The People Manager
All posts from: April 2012
If local authorities continue to cut the number of social workers working with older people, people with learning disabilities and people with physical disabilities or sensory impairment, then the impact will be felt by hospitals, GPs and community health services. So the recent interview with the new president of the Association of Adult Directors of Social Services should be of great interest to those concerned about inappropriate hospital admissions, delayed discharges or the care and support of vulnerable adults in their own homes.
Sarah Pickup, in her first interview on taking up her new post, is quoted as saying there is still a role for qualified social workers working with adults. By saying ”still” she concedes that it is no longer assumed that older people or people with a disability should be entitled to the same degree of professional support as children and young people. She confirms this interpretation by saying that in Hertfordshire she reduced the number of social workers working with older and people with a disability.
I am not saying there isn’t a role for social work assistants. I am not saying that everyone who works with older people or people with a learning disability should be qualified any more than I would say everyone working with children should be a qualified social worker. But as a profession we have been here before.
In the days of generic social work and generic social work teams the qualified social workers were allocated the childcare and mental health cases and most of the work with older people and people with a disability was carried out by social work assistants and students on placement. The result was that despite some very able, experienced and committed social work assistants the status of this work reflected the fact that it was carried out by unqualified staff. As a result there were fewer resources to help people stay in their own homes, vulnerable people ended up in hospital for non-medical reasons, patients sat in expensive beds awaiting decisions from senior managers whilst others end up in residential care when they neither needed it nor wanted it.
The reduction of qualified social workers working with adults is bad news for the profession, bad news for patients and bad news for the NHS.
An elderly woman with Alzheimers disease suffered physical abuse in a care home rated as excellent by the Care Quality Commission CQC. What were the inspectors doing? Did they have the wool pulled over their eyes by devious staff or were they incompetent? Is the CQC just not up to the job?
These are the questions asked in the Panorama documentary earlier this week, which exposed this shameful treatment, and these are the questions the papers and commentators have been asking since. But these are the wrong questions.
Inspections don’t stop abuse, managers do. Inspections ensure that policies and procedures reflect good practice and that homes have sufficient staff to deliver good practice - but inspectors aren’t there in the night when a resident calls for assistance to go to the toilet, inspectors aren’t in the bathroom when someone is being bathed or in the bedroom when they are being helped to dress.
So who does ensure that best practice is followed? The manager of the home and the manager on duty do. They are in the building, they are supervising staff, challenging bad practice and promoting good practice, or they should be. They should not be in the office but on the floor. They should be overseeing the delivery of care not drawing up staff rotas or ordering supplies. These tasks should be delegated. They should be recruiting staff because getting the right people is the most important guarantee of good care.
Managers of care homes cannot work 9 to 5 because care is delivered in the evening and weekends as well. Staff need to know that good care should be given whenever it is delivered - and whoever is watching.
Sent home in the early hours
It’s not just care homes where out of hours patient safety is under scrutiny. A recent report expressed concern about the number of hospital patients discharged in the middle of the night. How things have changed.
When I qualified as a social worker ward staff would conspire with hospital social workers to ensure elderly vulnerable patients were not discharged on a Friday. The ward staff would hold onto a patient over the weekend due to the difficulties of organising support services on a Friday afternoon.
In those days there was no Day Care on Saturdays and Sundays, the meals on wheels weekend service had a waiting list and home helps worked Monday to Friday; anything else was considered a special favour. The consultant who was so inconsiderate as to pronounce a patient ready for discharge on a Friday ward round would not be in at the weekend so what they didn’t know wouldn’t hurt. They probably did know but in those days they were less inclined to support hospital managers.
Services are now available at the weekend, well, a 15 minute home care “pop in” service - enough time to make a sandwich, a cup of tea and ensure the person takes their tablets. They will probably spend the weekend in bed and be padded up if they can’t make it to the bedside commode. Still, better than being discharged in the early hours to an empty flat or to the care of an equally frail partner with the promise that social services will be in contact.
The biggest reorganisation in the history of the NHS will supposedly give GPs have control over 60 per cent of the NHS budget. How will they spend it?
I was involved in a previous re organisation that was supposed to give GP’s more say in how the NHS budget managed by their local primary care trust was spent. As the social services representative I joined a group of GPs who sat on the Primary care Executive Committee with the chief executive and directors of the PCT. It was a very frustrating experience for the GPs.
Each meeting was dominated by progress reports against government targets and budget updates. A GP wish list of new services or extra money for community services was drawn up every year only for it to be withdrawn in light of budget pressures. So I guess that now they control the budget the first thing they will do is revisit their wish lists.
You might be surprised at how modest their bids were but you won’t be surprised that they reflected the frustrations they experienced daily in their surgeries. One GP put it very bluntly, if rather crudely, as the “shitty life syndrome”. He explained that an increasing number of his patients took up a disproportionate amount of his time.
Typically it would be a woman whose husband had been unemployed for over a year, debts were starting to overwhelm the family, she was concerned about her husband’s drinking, her teenage daughter had just announced that she was pregnant and her son was truanting from school mixing with a bad crowd, getting in trouble with the police and, she suspected, taking drugs. Not surprisingly she wasn’t sleeping well!
What could a GP do except listen sympathetically? These were not medical problems: the poor women was suffering from a “shitty life”. What he wanted was a social worker based in the practice that he could refer the patient to then and there, someone who could start to provide practical solutions to her social problems.
Of course he and his colleagues had approached social services many times with this request only to be told it was not a good use of scarce social work time and that with the current pressures on the department such a case would not be considered a priority. If they had the money this GP practice would definitely employ their own social worker.
Another example from the wish list was for additional mental health support. There were numerous patients presenting with low level mental health problems who the GPs felt would benefit from counselling - something they did not feel qualified to do and they did not feel was best use of their time. Requests to the local community mental health team had unsuccessful as the team said their priority was patients at high risk such as those who presented as a suicide risk or who had recently been discharged to the community. If they controlled the budget every GP surgery would seek to have their own mental health worker.
It is not hard to predict the tensions that will arise when GPs start taking money from specialist services to fund the type of services they want for their patients