Winter – Part 3

Each year the headlines going into the NHS winter seem to forecast a bleaker outlook.  

Whilst the 1st October still feels very autumnal, the build up to this years NHS winter is underway.

Which is worrying if you are responsible for arranging services for people who will need some extra support from adult social care to help them home from hospital.  In adult social care we rely on so called winter monies to fund out of hours, home care, intermediate care and transitional beds, all of which get people out of hospital and back to their communities so they can complete their convalescence and recovery.  This winter however the signs are that these funds won’t reach social care.  The NHS winter is biting and hospitals are needing every penny health commissioners can find.

This is further destabilising fragile social care providers, many of which are small local businesses who are really struggling to make things stack up.  As reported by the Kings Fund & Nuffield Trust social care providers face huges pressures in terms of retaining staff, maintaining quality and staying in business.

social-care-for-older-people        Social Care for Older People (home truths)

Our experience is that small, local providers are full of caring, passionate people who are trying to make social care work despite the challenges.  People like Mark, whose story from 5.05 minutes into this video about what happened on Boxing Day 2015 when the River Calder broke its banks left me speachless when I first heard it.

Mark and his team faced the worst that winter could throw at them.   But driven by deeply held convictions that it was their job to care, they are made social care work in the most challenging of circumstances.

Going into this winter we are anxious, but we haven’t lost hope.  People have an incredible capacity for caring and to find humour and happiness in the bleakest of circumstances.

winter-okie-aged-80

So going into the social care winter 2016 here are our suggestions:

1.  Remember why you work in the social care sector.  You care.  If you didn’t you could earn more somewhere else.

2. Nevet forget you are a guest in people’s lives and this is a huge privilege.  The minute it stops feeling that way it is time to move on.

3. Create space with your friends and coworkers to talk about the people you are here to serve and support.  Every person is a bright spark of colour in your life.  Sharing those sparks might catch a fire to keep you and your colleagues warm during the darkest of days when the pressure is on.

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Someone to Safeguard

The referral was pretty bog standard these days. The neighbours didn’t get Elsie’s permission for any of her details to be referred to Social Services. In truth it had never crossed their minds they’d be asked for this. When pushed by the call centre about the issue of consent they said that they didn’t think they needed her consent and that this was a matter that ‘the Council must take seriously for everyone’s sake’. And then behind the thinly veiled threat to act the neighbour stumbled upon four little words. Magic words. Words that suddenly change the meaning of everything and words that seemingly come with their own legislation, procedures, judges and juries. ‘It’s a safeguarding issue’. And boom, there it is. Elsie, aged 87, never known to the Council, never having failed to pay for council services or any other tax that propped up with welfare state that she didn’t really partake in, was known. Consent overridden. Case opened. Within moments Elsie had an electronic file. Elsie had a Reference Number. And Elsie would receive an automated letter thanking her for contacting the Council and she would receive a call within the next seven days. All done within five short minutes from the start of the phone conversation. Within ten minutes Elsie was on waiting list of other Reference numbers waiting to be allocated to a Social Worker and sat on the computer screen of the Manager. Whether Elsie used services or not, from that moment on to the day of her death, nothing was clearer – Elsie was a Service User and there was a record to prove it. There was, as far as everyone was concerned, someone to safeguard.

The social workers went in twos to the address. No-one was quite sure why. The referral mentioned that Elsie had got cats but there wasn’t any belief that the cats were dangerous. Perhaps the second social worker was there because social workers love cats. The referral said the house was ‘dirty’, ‘things everywhere’, ‘cluttered’, ‘soiled pads in the garden’ and Elsie, although not seen for some weeks, was wholeheartedly felt by the neighbours to be dirty herself. ‘She’s self neglecting’.

Having knocked at the door and getting no response the social workers pushed slightly at it and the door opened. A cat ran out and then back in again. No sign of Elsie in the hallway. The social workers called her name, walking gingerly through the hallway, past a sideboard with some framed pictures of a moustachioed man with the ‘Geraldo, King of Swing’ emblazoned on them. Calling out her name and holding out their ID badges the social workers continued inward.

Elsie was in the kitchen. She smiled when she saw the social workers and beckoned them in still further. The social workers introduced themselves and whilst doing so Elsie kept on smiling before raising her hand as if to stop the second social worker saying their name. Elsie bent forward and placed her right ear up against what looked like a radiogram from footage used to show listening to the broadcasts of Prime Minster Churchill telling them they wouldn’t surrender. Almost trance like Elsie’s smile remained fixed as she listened to the radio. Elsie probably listened to the radio for a full three minutes, to the social workers, observing the cats, the newspapers (one from May 1991 with a picture of Paul Gascoigne on) and moving their feet on the sticky floor tiles, the three minutes felt like a lifetime.

When Elsie moved away from the radio she asked the social workers ‘who are you again, love?’. The social workers explained who they were and said that they were there to see if ‘she was alright, you know, see how things are’. Elsie said she was fine and asked if the neighbour had asked for them to visit. ‘She’s lovely, like that. Looks out for me’. Elsie explained that she had lived in the house all her life. Her parents, who she said ‘died recently, in 1971 and 1975’ had left the house to her. The social workers listened. They wanted to be respectful, they had questions of course (and they had lots of boxes to tick) and had already decided that things ‘weren’t right’ but they listened nevertheless. Half way through talking Elsie’s eyes suddenly lit up. ‘John!’ she said. Within moments Elsie was back to the other side of the kitchen, head propped up against the radio, same expression on her face, which now to the social workers seemed almost rapturous. This time a longer a wait. Five minutes. Elsie broke her concentration just once, to beckon the social workers to sit down. Neither did. Elsie didn’t notice or care.

Elsie said that John worked for the radio. He was in his late forties and his job was a ‘broadcaster’ and that each day John ‘either announced the news or introduced big bands… sometimes both’. Elsie said that John was based in London and he still lived there. She said John sometimes slept in the radio station and sometimes broadcast during the night, but not usually. The social workers continued to listen but really wanted to talk about the cats and Elsie’s ‘daily routine and keeping clean’. More in an effort to wrap the conversation up about John and move on to the matters at hand, the self neglect, one of the social workers asked a question. ‘John sounds lovely. Is he someone you have actually met and know’? And with that the tone of the conversation changed. Elsie explained that John had spoken to her on the radio for over 60 years. He was her man friend and he was engaged to marry her. Her betrothed. John had promised Elsie that one day he would drive up from London in a white Bentley car and marry her. Their plan was to live in London and take Elsie away from all this, including the cats. Elsie said the social workers could have the cats if they wanted them.

On walking to the door with the social workers Elsie thanked them for coming but they had to go now as John liked to ‘talk to her alone’. Elsie smiled as she shut the door behind them. The last thing the social workers heard Elsie say as the door closed was that John was her man and ‘was not for sharing, goodbye’.

The social workers weren’t inexperienced. One had just become an Approved Mental Health Professional and the other had worked with older people for years. But as they walked to their cars and drove back to the office the silence between them spoke more than any words of completed boxes on the safeguarding form. ‘What was all that about?’
Safeguarding referrals can be complex. The social workers knew that. They also knew that to ‘help’ Elsie they had to get to know her, build up trust etc. So the visits continued throughout the next week. On each occasion Elsie spoke to the social workers but continued to ignore any questions about her health, her wellbeing, her cats and the state of her house. Most questions were met with ‘I know love. John’ll see to it’. All conversations were interspersed with long periods of Elsie listening to the radio and smiling with occasional, knowing nods and some ‘ah’s’ aimed at the social workers as if ‘John’ was further confirming plans that would need to be relayed to the social workers. For the most part the social workers just heard the hiss of the untuned radio. For them there was no voice, no programme and without doubt there was no John. However what bothered the social workers more than this was that there was no progress. No getting Elsie to see what state she was in. No getting Elsie to consent to sorting the house. No getting Elsie to realise the safeguarding issue. The self neglect. The abuse.

Safeguarding doesn’t allow for stalemate or for someone to continue to be abused. It identifies the abuse and through a list of ‘outcomes’ it makes the social workers do something. For the social workers things needed fixing for Elsie. She had a choice. Either Elsie worked with them to ‘improve the situation’ or they would ‘Refer to other agencies’. The case notes were clear. Elsie wouldn’t engage. She lacked capacity to make the decision. It was all in her best interests. The risks were unmanageable. The hoarding was a fire risk. The cats were underfed and the RSPCA would be cross. She needed safeguarding. If only she could see it! She was a problem. The problem needed fixing.

The social workers didn’t seek Elsie’s consent to refer to other agencies. In Elsie’s case the ‘other agencies’ was the Mental Health Team. Elsie was visited by a Community Psychiatric Nurse, who within hours visited again but this time with the Psychiatrist. The social workers received a call ‘How has this gone on so long? and ‘she’s in a terrible way, totally delusional, paranoid ideation’ and is ‘refusing all treatment because of this bloody John thing’. The next call was to the AMHP. Pink papers in the bag, the Mental Health Act Assessment was to take place that evening.

The Ambulance couldn’t stay and eventually the police were called. 87 year old Elsie was escorted out of her property by two young police officers. One of the police officers had to switch the radio off during ‘the incident’ in the house. He at least had the foresight to give the radio to Elsie and reassured her that she ‘could hold it’ in the back of the car. It was the only bit of humanity Elsie ever witnessed either that evening or throughout her entire dealings with the ‘support’ agencies.  Section 2 completed. Safeguarding outcome achieved. No more self neglect. Someone had been safeguarded.

The first thing Elsie did on the ward was to find a plug for the radio. John was there. Reassuring her and helping her to stop crying. And that’s how things stayed for a number of weeks. The medication was taken, Elsie complied. The nurses moved on to the next person, Elsie listened to John. There was no more worry about Elsie from the neighbours, the problem had been fixed. No more self neglect, no more self to neglect. Elsie’s care plan said ‘needs all cares’. And that’s what she had. All cares attended to and a continued love affair with John.

The discharge planning never once considered home. Home was where the ‘multi-disciplinary team’ had felt that the bad thing happened. Home was where the cats had had to be removed and where the social workers had found Elsie’s love letters to John, which had ensured merriment on the ward due to the details that she went into about her feelings for him. The self-neglect would re-start at home and why risk things? Elsie was happy enough. Everything was fixed, apart from the John thing.

The Care Home never fully read the care plan about Elsie and the new social worker had not really written much up about John and what had happened at home. The radio didn’t go with Elsie to the Care Home. Elsie noticed this on her first day at the home. However instead of asking for the radio Elsie screamed for 8 hours. In the end she was given medication. The Care Home didn’t call the hospital or speak to the psychiatrist about how distressed Elsie was. They made one phone call that day, which was to the social worker requesting more funding ‘due to the screaming’ and the impact this was having on other patients and staff.

Over the next 3 months Elsie moved into two different care homes and was returned to hospital following a fall. The radio was never switched back on.

Elsie died in a care home. It was four months, five days and 6 hours after the phone call from the neighbour.

Lord Justice Munby stated ‘what is the point in making someone safe if it merely makes them miserable’. In ensuring Elsie was miserable, we were unfit to even ensure her safety. John did exist for Elsie and we never saw that. John was the risk management plan. John stopped Elsie self neglecting, not the other way around. Elsie was the expert in her own situation and had an 87 year start on the rest of us who tried to study her and fix her within weeks. John was her flickering light of hope which we extinguished in the name of safeguarding people from themselves. I hope she saw John again somehow.

The elephant in the room in adult social work is often a cat

elephant in the room

Firstly, thanks to @Harr_Ferguson for the title which was inspired by this tweet:

I remembered this tweet today whilst driving home and reflecting on having heard several stories this week from amazing social work colleagues where pets featured in a critical role.  The colleague who, having tried to engage with someone through their letter box had the dog set on them.  The parents who were walking the dog every night past their son with a learning disability who was living independently in his new home to reassure them that he was OK.  The mum and son with very complex communication needs whose face lights up when he sees the family dog come into the room.  And finally, the amazing colleague who was planning to finish for the weekend only after they had sorted out 11 cats and 3 dogs so that the person they were supporting could feel safe enough that their pets were cared for to accept a period of convalescence and recovery from a period of acute ill health.

Social care is full of evidence to suggest that pets are associated with psychological and emotional well being.  Something that we could perhaps pay more attention to in adult social work.  Dr Sara Ryan (yes Connor’s mum) has written a really thoughtful paper on how pets are important members of the families they belong to and yet how often they are unseen by the “professional” in the room – it’s here if you want a read:

http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.12176/abstract

Sara’s paper reminds us that as social work practitioners, it is far too easy for important family member to become invisible when they are sat right in front of us – an observation which Harry Ferguson has written about in his brilliant piece about the unbearable complexity of social work decision making in the British Journal of Social Work.  See here:

http://bjsw.oxfordjournals.org/content/early/2016/06/29/bjsw.bcw065.abstract

In our induction for Newly Qualified Social Workers, we often talk about a real case which we got very wrong.  The lady had 20 cats.  We thought we knew best.  We thought we could see something as professionals that she couldn’t about her life and experience.  We took her away from everything she knew, everything that was important to her in her life.  The result was that she deteriorated very quickly.  It is telling, that when we talk about the lady with the cats, we only talk about her cats as a passing, almost jokey remark at the start of the story.

And if you want to know just how wrong we can get it in social care – see the case of Fluffy the Cat https://ukhumanrightsblog.com/2015/01/29/what-price-liberty-damages-dols-and-a-cat-named-fluffy/ whose 91 year old owner was removed from his home and unlawfully deprived of his liberty in a care home leaving his beloved cat behind.

Today, pets have featured heavily as we have reflected on this week, appearing in several of the stories which I have heard being told as part of the end of week come down.  All social workers will recognise the end of week come down.  It is the really important bit of the week when social workers take care of each other and the complexity of the decisions they have supported people to take.  It is the moment where social workers use story telling to reflect about the week which has past and as the social work office winds down, it is the process which enables practitioners to go home without carrying the weight of every potential risk with them into the weekend.  Without that moment of story telling, social workers, the best social workers, the ones who will be back fighting for people’s human rights once they have rested and recovered, will often spot the small things they have missed during the heat of the busy week.  That is the time when the pets emerge.

Today, as we told our end of week stories, we heard of that we had seen 11 cats and 5 dogs.  We spotted something we didn’t know before, something we didn’t previously notice about what is important to the people we are supporting.  And when we next speak to them, because of that moment of insight, we will be able to include in our conversations with them that they have another member of their family that we are interested in.

And crucially, we had a moment of laughter and mutual support which came out of that recognition – because we are pet owners too and we know what our pets mean to us. In that moment you become less professional and more human and you are closer to the person you are there to support.  Which is a really good thing.

This week, however, I am left with unanswered questions which I leave me unsettled – what happened to the lady’s cats?  What if we got it wrong?  What if it was being removed from her beloved cats that was the tipping Point?

Honestly, I will never know what happened to the cats.  But we do know what happened to the lady with the cats, we moved her, leaving her cats behind, she became very distressed and after a long and lonely 6 months on various hospital wards she died.  It was traumatic for all concerned.  Including the social worker who has never forgotten her.   To quote Professor Ferguson “The powerful impact of unbearable levels of complexity and anxiety on social workers requires much greater recognition.”

Have a safe weekend to all our EDT and hospital weekend colleagues working this weekend.

 

 

 

 

 

 

Hold the front page

Mary PoppinsThere is a scene at the end of Mary Poppins where the Banks Family go to fly kites together.  It is a joyous scene, celebrating a family with a renewed identity, purpose and open to possibilities about many exciting futures.  But it’s also really quite sad as it marks the moment where Mary Poppins realises how much she cares about the Banks Family just at the point when they don’t need her any more.  She gathers up her bag and quietly floats away presumably to another family in need.  The mix of emotions on display are really familiar to social workers.  As is the decision to walk quietly away from a successful intervention, leaving the family or the person to determine how they frame telling their story to the world.

For several weeks now there has been a lively debate taking place about the media image of social work following an episode of Dispatches featuring a Social Worker calling themselves Vicky. There are concerns within the profession that the constant barrage of negative media images about social work is resulting in people leaving the profession.  Some voices argue that we must step up and that individual social workers should tell their story about why they entered the profession and what it is that drives them.  The thing about Mary Poppins though, is that you never find out her back story, and crucially, that never detracts from the movie.  You never stop and think, oh if only there had been a bit all about Mary.  As deeply frustrating as it is that the media continue to only tell negative stories about social work, that doesn’t mean that individual social workers should be rushing to fill the press with their story.

There are lots of factor which influence retention within the profession, level of professional autonomy, access to resources and CPD, the professional relationships between agencies in the sphere of practice that social workers operate and most importantly alignment of the values of the employing organisation with social work values.  Media image however, there isn’t much evidence that negative media has quite the effect many appear to be assuming it does.  Given the extent of media coverage of the role of social workers in the cases of Victoria Climbie, Baby Peter, Winterbourne View, Stephen Neary, Connor Sparrowhawk and in the most recent of tragedies Liam Fee, it would surely be hard to find any social worker who has qualified in the last 10 years who wasn’t aware of the media image of the profession when they joined.

The thing that Mary Poppins reminds us, is that it isn’t our story to tell, it belongs to the person we are there to support.  If they choose to include in how they want their story telling that a social worker was involved, then we should be honoured to respect their decision.  However, the really hard thing about social work is that in most cases, the real test of the success of the social work intervention is that the person no longer wants or needs to acknowledge the social work. Good social workers get that.

A while ago a script writer made contact who was looking at making a six part TV drama ‘about social work’. The conversation with the writer was fascinating.  She wanted to know stories ‘about social workers doing social work’ and the impact it had on them. We decided that we couldn’t help her.  Our ‘best’ social work stories were essentially not ours to tell. Social work stories include the family in absolute crisis following a ‘honour killing’ which claimed the death of one family member and the incarceration of many others; a young mother admitted to hospital under a section following the death of her baby; a man ‘escaping from a care home’. These were stories and experiences that were vivid, powerful influences shaping our practice.  But they weren’t what the writer wanted. She wanted to know the impact on us of being involved in complex case work, what we felt and our role in ‘dealing’ with the pressure. Whether its part of social work training or our particular approach to practice, this isn’t something that we could articulate. It wasn’t important.  The effect of experiencing other people’s lives genuinely didn’t feel like a story we could tell.  Only the people we have worked with know if their lives were any better as a result and only they have the right to tell their story however they chose to frame it. People who experience social work are the ones who should be telling the media what social work is, both good and bad.

A palliative care social worker told us that good social workers are like chameleons. They blend in. You don’t often see them its enough for people who need social work to know they’re there and that’s enough recognition for the social worker too.  Thinking about it, Mary Poppins had chameleon like qualities, her carpet bag of social work having moved on from the traditional contents (day care, home care, respite, supported living) to a more exciting range of  modern options (Direct Payments, Individual Service Funds, Personal Health Budgets, Integrated Personal Commissioning).  You can still find if you look deep enough into the bag her spoon full of sugar.

But social work isn’t about looking down a deep hole at someone, turning on a blue light  and inviting the paparazzi around to film the drama unfold.  Social work is about getting into the hole with the person to give them the leg up so they can wherever possible scramble out of it clinging onto whatever dignity remains. If the person tells someone of the great work of the social worker then that’s great, if they don’t then that’s great too. It doesn’t lessen what the social worker did.  Social workers have their moments of fame. They know their worth. They are honoured at least one night every year when they have an award ceremony. The Queens honours list regularly includes social workers. But for the rest of the time they are OK going under the radar acknowledging that ‘their story’ was never really theirs in the first place.

If we are really critically reflective, is the desire to sell positive social work through the press really about us trying to get a message out that ‘we are here, please fund us?’. If it is then lets be honest. In times when food banks are reporting increased usage, records of people are requiring mental health care & the numbers of safeguarding referrals are reaching epic proportions we need to rejoice and celebrate social work. Our unseen, unheralded social work, is keeping more children and adults safe and alive. But hold the front page, we don’t want it.

Mary Poppins intervention in the lives of the Banks was mesmeric. But in the end, only the Banks knew about the magic she brought into their lives.  Having made that difference, she blended into the background and floated off.   No headline required.