Creative Approaches To Care And Support Must Be Provided
As the diversity of demands from older people puts its strain on the social care sector, Allan Bowman, chairman of the Social Care Institute for Excellence, explores the personalisation of social care and what it involves for local authorities, voluntary organisations and independent providers
The number of older people in the UK is increasing. Estimates suggest that by 2031, there will be nearly three million over-85s compared with 1.2 million in 2006 and around 0.6 million in 1981. Older people often need support to help them to remain independent, stay healthy and achieve a sense of wellbeing. In older age, people are more likely to have both physical and mental health problems, experience social isolation, live in relative poverty, and have a caring responsibility for another relative.
The increase in the number of people over 85 therefore has overwhelming implications for communities, and subsequently poses significant challenges for the way that we design, structure and deliver our public services.
The current buzzword in social care is ‘personalisation’ – a system that promises current and future users of care services a very different experience. Personalisation involves thinking about public services and social care in a very different way – starting with the person, rather than the service. There is cross-governmental support for this change, which was set out in the ‘Putting people first’ concordat last year. This shift in culture will take time, but it will ultimately mean change at every level throughout the local authority system to ensure that universal services such as transport, housing and education are accessible to all citizens. Although personalisation is a relatively new term, the practice of personalising services around the needs of an individual has its origins in traditional social work values, as well as public policy, including the themes of the community care reforms that followed the National Health Service and Community Care Act of 1990. Practices that come under the ‘personalisation’ banner include direct payments, a means tested cash payment made in place of regular social service, and individual budgets, consisting of combined resources from different funding streams, not just social care.
So what does personalisation offer older people? Firstly, the attraction is in the word itself. It suggests that individuals will be able to get the services they want, provided how they want and when they want. It offers control to individuals to determine how their own needs will be met. But as we promote the benefits of this reform, we need to recognise that older people don’t live in an isolated world – they are part of families and communities. Older people are as likely to be carers of relatives and good neighbours to others as they are to be cared for and supported by those around them. It is this complex picture of older people in their wider community that personalisation must address.
The Social Care Institute for Excellence (SCIE) has recently published a personalisation ‘rough guide’, drawing on what we know to date. It will seek to ensure clearer, common definitions of what personalisation will mean for local authorities, voluntary organisations and independent providers. We will also look at some of the necessary preconditions to deliver personalisation if users, and older people in particular, are to benefit from, and have confidence in, the changes.
The key elements are:
• Access to information
• Availability of high quality provision
• Development of preventive/supportive services
Given the current situation across the UK, the underlying prerequisite is a sensible lead-in time to ensure that key preconditions are met.
Access to information
For individual budgets and direct payments to work effectively, there needs to be clear advice and expertise readily available to people and their families. This will help them to make informed choices about the services they should access to ensure the outcomes they are seeking. Experience of working with the New Deal for Communities programme demonstrated that simply handing money to communities and leaving them to spend it as they saw fit did not work. However, nor did over-control by local authorities. What worked best was when communities and professionals collaborated – with professionals using expertise to help communities to achieve their ambitions.
This suggests that not only do we have to ensure that information is readily available but that a strong partnership is developed between those providing information and those using it. As the new system develops, this will offer the reassurance, particularly to older people, that there is still some clear public accountability through the local authority. It should also guarantee that those people who need considerable and ongoing advice will receive the right level of support.
Availability of services
Personalisation can only thrive if the services people want are available. Sadly, and principally due to budget constraints, the eligibility criteria for services have tightened in many places. Many services that used to be available no longer exist, unless you can afford them.
As a first step to addressing availability, the way we commission must change. Just as personal budget pilots have enabled people to buy services outside of traditional social care, so must commissioning look beyond social services – opening up opportunities to share other local authority services and budgets. If the quality of the workforce is to improve, there also needs to be greater investment in training and development.
The introduction of incentives to keep the best provision, while shifting away from the poor or mediocre, would fit very well with the new role of social workers – no longer financial gatekeepers, but advocates who seek the best for the people they advise. Addressing these issues will be complex and take time, but there must be a strategy to restore or introduce the types of services people want.
Prevention and support
At its peak, around 550,000 households received publicly funded home care services in England and Wales. Now the figure is below 400,000. The population of older people is growing, and many households are not receiving support.
Everyone believes that prevention works – that a little help given early will save higher costs later. What we lack is enough evidence to convince the Treasury to make the kind of investment and ‘spend to save’ that would change the current landscape. In the meantime, it falls to commissioners to develop sufficient accessible and affordable provision locally. There are increasing oppor-tunities to use assistive technology and ‘telecare’, and to develop the role of community wardens. With co-ordinated national policies, like free transport and swimming for the over-60s, targeted at improving the quality of life for all, it is possible to imagine a society that provides effective preventative community support, allowing social care to concentrate on the most vulnerable people with the highest support needs.
Dignity in care
The dictionary definition of dignity is: ‘A state, quality or manner worthy of esteem or respect and (by extension) self-respect.’ In 2006, the Department of Health launched the major ‘Dignity in Care’ campaign aimed at stimulating a national debate around dignity in care and creating a care system where there is zero tolerance of abuse and disrespect of older people.
As the organisation responsible for indentifying, advanc-ing and promoting good social care practice, SCIE supported this campaign by bringing together the evidence showing how social care and health workers can improve dignity for older people.
Our research into the experiences of older people, their carers and care workers has identified four main areas of dignity:
• Respect – demonstrated by courtesy, good communication and taking time to talk;
• Privacy – personal space, modesty and privacy in personal care, and confidentiality of treatment and personal information;
• Self-esteem, self-worth, identity and a sense of self – promoted by all the elements of dignity, but also by ‘all the little things’ like a clean and respectable appearance, pleasant environments, choice, and being listened to;
• Autonomy – including freedom to act and freedom to decide, based on clear, comprehensive information and opportunities to participate.
There are wide societal issues that affect the rights and choices of older people. Research has identified that threats to dignity include ageism, abuse, inequality, disadvantage and discrimination. All these issues can only be overcome by working with communities, ensuring social inclusion and promoting mutual respect. Public services can help this by interlinking community projects, community centres and schools to increase levels of intergenerational social contact.
Protectors of dignity have been identified as resilience, rights and person-centred care. Commissioners and providers need to ensure a personalised, not task-centred, approach to service provision; for example, a person being given support to cook a meal will help them to remain in control, and be far more rewarding and meaningful than passively waiting for staff to cook the meal or to have one delivered.
So there are many changes in demographics, policy and practice that bring a huge collective challenge. Now is the time for public services to work together, locally and nationally, to adopt new, innovative and creative approaches to providing support. SCIE is here to find out what works well, and we are ready to be flexible and respond to your needs.