The ‘think tank’ approach to care: Is personalisation really personalisation?

Personalisation occupies a central position in social work with adults today and has been welcomed by social workers as a positive step forward,   however, our understanding of ‘personalisation’ is sometimes somewhat different than governments.  This is not a surprise when we look at the driving force behind its development.  Personalisation was driven not by social work, but by the think tank DEMOS (favoured first by Tony Blair) and in particular Charles Leadbeater, a journalist and writer who spent ten years working for the Financial Times and who was an adviser to a number of major private companies, including Chanel Four Television and British Telecom.  A key document from DEMOS should have set the alarm bells of social work ringing in 2004.  The ‘Pro-am Revolution’  provided the rationale for delivering personalisation.  The pre title blurb sets the direction of travel

‘The 20^th century was shaped by the rise of professionals. But a new breed of amateurs has emerged….’

The central tenet of the Pro-Am Revolution is that with the advent of new technologies and educational systems we no longer need to rely on professionals to undertake particular tasks because amateurs are now able to operate at the same level as professionals, but without requiring large organisational structures.  DEMOS looked specifically at areas such as web design and astronomy, suggesting the same premise could be applied to education and social care, going onto say ‘Pro Ams are creating new, distributed organisational models that will be innovative, adaptive and low-cost’ which will also be ‘light on structure and largely self regulating’.  Hmm sounds familiar.

For DEMOS, a service user was a service user, no distinction was made between the needs of those with disabilities or mental health difficulties or older people (nor for that matter the difference between a web designer and older person with dementia!).  This resulted in a flawed conception of the people who use services and their ability/willingness/desire to manage their care and the markets that would provide care.

The conception of personalisation in a think tank has never boded well for its implementation.  However, it has been useful at a political level as it has acted as a mirage to conceal a very different agenda linked to the equally nebulous concept of ‘choice’.

Clarke (2005) suggests choice is the engine of public sector reform, with choice seen as desirable in empowering individuals to move from passive consumers to activated and responsibilised citizens. Choice as a concept remains controversial for some as it is also viewed as a route along which the marketisation of public services can travel without challenge. Whilst this is a logical extension of the previous government’s agenda for Cameron and Co, for many in practice a free market approach to service delivery underpins many of the problems experienced in social care today.

Government has exploited the ambiguity in meaning of words such as personalisation and choice to enable the social work profession to retain a semblance of loyalty to its own values, whilst unknowingly carrying out the bidding of politicians with very different ideas about social care.

Research has explored how organisations encourage workers to engage in an agenda they do not necessarily agree with. Courpasson (2000) introduced the notion of ‘soft coercion’ which induces, simultaneously, commitment and obedience to the organisation and its aims.  Ambiguity in meaning is one such instrument of soft coercion, however, you also need to ensure the workforce accept your perspective.  One strategy used by large organisations has been the ‘company song’, often represented by the company policy which provides an organisational mantra, for example ‘personalisation leads to greater choice’.

Maybe it’s time to change the company song and for the social work profession to choose its own playlist, if it does not there will be many in government who will be happy to do it for us!

The mis-treatment of older people in hospitals; is a ‘trip advisor’ approach really the best way forward?

At what point does the government stop relying on gimmicks, voluntary codes and recommendations from those without any power to implement change and actually take a lead to improve nursing care for older people? 

The Royal College of  Nursing’s research into the provision of care to older people suggested staffing issues were central to good nursing care, government have responded to this by suggesting we need to take a ‘trip advisor’ approach to raising the quality of services (photos optional presumably!).  However, this is only part of the answer,  problems extend beyond staff to patient ratios and will require more than patient recommends to improve quality.  Working practices imported from the business sector into care provision, along with a poor attitude from wider society and government toward the care of older people in the UK also need to be addressed.

Abraham (DoH, 2011) suggested the mistreatment of older people in the NHS is not just about people being too busy, but also about staff  being indifferent to older people,  i.e. showing no particular interest or concern about older people.  Coming from a professional background, where I have worked with nurses in hospital settings and as an academic teaching student nurses, it is fair to say I have never met a nurse   who has purposely set out on their career to mistreat an older person.  On the contrary, they have entered the profession because they want to care for people.  So what changes once on the hospital ward?

Arguably, such indifference radiates from wider society onto the hospital ward.   Both Government and society are disrespectful of older people, describing older people as a ‘demographic time bomb’, their care portrayed as an expense we can ill afford.  Once such an attitude is prevalent in mainstream society is it any wonder a culture of disrespect flourishes across society, leading to the de-humanisation of the older person, wherever they might be.  As Jo Webber of the NHS Confederation rightly point out; once in a hospital bed the older person no longer matters – achieving the task at hand efficiently is more important than the individuals’ dignity. This then provides the foundations from which poor practice in the care of older people develops across a multitude of care providers from public sector institutions to private sector providers through to the individuals that make up society.

Whilst external factors have an important role in shaping attitudes toward older people, this alone does not fully explain professionals’ indifference to older people when providing care.  Understanding what happens between individuals embarking on nurse training to actually working with older people on a ward is also significant. Menzies Lyth’s research provides an interesting insight from which to understand what happens once on the ward.  Menzies Lyth drew on  Jaques (1955) notion of  ‘social defences’ used by nursing staff to manage the anxieties inherent within their practice to understand behaviour within organisations.

Jaques (1955) initially used social defences to understand how nurses cope with the high levels of stress and anxiety associated with the job. However, it was developed later to take into account structural factors arguing that social defences were the result of poor organisational structure. This provides a useful framework from which to explore how current structural systems interweave to produce an environment where mistreatment flourishes on hospital wards.

Social defence mechanisms include care for patients split into individual tasks undertaken by a number of nurses; one person performs the same task to many patients rather than working with one patient to provide all their care. This facilitates a distancing between the patient and nurse, which protects the nurse emotionally. Organisational factors support a depersonalised approach by moving nurses around wards, which then allows the nurse to distance themselves from patients so as not to become emotionally involved.  Other social defences include a denial of feelings and over emphasis on professional detachment and strategies to reduce anxiety around decision-making, for example working in prescriptive ways, performing repetitive tasks, and delegating decision-making.  The lack of connection between patient and nurse arguably facilitates an environment in which mistreatment might develop, or is ignored.  Therefore, the organisation and delivery of care at a structural level within the NHS is of relevance to improving care for older people.  Higher staff ratios would be a good start because we have to ask is it possible, emotionally, for an individual to deliver high quality care with compassion and dignity consistently in the current system?

Poor levels of care appear endemic within the current system, the speed with which each new revelation now appears is in danger of convincing government and society such an approach is the ‘norm’, however, we must be careful not to just accept this as inevitable, or somehow acceptable in a time of austerity.  Indifference toward the care of older people represents the tangible outworking of a system of care that has lost its way; where commissioning outweighs compassion and meeting the demands of the system outweigh delivering care with dignity.

At what point does the government stop relying on gimmicks, voluntary codes and recommendations from those without any power to implement change and actually take a lead to improve nursing care for older people?

Adoption:A ‘good’ adoption is not just about being faster

 As the government seeks to speed up the adoption process with Michael Gove highlighting the value of a stable and nurturing environment, an adult adoptee suggests the actual adoption is just the beginning and more support post adoption is needed.

On this, Michael Gove and I agree, adoption has to be better than a child languishing in the care system, farmed out to a multitude of foster placements that may break down.  Just as Mr. Gove’s personal experience shapes his thoughts on adoption so do mine.

What I think the government and Mr Gove fails to understand is the change in reasons why children are adopted today compared to when we were both adopted.  In my case I was adopted  because I was illegitimate and my mother did not have the means to care for me in terms of a home, cash or family support, I think this is less the case today.  The reasons for adoption today are far more complex and involve problems such as mental health issues, substance mis-use, domestic violence and child abuse, these along with the knowledge gained from neuroscience means that some of the children who need to be adopted now may have far more complex emotional and psychological needs than I did, and thus require adoptive parents  able to cope with whatever this might bring.

Whilst the system does require reform, lets base it on facts and evidence not personal experience.  Yes personal experience is important, it can act as a motivator to improve the system, lets just make sure its the right change, otherwise we are in danger of letting down the next generation of adoptees.

An adult adoptee and ex social worker describes how it feels to be a ‘service user’ as she attempts to access her adoption file

Adult Adoptees and Identity: the adoption process is currently under government scrutiny, getting it right is so important for adoptees futures. However, getting it right is not just about policy and procedures; it is also about social workers being professional and flexible in their approach. An adult adoptee, and ex social worker, describes how it feels to be a ‘service user’ as she attempts to access her adoption file.

(this is the 1st of a series on the ‘adoption file’, read ‘Lost Families’  if you want to see what happened next)

Whether who we are is determined by some invisible invention of science called genetics or the parenting skills of our parents is commonly known as ‘nature vs nurture’ and is the subject of much research. The truth is we may never know the exact ratio of influence, it may well vary from individual to individual, but it is fair to suggest both play a role in making us who we are. Whilst for many this is just an interesting debate for some, like me who have been adopted, it is a significant factor in shaping my understanding of who I am and how I feel about myself.

This blog is not written by me as a social worker or academic but as ‘adoptee me’. I was adopted over fifty years ago and have been trying to find information about my genetic family and my birth mother for thirty four years. Many years ago I accessed my adoption file in the hope it would provide me with information that might lead me to her. Unfortunately, it did not, although it did give me some useful information regarding the circumstances of my adoption.

Fast forward thirty years to August 2011 when I decide to have another look at my file in the hope that being older (possibly wiser?) it could still hold something useful that was missed before and might take me a step closer to finding my birth mother. And so with high hopes I contact the local authority where my adoption took place, hence forth known as ‘Never Never Land’. After being diverted to several departments I eventually reach the right one and speak with someone. The first question asked at this point is “why do you want to see the file?” Although taken aback, and to be honest rather annoyed to be asked this, I answer “because it’s about me and who I am, my family history”. The social worker explains the process to me. No I can not contact ‘Never Never Land’ direct to access my file I have to go through another authority, hence forth known as ‘La La Land’, and they will request access to my file on my behalf. Okay, why a third party needs to be involved is not explained. When I asked if I can have a copy of the file the response is guarded “possibly, but no third party information would be shared unless the third party agreed”. Okay, what if the third parties are dead i.e. my adoptive parents…..no reply, it felt like the worker was following a script and this question did not appear on the script, we end the conversation with one last question ”why do you want to see your file?”, “because etc etc etc……”.

My main concern at this point is who is going to decide what I am allowed to see, and will they leave out that one vital piece of information that might lead me to my birth mother? I feel powerless.

To say my first contact from the other side of the fence, so to speak, was unsatisfactory is an understatement, even after one phone call I felt frustrated and disempowered. It was clear there were hoops to be jumped through, and I was going to have to jump! I felt I had to fit the system regardless of whether it fitted me, or was appropriate.

Next step, phone call by me to ask how long the process might take, “No idea!”, followed by explanation they only worked part time, was going on leave and this was non urgent so would not be prioritised, expect a minimum of 6 months, that’s not including any delays in ‘Never Never Land’ responding. Further contact with social services is equally unsatisfactory, and still they asked “why do you want to see your file?” ………….”because…etc.etc!”

I eventually meet my adoption social worker and am pleased to report they are experienced and professional, they do not appear to stick to any particular agency approach and make me feel I am listened to as an individual, I do not feel like a service user with this social worker, this is an equal partnership.

So, have I seen my file? To cut a long story short the file is still in ‘Never Never Land’, however, it is going to arrive in ‘La La Land’ soon. Reasons for delay range from workers and mangers going sick, people working part time, supervision being cancelled and window repairs (don’t ask!!!). In all honesty, I am not interested in knowing any of this it only serves to heighten my annoyance and sense of powerlessness.

I do understand the pressures in practice, and of course the protection of vulnerable children must always come first, however, whilst not urgent it is actually very important to me. Seeing my file again is a desperate measure on my part because I’ve exhausted all other avenues, my mother is approaching eighty years of age, time is not on our side. An acknowledgement of how important this might be for me on my first contact with services would have been nice.

How does all this make me feel? Angry, powerless, frustrated, sad. My contact with services is minimal and time limited, unlike many others. The professional social worker in me knows the pressure systems, and people, are under and how my request is insignificant in the scheme of social work practice with Children and Families, but, it is important to me. Whilst at an organisational level it is just an old file, for me it is my life and about who I am. This process has made me reflect on my own social work practice, I’d do things differently now!

(This is one of several blogs, if you would like to read the complete story of what happened in my search for my natural mother you can read it in a free ibook here <a href="here“> You will need an ipad to read it)

Dignity in the care of older people – “If you tolerate this then your children will be next” (Manic Street Preachers)

Improving care provision for older people is not just about today’s older population, it is about all our futures, our own and our children’s.

Securing dignity in care for older people is something society should strive for, however, change in the longer term requires more than a reorganisation of structures. Fundamental to change is how the care of older people is conceptualised in the UK.

The Commission on Dignity in Care for Older People has identified many significant issues, which if addressed could make positive changes to the future of care for older people.  Whilst such changes could make a difference, lasting change arguably requires new thinking at a philosophical and ideological level at all levels of society.

Ideologically government needs to shift its continued emphasis on a consumerist model of health and social care provision.  Whilst a consumerist approach is clearly of benefit to market providers, and the public purse, it is questionable whether such an approach is of benefit to older people.  Many of the problems experienced in private sector care provision originates from the under regulation of the care market, which, whilst enabling providers to cut cost and make profit, does nothing to address the poor quality of care many older people receive.

Models of management imported into health and social care from the business sector to support a consumerist approach exacerbate the problem.

Organisational structures support a depersonalised approach, for example working practice which allows carers to distance themselves from the older person, so as to reduce any emotional involvement between carer and cared for.   The breaking down of care into component parts, such as 15 minute visits, whilst, considered efficient from a resourcing perspective does not facilitate the building of a relationship between older person and carer.  Surely, care is more than a timed task to be done to another?

Managerialistic approaches taken from the business sector influence not just health and social care professionals, but also wider society.  Leading society to focus on the ‘management’ of older peoples care needs, such an approach serves to separate us all from the lived experience of the older person, care then becomes a transaction, intervention, a process, or target, by which governmental and wider societies’ need to reduce public expenditure is met, is cost really all that matters today?

Have we reached the position predicted by Zymunt Bauman  (2008) who, when considering if ethics has a chance in a world of consumers, suggests designing, elaborating, and putting into operation values of mutual hospitality must at some point become a necessity for the human species?  Bauman argues no place on the planet is spared a point blank confrontation with the challenge, because as  Levinas (1961) suggests, the moral impulse to care for one another is a poor guide for behaviour when one moves beyond a one to one relationship to plural others (the Third) because it cannot be sustained.  Something more is required, and that something requires substance.

A change in the philosophical foundations shaping our understanding of older people and their care should be the starting point.

German philosopher Immanuel Kant’s (1724 – 1804) ‘Categorical Imperative’ suggests everything in life has either a price or a dignity.  A need for example for material resources has a price because it is replaceable, but that which is irreplaceable has a dignity.  Morality, Kant suggests is one such dignity that cannot have a price. Arguably, compassion toward the most vulnerable in society is one such dignity that does not have a price, and is therefore above monetary value.

Dignity should not be viewed as an optional extra, dignity is integral to the care of older people across society.  In the longer term for structural change to be effective a deeper and more meaningful approach to care is required because if we continue on the current pathway, as the Manic Street Preachers might suggest “if you tolerate this then your children will be next”.