More Bills

Love, Belief and Balls

Bollocks. I’m just going to write what I feel and deal with the fallout later.

In 1992, I went to see the Gloria theatre company’s marvellous musical adaptation of the Ruth Rendell book, “A Judgement In Stone.” Sheila Hancock won several awards for her lead role as the housekeeper, Eunice. As I had to wait for my wife to finish her business in the Ladies, I missed the opening three minutes of the play. What I didn’t realise until many months later is that the production had used the conceit, rather like Blood Brothers, and given the ending away in the first scene. So, ignorant of this, I watched on in horror as the nice, benevolent Ms Hancock was revealed to be a mass killer in a terrifying denouement.

Why do I keep thinking of this play whenever I read anything about the much publicized Downs Syndrome Bill?

I’ve been…

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Social care work – at the butt end of downward mobility

Vic Citarella postulates that investment in the social care workforce will improve social mobility

One factor that contributes to divisions or unity between people is the nature of the labour market. Work features large in how we see ourselves and how others see us and our families. It is integral to our identity. It is about the pay-off from hard work that politicians talk of when they use the language of social mobility. They usually mean better paid and more secure jobs lead to the \’good things\’ in life. It is those jobs that enable mobility and which, for politicians, can only go one way – upwards. When people identify themselves as downwardly mobile, it is then that they get angry and lash out at governments, officialdom, the establishment, outsiders and eventually each other. When a majority of people who perceive themselves as downwardly mobile are given any plebiscite the result is predictable. In the case of the referendum on membership of the EU an outcome exacerbated by the perceived comparative upward mobility of many immigrant workers. 

My understanding is that employment in the UK post the crash of 2008 is strong and has recovered. Today, after the recent turmoil, there remain a growing number of work opportunities and a shortage of applicants in many sectors. However my view of the labour market is of one that has polarised in many parts of the UK. Polarised between the low paid, low skilled often temporary and part-time workforce and the higher skilled and permanent, full-time workforce. The former characterised by the largely female social care workforce and the latter by ICT professionals. Jobs and opportunity in the middle range of skills and reward are evaporating – in manufacturing, construction and critically the more clerical professions. The consequence is that workers have to set their sights higher or accept supposed lower status work. 

Such divergence in the labour market is one root of the current discontent and in my view social care is at the butt end of it. Much of social care is seen as unpleasant work, poorly paid and not requiring skills. It is viewed as work for women and girls not worthy of more than minimum pay. Social care – along with flipping burgers, waiting tables, cold-calling and stacking shelves – is what the displaced workforce in the middle, who are unable to attain higher, see before them and they don\’t like it. They recognise themselves as being downwardly mobile and will vote accordingly in their droves.

The current social care workforce is upwards of 1.5 million and the demand will soon exceed well over 2.0 million people. This is a significant number and nearly doubles when the NHS equivalents are added in. This is not work that can easily be automated or undertaken off-shore like much clerical work. It is work that requires hands-on skills, heart in the right place attitudes and an astute awareness of context and circumstances. In short it is not low skilled work at all but, nonetheless, has the low skills status. It therefore seems to me that there is a win-win for the country in a concerted effort to up the status of social care work. A first win in that we have the workforce that befits all our aspirations for ourselves and our families that need social care. Our willing dependency on family care would be supplemented, enhanced and supported instead of stretched to breaking point. A second win in that the schism in the wider labour market is repaired as people increasingly seek social care employment as a route to upward mobility. Having social care jobs with status, reward and recognition will go a long way towards reconciling social discontent. There is a third win around the reliance of some social care employers on an immigrant workforce – their contribution would be valued at the same time as the dependency reduced. 

How does a country boost the standing of a workforce you may ask? 

• Political leadership – lets have a Department of Health and Social Care with a minister to make real the paper policies of integration
• Professionalisation – lets demand a social care workforce that is competent, qualified and aspirational
• Personalisation – lets either commit fully to a consumer/user-led approach to the social care market or parallel the NHS with a National Care Service as suggested in 2009. The alternative is that market forces will entrench a two tier workforce. The privately funded care workforce having just low status over the very low of the publicly funded one.
• Pay – lets be honest and openly evaluate the rewards allotted to a care worker in respect of what they do. Lets challenge traditional job evaluation criteria that determine pay rates.
• Prices – let the market do its work and limit the local authority to inducing variety and policing local standards. We could move more rapidly towards a position where a local authority only makes the social care purchases when they have permission from the Court of Protection. Otherwise the actual purchase is undertaken directly by the customer or their agent albeit, in full or part, with public money.
• Public relations – lets get more media savvy about working in social care.

One way or another this will cost the service user more money in fees. Government will need to do more than the current tinkering around the edges that has gone on since at least 1990 when the country moved decisively away from a municipal model of social care provision. It will need to pull levers and apply brakes. The cost to us all will either be more tax or different use of current taxes. The incentives though are substantial:

• People being able to purchase a safe social care service at transparent levels of quality and affordable price
• Protection for those lacking capacity
• A motivated workforce recognised for its skills
• Social care work as a badge of upward mobility and a unifying force in communities. 

The time is right for the social care workforce to move from butt end to front end of labour market thinking. If not we are destined to have a social care workforce that churns within itself, is riddled with self-deprecation and is scorned by the upwardly mobile. It will remain at the wrong end of an unequal society to all our detriment.

Self neglect – Jackie Hodgkinson asks: when does a social worker say enough is enough?

Self neglect is a term that social workers are very familiar with. It often causes concern for both professionals and concerned neighbours and family. I can recall, within my social work career, many individuals who chose to live at home, in a condition that was considered by professionals as unacceptable. Was this their informed choice and was it in the best interests of the individuals? This depends on who you ask?

What is unacceptable? And who are we as a wider society to define how someone should or should not live, often those individuals had been what were considered as “eccentric” or “a bit different”. Using the definition of mental capacity as defined within the Mental Capacity Act 2005 would deem these individuals to have capacity to make what we may consider as unwise decision. Within society we make judgements based on how vulnerable we perceive a person to be.

Champagne lifestyle

If a young executive chose to spend their salary on a champagne lifestyle and then could not pay the bills at the end of the month would anyone pass judgement on this choice? If that person was a 79 year old man with motor neurone disease who enjoyed betting on horses and sometimes didn’t leave enough money for 3 meals a day, home care providers would instantly contact social workers with a safeguarding alert or his neighbours would be stating that he should be in a home! And asking how can we let someone live in this way.

The public expect that the adult social care department should protect all from harm and danger, regardless of the capacity of the individuals to choose how they live. Social work teams receive many phone calls from families or friends stating “it is a disgrace how you let people neglect themselves you should do something to stop it”. This implies we have the power to impose services and support on any unwilling recipient. A greater awareness of our statutory duties and the limitations of these perceived all-embracing powers is required to educate the wider public regarding when we need to intervene.

There needs to be more publicity on positive risk-taking, where social workers actively promote the human rights of the disadvantaged. We often see the potential in individual’s strengths or protective factors within them or their lives, where others see only problems.

Risk averse

In these risk-averse times, it is important to hold onto the concept of choice and respect for decision making. In my opinion as a social worker, it’s intrinsic to what social work should be about and is core to social work values. This requires a recognition at all levels of management and within wider society.

The Department of Health official definition of self neglect is the inability to understand the consequences of that failure. That definition of self-neglect excludes the individual who makes conscious and voluntary choices not to provide for him or herself. The person who denies themselves certain (accepted) basic needs as a matter of personal preference and who understands the results of that decision is ruled out.

Self-neglect implies a lack of wilful intent. Self-neglect is an act of omission. There is no perpetrator. Unlike perpetrator related abuse and neglect, self-neglect is not treated as a wrong-doing or a potential criminal act. Capacity is a highly significant factor in both understanding and intervening in situations of self-neglect. Decision-making autonomy by those who have capacity is widely recognised and respected. There is strong professional commitment to autonomy in decision making and to the importance of supporting the individual’s right to choose their own way of life, although other value positions, such as the promotion of dignity, or a duty of care, are sometimes also advanced as a rationale.

Research into self neglect

SCIE Report 46: Self-neglect and adult safeguarding: findings from research, examines the concept of self-neglect. The relationship between self-neglect and safeguarding in the UK is a difficult one, partly because the current definition of abuse specifies harmful actions by someone other than the individual at risk.

The perceptions of people who neglect themselves have not been extensively researched, but where they have, emerging themes are pride in self-sufficiency, connectedness to place and possessions and behaviour that attempts to preserve continuity of identity and control. Traumatic histories and life-changing effects are also present in individuals’ own accounts of their situation

What can we social workers take from research? Evidence demonstrates that self neglect is reported mainly as occurring in older people, although it is also associated with mental ill health in both older and younger individuals. Social workers when assessing levels of risk need to take into consideration both the inability to care for oneself as opposed to the unwillingness to self care. The other key determinant is the individual’s capacity to make the decision and understand the consequences of this action. The social work response will vary, dependent on these key risk determinants. Professionals will have a tolerance to someone who chooses to self neglect as a life style choice, perhaps that is how they have always lived. I once assessed an older person who chose to eat out of date food to save money even though they had £500.00 in the bank. Professionals, understandably, have a greater level of concern regarding those individuals who have made life style choices but due to onset of mental impairment struggle to understand the consequence of those actions.

Comprehensive risk assessments are core to all interventions. A balanced approach is required to ensure we are not foenough is enough.

cused simply on keeping people safe at all costs; all risk assessments should be person-centred, taking into consideration previous lifestyle choices. They should promote independence, choice and autonomy. They should also be reviewed regularly. Care plans should be lifestyle sustaining. Potential harm has to be balanced with potential benefit. Working in a multi disciplinary team, virtual or otherwise, enables us to gather evidence to make those decisions about when statutory intervention is required. We should check things through a mental capacity lens frequently. The profession needs to engage with the public about people’s rights, the wider duty of care and when

Jackie Hodgkinson is an independent social work practitioner and trainer