as tough as they’re getting, any port in a storm, leave the hospices to suffer.

The Commission proposes leaving it as it is; I think hospices should be arguing fro it to be applied to all in-patient units, because it is unfair for a benefit (if it is a benefit) to be conferred on someone just because of the type of unit they are in, especially when the government says it wants to cooperate with the voluntary sector.

Prisons

There has been a lot of consideration of palliative care in prisons, and there have also been moves to get the NHS involved in prison health services, to improve the quality. Prisoners are eligible for community care assessments, and more will need them because the prison population is getting elderly. We should also be doing better for mentally ill people and people with learning disabilities; a high proportion of the prison population have such problems. Rather than needing punishment because they’re bad boys and girls, a lot need help with their problems, either as well as or instead of prison.

So, who should provide adult social care for prisoners and are special arrangements needed? Prison governors have a common law duty of care and duties under the Disability Discrimination Act to make reasonable adjustments for disabled prisoners. Currently, adult social care legislation and regulation does not deal with prisoners specifically. They would get an assessment and services (with certain exceptions) from the local council in the area they were living in before they went into prison. The Commission thinks that prisoners are not excluded from adult social care, but no efforts have been made to consider their position, and the Commission asks for comments about whether they should be included in or excluded from the adult social care legislation. It’s not clear that prisoners are equal under the law, because they mostly seem not to get assessments and there are practical difficulties in getting them services.

My view is that they should clearly be given the same rights as everyone else. But more is needed, because they will not get this unless we specifically provide for their special needs. This is also important, because healthcare comes from the NHS and usually this would involve some elements of adult social care. We should really be thinking seriously about this.

S117 Mental Health Act

I’ve tried to avoid getting into specific legal stuff in this post, but there’s no choice here. S117 makes provision for after-care planning where someone has been held compulsorily under the Mental Health Act 1983. It’s a ‘free-standing’ duty, separate from the normal provisions for adult social care: so should it be made to fit in? Legal decisions mean that it is not a gateway to other services, so it does not give the legal power to choice of accommodation, as (see above) service users under the National Assistance Act have. There is also no power to charge for residential care, so mental health patients also cannot top-up accommodation charges to get what they want (you can’t top-up what you’re not getting in the first place, unless it’s a payment direct to the care home instead of to the local authority – perhaps). Furthermore, the arrangements for which local council is responsible are different under the mental health legislation from the other legislation. It’s a mess, and the Commission proposes:

- choice of accommodation directions, and
- additional payments regulations should cover residential accommodation provided under section 117 of the Mental Health Act 1983; also
- the concept of ordinary residence should be extended to apply to after-care services

Another difficult part of the mess is that it’s not clear whether health care and social care authorities have to provide their specialist area of after-care or all of it – which does what? Also it’s not clear that they can commission services, even though they are required to cooperate with voluntary organisations. To sort this out, the Commission proposes:

- section 117 should be amended to clarify that:

1. the duty falls on health authorities to provide health care after-care, and on social services authorities to provide social care aftercare.
2. health and social services authorities can commission after-care services

– If the section 117 duty is split should the termination of the duty also be split so that, for example, social care after-care ceases when the social services authority is satisfied that the person no longer needs social care after-care; or should both authorities be involved in the decision?

The Commission also asks for views on whether the free-standing duty should be merged into the main legislation. I take, as I have throughout this post, a rights view of that: I think all service user groups would all benefit from a duty to plan after-care; this might also help with delayed discharges. Go for it, I say.

Duty to cooperate: I agree it should be clearer

Some legislation makes it a duty to cooperate to provide services. Usually it is clear who has the duty to cooperate and to lead a particular aspect of it. But it often does not go very wide (usually not mentioning all providers, in particular – thinking palliative care again – voluntary sector providers, who may be the main players) and it often gives a duty to cooperate without requiring potential cooperators (I’m thinking foundation trusts but no doubt there are others) also to cooperate; they can say ‘we’re not playing ball’.

To deal with all this, the Commission proposes:

- a general duty on each social services authority to make arrangements to promote co-operation between the local authority and specified relevant organisations.
- a local authority can request certain authorities to assist in a number of circumstances, including when an assessment of a service user or carer is taking place and in providing services to a service user or a carer. In such cases, the requested authority would be under a duty to give due consideration to the request.

Safeguarding adults at risk

What should the law do about adult safeguarding? Some professionals involved want to have legislation, like they have in Scotland, that gives them powers like those in child safeguarding. I worry that this is about giving adult social care departments some macho responsibilities that give directors power and push within the Council for better resources. The Commission looks at powers to investigate and take coercive action. The problem with investigative powers is: what kind? Would it be like police powers, or something different? How would it interact with police powers? – an issue that children’s social care has faced. And how would coercion interact with Mental Health Act, Mental Capacity Act and human rights responsibilities and powers. What should be done about the controversial power to compel people who are not looking after themselves (S 47, National Assistance Act) – this offends against all sorts of modern legal arrangements. And how should we define someone who is vulnerable?  – currently this refers to services that they might receive, rather than referring to their needs. The Commission explores a whole range of definitions and looks at whether local adult safeguarding boards should be included in the legislation to formalise the administrative structure for cooperation.

Local authorities have responsibilities to look after people’s property (especially in my experience their house and pets) when they are admitted to residential accommodation or hospital; should this continue, or go to a body like the public guardian. The issue here is, to me, the most efficient organisation: the NHS is not a general purpose body and the public guardian is not local.

Not an easy one, and the Commission proposes:

- a duty on local authorities to make, or cause to be made, such enquiries as it considers necessary where it has reasonable cause to suspect that a person appears to be an adult at risk and consider whether there is a need to provide services or take any other action within its powers in order to safeguard that person from harm
- the term vulnerable adult should be replaced by adult at risk for the purposes of the duty to make enquiries,
- an adult at risk should be defined in our statute as anyone with social care needs who is or may be at risk of significant harm
- if the Government in England or the Welsh Assembly Government decides to introduce new compulsory or emergency powers to safeguard adults from abuse and neglect then these will be included
- the enhanced duty to co-operate, proposed above, should include specific provision to promote co-operation between the organisations in safeguarding adults from abuse and neglect
– No Secrets [the English policy] and In Safe Hands [the Welsh policy], or their successors, are linked clearly to a local authority’s statutory functions to safeguard adults from abuse and neglect
- section 47 of the National Assistance Act 1948 should be repealed
- a local authority should continue to be under a duty to prevent the loss or damage of a person’s property when they have been admitted to hospital or provided with residential accommodation

Strategic planning

The legislation contains various arrangements for strategic planning. This includes the register of disabled people, which is supposed to help planning. But you do not have to register, and you can get most services even if you are not registered because there are specific administrative arrangements for them. Therefore, it no longer really helps planning. On strategic planning generally, there are NHS powers for this purpose, and local councils have wider responsibilities to plan all sorts of things. The Commission does not think that there is anything to be gained by adding legislation on specifically adult social care strategic plans. However, providing information is a different matter; citizens should be entitled to appropriate information in a complex system.

In addition to not proposing any specific strategic planning duties or powers, the Commission therefore proposes:

- the disabled persons register should be abolished
- a duty on a local social services authority to provide information about services available in the local area.

That’s it: do have a look and write in to comment; of course you can comment to this blog, but this is your chance to talk to a very influential official body that could be making arrangements that will be here for our lifetimes and beyond.

The website again: http://www.lawcom.gov.uk/docs/cp192.pdf

Among the first-half drones at this conference was a duo talking about something called ‘connected care’. It turned out that someone in healthcare has found about about community audits (a technique widely used in community work for forty years or more): you train a few people to carry out and analyse a survey of their local community to find out what you already know, but the results have more credibility because they’ve found it out themselves by participating (ie doing what they’re told would be a good idea by the professionals – this is my new definition of participating in the NHS).

Someone on their film identified the main concern about people presented with another survey from the NHS, that they can’t be bothered to respond because they know nothing is going to happen as a result. This of course is why getting someone from the local community to do it is an ace, because it’s harder for people to say ‘no’ to an earnest neighbour, preferably young or old, so they’re harder to abuse.

Apparently, though, the latest management-speak for dealing with people who don’t believe you’re going to do anything is to tell respondents in advance that you cannot afford anything, and then they won’t be disappointed afterwards. This way of getting people more connected to the NHS was hailed as a new project development insight. I was always taught to see it as ‘not raising expectations’ – it’s been a standard social work technique for at least the forty years I’ve been using it; it’s always been vital in social work, because it’s really hard to get anything for anyone from a deprived community, so it’s best not to raise their hopes.

The survey apparently found out useful things: for example, local people would like more social activities, especially for older people. Unfortunately, the presentation did not go so far as to say anything that they’ve actually done as a result of their community audit; we were invited to accept that this ‘industry best practice case study’ is going to lead to wonderful things if we do the same, only they haven’t quite got there yet.

And probably won’t, if normal life and the economy is anything to go by.

A useful accumulation of stuff at NHS evidence on social enterprise (what a nicely broad definition of evidence that is – useful information). It seems to me that social enterprise is not much different from social work, at least the community end of it, a generation ago. I wonder why government and others seem to need to see social enterprise as better or more important than social caring or social involvement; is it just because they hope it will make money?

http://ow.ly/15QWI

David Cameron the Conservative opposition party leader, made a speech last week on the ‘Big society’, which put forward his thinking on poverty and social intervention generally. As always, they’re against the state doing it, and many people can accept that there is a considerable degree of state failure in social provision. The problem for the Conservatives is that there’s a high degree of market failure in social provision as well. Often everyone accepts that the market is not the place for social interventions, or they have to set up some convoluted quasi-market system that is not really a market, and institutionalises complex state controls over voluntary action.

Voluntary organisations may be wonderful, but to rely on voluntary organisations to deliver wide-scale state services is inappropriate; it twists voluntary action by making it involuntary.

You can see this in the hospice movement. Hospices in the UK are mainly in the voluntary sector because St Christopher’s was originally a demonstration of what was possible in care for the dying and their families at a time when not a lot was done. Now Conservatives routinely say how wonderful voluntary hospices are as an example of how lots of other services should be run. But proper care for dying people and their families is a responsibility of society where government should take a lead and make sure that a high standard of care is widely available. They should not be pleased that they can offload that responsibility because enough sentimental and well-off people will make donations to support it,

Cameron’s speech on the web: http://www.conservatives.com/News/Speeches/2009/10/David_Cameron_The_Big_Society.aspx

The Touchstone blog by Richard Exell has a useful discussion of the speech, with references to many of the past Conservative documents on the topic that many people will not be aware of and rehearses the arguments against it; however, be aware that Touchstone is a TUC (ie trade union) blog:

http://www.touchstoneblog.org.uk/2009/11/david-cameron%E2%80%99s-big-society-speech/