Author: Helen Duff

Helen Duff

About Helen Duff

Helen blogs about statutory and voluntary social work issues, plus the provider perspective. Helen is social worker who has practised in the statutory adults sector as a care manager and senior social worker, worked as a palliative care social worker in the voluntary sector, and is currently a team manager with a Shared Lives scheme. She will be blogging about issues pertinent to Shared Lives and Personalisation

A Celebration of Ordinary

I have spent the last four years working for Shared Lives. I am leaving, imminently, to do something completely different. This ending is causing me to look back over the time I have spent within this wonderfully quirky organisation.

I saw an advert for a job at Shared Lives shortly after relocating to the South West. I had been qualified as a social worker for around 9 years, working in outer London, and had never heard of Shared Lives. Seeing the organisation described within the advert made me want to find out more.

Maybe I hadn’t heard of Shared Lives because I worked within a generic adults team, whereas the Shared Lives model is more widely used within the learning disability sector, for no other reason than this seems to be where it started. The more I read, the more I started to think “Yes! This is what I would want for myself! This is the kind of care I would want if I was unable to live without support.” I admit to a certain amount of selfishness when thinking about how positive it made me feel that there might be another way to receive care. I had feared becoming disabled in some way and then not being able to continue my lifestyle in the way I wanted – going out late and not telling anyone when I might get back, for example… How would that work with multiple risk assessments coupled with my desire to lead an unhealthy and unwise social life filled with the wine that I’d spend the majority of my money on!? It always amazes me that social care is not more to the forefront of all of our minds. We are all, at risk of sounding morbid, only one accident away from life changing injury that might suddenly plummet us into a world of lessened choice and control.

As I started to learn more about the people who work as Shared Lives carers, and the people who live with them, I also started to hear questions from professionals. I remember one in particular: “aren’t you creating dependency by encouraging people to forge deep relationships with their carers?” Shared Lives carers care deeply about and, dare I say it, often love the people they support. Only recently I spent time speaking to a tearful grieving carer who had spent in excess of 20 years caring for someone who had recently died. She had lost a member of her family and she felt this as acutely as anyone else, regardless of her ‘paid carer’ status.

I started to think about the people who make my life fulfilling; my friends and my family. Am I ‘dependent’ on them? Well I guess yes, in a way I think I am. But does that mean I should protect myself from all hurt, and hold back? Is it better to have loved and lost than not ever to have loved at all? Yes, relationships break down, and it hurts – really hurts. But does that mean I should stop forging relationships that might inevitably cause me heartache?

This led me to think about a wonderful story that shouldn’t even be a wonderful story – we recently celebrated a couple getting married within Shared Lives. Leaving the Article 8 ‘right to family life’ aside for a minute, these two people had cared about each other deeply for many years. However, the system they lived within had kept them apart. One was in a residential home and another wasn’t. It took the combined will of a number of professionals to seize opportunities when they arose. Firstly, the man moved in with Shared Lives carers due to a change in his circumstances – that took a worker who listened to him. After moving in, he continued to see the woman he loved with the support of the carers. It then took another worker who knew the woman well and who listened to her, to work with a range of professionals to support her to have her wish (and human right) to move in with the man she had loved for years. It worked – they moved in together, got engaged and were married – she in a beautiful dress with the biggest smile, and he looking as proud as any husband could do. They had bridesmaids and plenty of guests. Their carers helped them to organise everything and were there as part of their family to celebrate. The carers’ children were there as part of the family to celebrate; and what better way for children to grow up – without the lines that often divide those of us without disabilities from those of us with them.

Although I felt really happy looking at their photos I also felt sad and angry that this should be something so special. Why should they have had to wait so long? Why IS it so unusual for two people to do something as ordinary as the rest of us?  When asked, they rightly both wanted to know why would we want to celebrate their story. Why should we? Why can’t they just get married and then get on with their lives, like you or I would…? We appreciated their agreement that we could put their story in our newsletter, but we respected their wish for an ordinary wedding followed by an ordinary married life, regardless of our desires to shout about this story from the rooftops. But we shouldn’t have had to shout about it, should we? It shouldn’t be unusual, it should be something we don’t blink an eye about, other than to wish them well.

Every time I talk to anyone involved with Shared Lives they relay the ‘success’ stories of people just living their lives. The people who live with Shared Lives carers don’t necessarily talk about the cruises around the world they have had, the holidays abroad, the travels in the family caravan, the camping trips in France, the meeting with celebrities. They talk about the people they know, the children they live with and help out with, walking the dog, going out with friends, going to church, travelling to the shops, getting a motorbike licence, work, college, decorating, going out for coffee, shopping, cooking, having their hair done, having their own children, finding a partner – all the ordinary things that we take for granted, because we live outside of ‘serviceland’.

Of course Shared Lives isn’t perfect – we have the same struggles that many other providers have; demonstrating outcomes, ensuring our MCA compliance, evidencing our MCA compliance, negotiating payments, considering DoLS, evidencing that we have considered DoLS, writing our contracts for commissioners, evidencing that we are a safe service, writing plans, reviewing those plans, setting more outcomes, demonstrating value for money, evidencing value for money. All of these things need to continue to be done, hopefully in a way that doesn’t impact too much on the lives of the people – who, if we are really successful, need not feel like they are receiving a service at all.

Other than my departure, the other thing that caused me to reflect on my time in Shared Lives was a tweet shared by @sarasiobhan – it was a quote from a book by Dean Shrock ‘Why Love Heals’.  I have not read the book but the words struck a chord: “…no other factor in medicine, not diet, not smoking, not exercise, not stress, not genetics, not surgery, affects our health, quality, and length of life more than feeling loved and cared for…”

And I think that just about sums it up.

The Red Herring RAS

When talking to social workers and community care assessors/workers, nowadays, the RAS is often part of their everyday language. RAS stands for ‘resource allocation system’ whereby an assessment document produces a monetary amount, depending on the answers about ‘needs’ which the assessor puts in. Most RAS tools are based on the local cost of service provision for different service user groups. This varies across the country, and therefore each RAS calculator is going to be different based on the costs of services in that area.

Some companies who design RASs believe their model to be extremely accurate at predicting an adequate sum of money, IF the correct costings for services are entered and IF the workers input the correct answers, having interpreted the questions within the assessment correctly. Quite a lot of ‘Ifs’, one might think, in this current culture.

The RAS is a hangover from the implementation of SDS (self-directed-support). This was brought in amongst lots of excitement, ‘blue sky thinking’, and talk of personalised services and person-centred support plans. My first blog post talks more about this era but for now we have what we have; many councils use a RAS on a day to day basis. The acronym has become a standardised piece of jargon that workers have to explain to often perplexed individuals who don’t have the knowledge or understanding of the original concept.

Many councils tell their workers that ANYTHING (even £1) contended for over and above a RAS-modelled sum needs to go to a panel for approval. Funding panels are another issue generating a lot of emotion in workers and managers alike, and are a topic for another posting. However, often workers want to try to keep a package within a RAS to negate the need to go to panel, what with all the additional paperwork and emotional energy generally required to evidence one’s case for additional funding.

The RAS is a delicate instrument and can so easily become completely unworkable. For example, if a finance manager within a council realises they need to make 20% savings from the social care budget, it would seem a simple solution to write a 20% deflater into a RAS calculator. The effect is to constrain practitioners to attempt to design or co-produce a plan within a budget that is logically far less likely to meet an assessed need. Inevitably this results in perplexed workers fiddling and adjusting the assessment to try and make the money fit the needs they know that the person in front of them has.

Companies who sell RAS products are often despairing at such tweaking behind the scenes, because it makes their product look bad; and service users are in the middle of a whirlwind of discussions and strife, whilst the workers cannot fathom why they cannot make a budget fit the need.

There are obvious risks with an approach that sees the RAS as more than merely one factor in the process. Under the Care Act, a service or a budget offered to meet an assessed eligible unmet need, MUST be sufficient to meet that need. It doesn’t matter whether a RAS tool tells you there is £50 a week available, if you, the professional, know and have assessed that person as needing a package that you know to cost £100. If it costs £100, then this is the service which the council MUST provide, in order to remain lawful. This principle remains the same as it was pre-Care Act; if a worker decides, maybe because of the desire not to go to panel, that they will only put in a package that meets some of the needs, even with the agreement of a service user who knows no different,or decides to describe some of the need as a want, they will be wittingly or unwittingly exposing themselves and the council to the risk of judicial review. These basic legal principles are so often lost within cultures where it is processes that lead and where workers use automated systems and databases as their guide, rather than an awareness of the law.

The Care Act Guidance gives some warning about an unthinking reliance on a RAS:

There are many variations of systems used to arrive at personal budget amounts, ranging from complex algorithmic-based resource allocation systems (RAS), to more ‘ready reckoner’ approaches. Complex RAS models of allocation may not work for all client groups, especially where people have multiple complex needs, or where needs are comparatively costly to meet, such as deaf- blind people. It is important that these factors are taken into account, and that a ‘one size fits all’ approach to resource allocation is not taken. If a RAS model is being used, local authorities should consider alternative approaches where the process may be more suitable to particular client groups to ensure that the personal budget is an appropriate amount to meet needs.(11.23)”

There are then three requirements for funding within the Care Act Guidance:

  • Transparency – you must be able to explain to people how your RAS works. Eeks! This doesn’t mean the PhD level maths about the algorithm that’s driving the end result, but the basic factual and rational link between the needs, the points, the pounds, and the market rate for the proposed response for meeting the need!
  • Timeliness – the guidance talks about how important it is to give people their indicative budget UP FRONT so the person knows how much there might be to meet their needs (and their reasonable preferences). Eeks! This is awkward isn’t it? Lots of councils don’t tell people what their indicative budget is for a number of reasons: setting people’s expectations too high when they see a large monetary amount written down and then having to re-educate them into realising that the indicative budget isn’t the final budget, for one! For this reason, some councils have stopped the indicative budget figures being printed onto the assessment document. This creates a mystery around the indicative budget because people don’t know how much is in their ‘purse’ to begin with and therefore can’t possibly begin to shop for themselves! Another reason why some councils don’t provide the indicative budget amount is a general belief amongst workers that the RAS is NEVER accurate and therefore they don’t want to worry someone by telling them their indicative budget comes out at £50 for a package that will, and always has – cost £300. (Maybe that indication is because someone somewhere has had the brainwave of writing in an automated deflater?!)
  • The final requirement for funding is Sufficiency – the amount of budget that the council makes available for someone HAS to be enough to meet their needs. As explained earlier, this is a longstanding legal principle that is simply reinforced under the Care Act. So don’t plan solely with the RAS amount – you need to be confident that the final package is sufficient to meet the person’s needs.

 

Confused? Yes, it’s baffling. The RAS has unwittingly morphed into an entity with more power than it should ever really have had.

However, it needn’t be this way. The RAS can be a useful tool if councils trust their model enough to make service users aware of the indicative budget, which in turn will allow them to genuinely be involved in spending this in a way that promotes control by the individual over their life and their care (the 4th of the Section 1 areas of Wellbeing). It will also require workers to appreciate that the RAS is there, but it’s really just a red herring – a tool there to help them, as well as management. The risk is that using one can divert attention away from the requirement to provide a care package which is sufficient to meet the assessed eligible unmet needs of service users. One way of understanding how to view the RAS is to remember, when care-planning, that the staff are professionals exercising skilled judgement and that without their authentic opinions and reasoning as to why £x is enough, to meet a particular need, councils would have no evidence basis for backing up the view that the statutory function has been lawfully discharged in the first place, if challenged via the legal process. They can and should use a decent RAS as a guide, but not a determinant of the cost of a package of care.

 

With understanding of the question of sufficiency, balanced with respect for reasonable preferences for people, balanced with a notion of achieving Best Value which is not solely financially driven, we can, as staff, navigate our way through the requirements of the Care Act, whilst freeing ourselves up from being driven purely by process. When we assess people and work with them to meet needs, we can regain control of our practice if we can see the opportunities that the Care Act gives us. They are there for the taking; we just need to be brave enough to pick them up, work towards understanding them, and be mindful of the red herrings that can divert our attention along the way.

This Week’s Star Prize – a named worker!

Warning – certificate 35+ (this post contains entertainment references only understood by those of 35 years and over)

I will always remember an ex-manager’s lament that social workers were not getting to see people who needed care or support early enough, and therefore missing opportunities for, in particular, safeguarding prevention.  I remember thinking that I could probably purchase a range of illegal services/substances/items much more easily than getting through to a social worker, in a council. Their phone numbers and contact details have become a closely guarded secret, to for helen 1which one can only win access, after winding one’s way through the Crystal Maze and scrabbling around for enough golden tickets in the Crystal Dome.

 

Think about the average journey a person makes before they ever get a sniff of someone who will provide them with an in-depth and holistic assessment. Most of the time a GP will give out the leaflet with information about their local contact centre for social services. Thereon in, they are thrown into a Labyrinth of services, people, teams – and all without even catching sight of David Bowie in obscenely ill-fitting spandex.

The Care Act recognises that people don’t know what they need to know, in terms of their journey through the confusing system that is social care. Good information and advice will be a welcome relief for helen 2for those who are understandably perplexed about heading towards teams whose names have no meaning in the real world: ABC team, A&R teams, ART workers, CC teams, Zone teams, SPOCs, ICT, numerous HUBs and my favourite of all: ‘The proof of concept team’ – hurrah for that one being the most inexplicable.

The Care Act retains the low bar from the old legal framework for accessing an assessment of need: “Local authorities must undertake an assessment for any adult with an appearance of need for care and support, regardless of whether or not the local authority thinks the individual has eligible needs or of their financial situation” (para 6.13 of the Guidance). So, people in contact centres in Local Authorities need to understand this to ensure they are not inadvertently turning people away without offering an assessment – or something else that should come before even that part of the process, such as advocacy or prevention/reduction suggestions.

According to the Guidance, an assessment begins as soon as a Local Authority starts to gather information about a person – therefore once someone in a contact centre begins to discuss and record potential needs, the assessment clock has started ticking. It isn’t actually ticking towards anything, though, because there are no timescales for completion of assessment written into the Care Act.  However, there are a range of other issues that need to be considered at first contact, including pausing the assessment, and knowing you are doing this in order for a round of prevention to be accessed.

The duty to provide advocacy for those who might have substantial difficulty being involved might be triggered for the purposes of assessment, which might begin at first contact, which means contact centre workers need a working knowledge of the test to ascertain the level of difficulty in being involved. This is not to be confused with the test for capacity – which in itself means workers need to know the difference. The Care Act recognises this complexity: Local authorities must ensure that their staff are sufficiently trained and equipped to make the appropriate judgements needed to steer individuals seeking support towards information and advice, preventative services or a more detailed care and support assessment, or all of these. They must also be able to identify a person who may lack mental capacity and to act accordingly (Para 6.25)

Carers now need to be viewed in the same vein as people who need services, and that is both a change of mind-set and cultural shift within many Local Authorities. First contact workers need to understand the issues regarding whether they are offering Carers’ Assessments or Carers’ preventative services, as Belinda discusses here.

First Contact is a complex area, and one which tended in recent years to be staffed by people lessfor helen 3 qualified than those at the end of a very…long…line. Before one can get the golden contact number of an actual social work team, let alone an actual named worker (wowzers!) the journey through this vortex is governed by the triage work within first contact centres – as with most triage, it’s not best done with a script, because it involves making complex judgements, which need to be addressed in a legally compliant and knowledgeable manner.

This area of first contact is both a skilled and sensitive role. Oh how I remember when local teams used to have direct contact with members of the public – straightaway, no less! We were in touch with families and GPs, we could see issues coming from a distance in order to react and actually do some prevention! Pull up a beanbag and make yourself comfy whilst I regale you with tales of how much better it all was…a few years ago.

The Guidance continues to speak to first contact workers: Staff who are involved in this first contact must have the appropriate training and should have the benefit of access to professional support from social workers, occupational therapists and other relevant experts as appropriate, to support the identification of any underlying conditions or to ensure that complex needs are identified early and that people are signposted appropriately. (Para 6.27)

for helen 4Maybe this means that people WILL get access, quickly, to someone who at least has had some support from someone qualified and legally astute?  Perhaps once again, workers in local teams will regain a sense of the community they work within, a sense of the community so many of us crave within our working and personal lives.

And maybe, it will be a little easier to win the golden ticket – the one with the phone number of a team whose name isn’t akin to a Krypton Factor challenge, on the back. And of course, this week’s star prize – a named worker!

for helen 5

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The Care Act – Another New Dawn?

As a Social Worker who once felt inspired and excited when ‘self-directed support’ was implemented, I have grappled with feelings of disappointment and genuine sadness at what I felt to be the demise of a real opportunity.

I was a relatively new social worker when SDS was first mooted around 9 years ago. I was whole-heartedly engaged with making it work and became immersed in promoting and celebrating the ‘personalisation agenda’.

I then began to watch, with dismay, as the ideology and philosophy of this was gradually dismantled. It felt like all that was left of this amazing opportunity was the RAS (Resource Allocation System). I have nothing against the concept of the RAS in itself but what saddened me was the way it had turned into something solely being used to monitor and control spending. It grew into a monster through no fault of its own. I understand the very real and difficult job of managing a short supply of money, but my perception was that this was being muddied with the RAS and the philosophy of SDS and I found that difficult to watch.

I began to drift towards the cynicism that so many within social work begin to feel. I admit to having a healthy dose of cynicism and a potentially unhealthy dose of sarcastic humour, but this other feeling was something I didn’t enjoy and I didn’t want it to overtake my passion for social justice and equality; the very reasons why I went into social work in the first place.

When I became aware of the impending Care Act, I decided to take any opportunity to understand this new legislation. I started to read around it, tried to keep up to date with people who tweet and blog about social care law, as well as gaining as much information from training. I have an increasing belief that understanding the law is the way for people to appreciate what their rights are. I see law and social work as natural partners; it is the opportunity for social workers to have half a chance of ensuring people get what they need.  It also provides practitioners with an understanding of what Local Authorities don’t need to provide, which in itself is far more liberating than having a funding panel telling you!

As my understanding of the Care Act has deepened I again find myself inspired and excited about what this means for the culture of social care and social work. In so many ways, my lack of legal knowledge made the policies around personalisation seem weak. But if I had been equipped with the knowledge that I have now, even in respect to the laws that have now been repealed, I wouldn’t have felt so helpless.

I appreciate it will take time for culture to change. I know that for advocacy to have any real impact the people who do it need be to legally literate and there needs to be enough of them. I know that in order to be truly preventative we need to tackle the culture of only being able to firefight and manage crises. I know there needs to be a change in how we view the importance of carers’ assessments, as this is where prevention starts. I know we need to put our most qualified and experienced workers right at the first point of contact, rather than at the end of a convoluted pathway. I know money is tight and spending is going to be reined in even more. All these topics are for consideration in subsequent blogs.

However, amongst all these tricky issues there is the glint of what could be possible. It’s there, in actual law; true personalisation, real involvement for the people we support, and an end to fitting people into the same old services.

The Care Act could be the way we change things for the better. But only if we open our minds and dare to be hopeful, all over again.