Martin Stevens Social Care Workforce Research Unit King’s College London

• Personalisation • Safeguarding • Perceived risks • Evidence • Synergies

Personalisation: individuals not institutions take control of their care. Personal budgets, preferably as direct payments, are provided to all eligible people. Information about care and support is available for all local people, regardless of whether or not they fund their own care.
DH (2011) A Vision for Adult Social Care: Capable
Communities and Active Citizens p8
open university May 2010

• A goal for a very long time – back to 1980s at least • Twin drivers – Challenging inflexible services to maximise autonomy – Reducing role of the state and promoting market solutions

This vision focuses on the Government commitments to...
• extend the greater rollout of personal budgets to give people and their carers more control and purchasing power; and • use direct payments to carers and better community-based provision to improve access to respite care.
DH (2011) A Vision for Adult Social Care: Capable
Communities and Active Citizens p6
open university May 2010

 ‘all work which enables an
adult "who is or may be
eligible for community care services" to retain independence, wellbeing and choice and to access
their human right to live a life that is free from abuse and neglect’ 5  ADASS, 2005 - National Framework of standards Safeguarding Marblehead Carol McClain Cosgrove

Personalisation ?
Risk

• Mental Capacity Act 2005 and revised regulations are enabling people with dementia to make use of proxies • Putting People First (2007) – Linked personalisation with improved safeguarding • Initially people with severe dementia excluded from direct payments if unable to consent (as lacking capacity to make the decision) – Health and Social Care Act 2008

• Some predictions that personalisation will enhance safeguarding (SCIE,2008; Poll, et al 2005) but many fears expressed • No Secrets review (DH, 2009) discussed need to integrate safeguarding and personalisation • Adult Social Care Vision (DH, 2010) argued for: ‘sensible safeguards against the risk of abuse or neglect. Risk is no longer an excuse to limit people’s freedom’ (p8).

• Two tier workforce – checked and unchecked (ISA and CRB) – trained and untrained • Vulnerability and isolation of service users and carers • Lack of intervention powers • Easy prey • Practitioners ‘policing’ roles • Under protection and over protection • Much articulated in the Consultation on the Review of No Secrets

• Poorer quality services • Service users being overwhelmed by the need to manage the IB – If there’s a problem they can’t just ring us up and say, ‘Sort it’. Because if they’re actually employing the person, they’ve got to sort that out with whoever it is that’s supporting them to employ that person (Team manager people with learning disabilities team). • IB used inappropriately and unproductively Glendinning, C., Challis, D., Fernández, J-L., Jacobs, S., Jones, K., Knapp, M., Manthorpe, J., Moran, N., Netten, A., Stevens, M. And Wilberforce, M. (2008),Evaluation of the Individual Budgets Pilot Programme: Final Report, York, The Social Policy Research Unit

• Hiring suitable and firing unsuitable workers – Are they able to deal with the problems of employing people that aren’t up to what they should be providing? (Care coordinator, people with learning disabilities) • More open to physical and financial abuse – And I think we may have to consider with phenomena like domestic abuse could play a part in choosing to pay a family member. (ASCS ) • Loss of collective ‘voice’ IBSEN – Glendinning et al 2008

We actually need to point out to service users, ‘Maybe the reason we don’t want you to do that is because you could get hurt, and we can see it’. But again, it’s about risk learning. You know, it’s positive risk taking. And we’re not good at that. And so that’s fear for us. (Care Coordinator, Mental Health) IBSEN – Glendinning et al 2008

• Skills for care survey of direct payments employers – No evidence of increased abuse – Psychological abuse the most common, with PAs and LA provided care workers – Less physical abuse • Less abuse for DP users compared with their own use of local authority provided services • Some health warnings: – Those using Direct Payments may have changed because of bad experiences – Participants may have been using local authority provided services for longer than Direct Payments IFF Research (2008) Employment Aspects and Workforce Implications
of Direct Payments,

• Increasing involvement of safeguarding professionals – Transforming Social Care – Local approaches to risk assessment • Local Safeguarding policies under review – ...they will have IB at the forefront when they start reviewing the adult safeguarding policy’. (ASCS) • PBs discussed with local Safeguarding Boards

• Publicity and information to people using services and general public eg use of local free newspaper – For example, on how to respond to allegations, seek advice and make a referral. (ASCS) • Training for people using services and carers – ;We are setting up user groups to advise on the policies and we are going to other service users’ training on policy and categories of abuse’ (ASCS)

• Following up complaints • CRB and ISA checks for Direct Payment users • Streamlining risk assessments and integrate all PB risk assessments

Mrs James has dementia – after the diagnosis she drew up a Lasting Power of Attorney - her daughter Sharon now makes decisions when necessary in her mother’s best interests.
Sharon gets Direct Payments from the local authority (Mrs James is eligible). Sharon is now able to fund a care package using a rota of 3 workers and one day at a day centre.

Positives • Care workers are known and Sharon is employing them • Sharon had to get a CRB check (new DP regs – she is not co resident) • Sharon was worried about her mother being at risk previously • MCA offences apply to Sharon and the care workers • Monitoring can stop/change arrangements • Mrs James may have a better quality of care/quality of life • Sharon may be less stressed Negatives • Care workers may be abusive or neglectful • Sharon might not be acting in her mother’s best interests • Monitoring may be limited • Pressure on Sharon

• Parallel tracks – little engagement of the IB pilots with adult safeguarding • Little building on adult safeguarding experiences among social workers • This reflected some uncertainties around Direct Payments etc & duties of care • Fears that raising safeguarding issues was at best reactionary, at worst subversive Glendinning et al 2008

‘What aspects of safeguarding do we need to build into personalisation? What training, risk assessment and risk management should we use? Please tell us what you are doing locally and what more needs to be done?’ Q4 from No Secrets consultation

‘What aspects of personalisation – greater independence, choice and control – can we build into safeguarding? How do we better reflect service users’ informed choices? How do we facilitate informed self-determination in risky situations and in the safeguarding process? How can we move forward on this agenda?’ Q5 from No Secrets consultation

• Not a bolt on • Risk and recording • Finance is a fear • Don’t neglect neglect • Addressing carer issues (see Cooper et al BMJ 2009)

• What links a support plan with a safeguarding plan?
• What links a best interests decision with a right to risk?
• Who will stand up ‘come the inquiry’?
• How are outcomes for people who are vulnerable built into safeguarding investigations?

• Recording (being clear) – on paper? on video? – use of advance decision making processes? • Best interests debates • Learning from IMCAs and MHAs • Duties of care

• Monitoring? (how and who? And who pays?) • Role of regulator? (Care Quality Commission) and Health Professions Council; ISA/CRB) • Managing with less money • Mixed support for increased right of entry/ intervention - No Secrets Consultation & Law Commission

• Converging of systems • Mutual understanding of values • Skills sharing between safeguarding and self-directed support • No quick solutions or transfers (eg a Risk Enablement Panel) • Balancing choice with legitimate interests in service infrastructure (preserve collective voice) • Identifying those more at risk from personalisation

• Not just a council affair • Nor even statutory sector • Way of revitalising adult safeguarding • But there will be decisions about monitoring (over and under protection) • And the safety net of social care may be tested.
• Need more evidence!

Martin Stevens Social Care Workforce Research Unit King’s College London Strand London WC2R 2LS martin.stevens@kcl.ac.uk
020 7848 1860