The problem with our NHS/Social Care (personal budgets)

Over five years since the since the Care Act came in: 100+ pages; 78 sections, of the act; 22 (and counting) sets or regulations; and 600+ pages of guidance notes, which has been amended twice a year nearly every year. Talks, talks… and more talks. Meetings: daily; weekly; monthly; yearly, literally unfathomable hours in discussion (all by people getting paid.) More talks on green paper on funding, Yet has anything improved or even changed?

Let’s start from the beginning… As a person with disabilities, and what some may call a service user of at least seven years, I have a background of 17 years working for Local Authorities in Enforcement across the country, with fluctuating conditions which gradually get worse year on year. Though I’ve heard, talked, and even been involved in (via running a service user group), nothing has changed. We still talk and frequently hear about independence, choice and control, but apart from brief flashes here and there, we've seen nothing of substance.

The local authority implementation of these principles it is ad hoc at best (perhaps a nod here and there) and we'd like to, but their argument is "austerity or old people are living longer". My first assessment with Social Services took 18 months before my personal budget was fit for purpose, by which time id deteriorated, and it was no longer fit for current purpose which meant I required another (this was pre austerity days). At the current time due to my deterioration, I have been moved over to Personal Heath Budget. Though the Care Act and National Guidance is very clear that the responsibilities carry over and they should meet all needs, a year in, after seven different visits, I am no closer to being satisfied with the way it is run, or any closer to getting an answer as to what needs are being met. 

Even though the Care Act is very clear that Social services and NHS need to work together, five years on, I  haven’t see much or any joined up thinking, the savings for both parties here could be huge!

People really need to realise austerity is a political thought process, which in the most has failed. The Care Act and ensuring the duties therein are met is the law, made by the whole of Parliament. So which needs to come first? How can we continue to cut essential services, axe benefits for the most needy, whilst pandering to the rich? Last year saw tax cuts for the rich and more and more devastation for those on the breadline. I work as an advocate and therefore hear real life stories every day. Some of these stories really frighten me, as to the path we seem to be taking. Yet the authorities brush them off as individual complaints and don’t seem to see the issues or bigger picture.

In my part of the country for the last five years there has been cut after cut. Not all I believe have been considered, let alone implemented, following proper, thorough consultation. A consultation is as required by law, in fact, most authorities have pushed through a lot of changes on the basis of ‘keeping fingers crossed’ and not being challenged via the Judicial Review system.

What about the argument that people are living longer? As usual I’ve heard and believed this rhetoric. Looking at National Statics Office data, less people are being born year on year and MORE elderly people have died over the last five years than before, so much so, that apparently public health are asking questions? One of the papers I read on this subject actually correlate this fact to cuts in Social Care. 

Our authorities Social Services over the last three years have not only come in on budget but have sent money back to the pot. The overall cost and effects have been all on the service users. So the argument that there is no money doesn’t really stand up. I believe as with NHS (again there is money in the National Insurance budget, which can’t be spent on anything else but the NHS) is more about privatisation than savings. When privatisation occurs, only people at the top, the elite who are making all the decision’s, do well out of it. If you don’t make a profit why do it?

I really believe as people are pushed further and further in to crisis it won’t be long before service users try to bring potential criminal complaints against heads of social care and councils. Examples of these being, charges of ill treatment, or wilful neglect, or even under the common law duty of care that is owed under our legal system. If an authority knows because they are being told that they are not meeting their duties under the act, then potentially if anything happens or doesn’t happen to a person due to care not being provided the authority and officers could be held liable. No one wants this, but as people are pushed increasingly sooner or later they will push back.

It would seem to me that the only bits under the Care Act most authorities are keen to implement are those that give them powers to make charges. Generally the authorities are not really focusing on those areas where savings can be made by giving independence choice and control.

One of the main issues from close up, is not the legislation, it’s not even front line commitment (I haven't met a bad or uncommitted social worker yet), It’s as Shrek would say, “down to the layers”. In itself, the Act is a really good piece of legislation. Its main points are clear and the essence is there. When it all goes wrong however, the costs start adding up due to layers that are added subsequently by local authority managers. These managers in social services or other departments in local authorities or even NHS tend to be excellent officers, who get may get promoted with very little real practical management skill. This is usually through no fault of their own, however often this, in my opinion, leads to unnecessary bureaucracy being created. 

An example of this in reality, you have a Social/Community worker who is tasked with going out to do an assessment, as required by the Care Act. That’s fine…Then internal written or unwritten policy states that person has to go back to their supervisor/Manager and get approval from them for the budget. Hold on… so you are paying a trained person to go out and do the job, which they do, but then that person has to back to another person go through the assessment based on a written document? Then that second person approves or tells the officer to go back and change it? Which, in essence, means the assessment is being done twice, and the actual decision is being made by someone who hasn’t seen me or met me in my own home, yet makes the decision on my budget? The assessment is being done by two people over, potentially, weeks. Sometimes it’ll be a lengthier process with personnel involved and requirements to go panel. Again, none of those people having met the person, or the person in a lot of cases not being even able to attend. Most of this isn’t required by the Care Act.

When I’ve put this to the people in power, the answer is where accountable for the rate payer’s money. Totally agree, but what often is overlooked is the costliness of the process often it is more expensive than the item or need itself. As an example, I was asked to put together a list by the NHS personal Health budgets of every single thing I paid for myself, which could be seen or categorised as a health budget cost. I included in the list some medicines that cost me 69p a month (for note, this wasn’t important to me as I’m happy paying for this). When I gave them the list at a meeting. I received a call week’s later for a follow up meeting, I asked if this could be done via phone or email, they insisted that a visit was necessary. On the day the assessor travel to my house and eventually told me that couldn’t have what was listed. This visit, in essence, cost the NHS more than I was asking for or than required. I also had told the assessors, repeatedly over the period of two years, to send all correspondence via email, as due to disabilities this makes it easier to access and file. Two years later, every month, I still receive an invoice through the post. This is just my experience, imagine multiplying this to factor in the other people receiving budgets and the possible savings from one minor adjustment.

This often is the case for meetings and discussions that staff attend. They are not empowered to make decisions, everything has to go back and be discussed repeatedly. Even when it’s absolutely black and white, things are passed on and on. Meetings occur month after month, people talk, meet and carry on. I see no SMART plans clearly showing accountability, responsibilities or time frames. I also see a very serious lack of accountability when things aren’t done people seem to just burry their heads.

Having worked for Local Authorities, I believe one of the issues may be down to a loss of belonging. When I started working for Local Authorities in the late eighties there was a real sense of pride and public service. You knew you weren’t ever going to get rich working for the local authority, yet there was sense of civic pride.

On a side note, there seems to be an idea that if you send people out with a laptop they’ll get the job done more efficiently. I’m sorry, but that only works if the person is a trained typist, more often than not the first thirty minutes is spent in the assessor getting the laptop fired up, finding somewhere to charge it, and spending hours filling in pre prepared computerised forms, which they go back to the offices and have to completely amend. I have yet to see an assessor finish and email me a copy in less than six weeks after completing the visit.

At this point I must say I don’t understand the need for all the authorities to have their own polices. It must be more beneficial for someone, say at ADASS to create a master copy of assessment or other policy and all authorities across the country follow it. Just the time wasted on managers across the country writing policies must be horrendous…and after all time is money! Perhaps a centralised online policy and process library? The next problem is what these polices offer. Apart from a line or two mentioning independence, choice, control, or co production, they don’t seem to be written with these things in mind. Even with the current assessment processes, the statutory guidance (which is in essence law) clearly shows how need must be met and how this should be identified in the assessment process showing how this improves wellbeing. I’ve had six assessments so far and I haven’t seen this included yet.

In relation to coproduction, stop talking and let people be involved! People are offering their time for free (huge saving on officers time, and an opportunity for fresh thinking)and I keep hearing, we are the experts in our lives, yet again and again its followed as tick box. It shouldn’t be just for a video or leaflet, those who use the service need to help you design and run the service at every stage. If you’re not listening and making it happen, then you’re wasting money and officer time by having meetings for no reason. I could go through my diary for the last five years and show you the meetings, consultations, engagements I’ve attended that have achieved nothing. The cost of these added up would I’m sure be a scary sight for some senior managers. Do not meet up unless there a reason and at the end of it you can come up with a measurable action which is tracked. If you wish to inform people just send out the documentation.

Here’s a few more examples of things that could be implemented, which whilst saving authorities money, would also improve people’s independence choice and control:

The Care Act, allows for assisted assessments, what this means in essence is the person does the assessment themselves and the authority hold their hand and are available to guide. To me, just what independence choice and control are about? Yet I haven’t seen one step forward by my authorities in this area. How much officer time could this save?

The Care Act now allows family members to get paid for manging and administrating direct payments, again with the right support substantial savings can be made as management costs could be lowered for those who previously couldn’t have direct payments. Yet again, nothing in this area.

The Act also allows for less monitoring, and actually says long term users, who have shown that they can manage their own direct payments, should only get cursory checks. Our authority has done the opposite and in order to save money restrict people’s usage of their direct payments repeatedly questioning everything.

What ever happened to the quick efficient complaints process? This was promised in the statutory guidance. Looked really good in theory but then disappeared completely.

There are many more areas that, by supporting people to live independently, authorities could make substantial savings that would improve people’s lives without adding but actually helping cut costs too. It seems to me that authorities don’t want to give choice and control, they want to be in charge, listen and be controlled by those in power and tell us what we can and can’t do. After all how many of them have had personal cuts to their lives, or taken an actual stand and not just talked or had a meeting about it.