The Ghost in the ATM

ATM

A few years ago, when I was a Team Manager, I chaired a meeting about a man who the Local Authority had recently placed in a care home. During the meeting I noticed that the man’s mother Sheila was becoming increasingly frustrated by the meeting, in particular she became fidgety as the Social Worker insisted that he go carefully and line by line through (what was then) Community Care Assessment. The Social Worker patiently explained to Sheila that he had to make sure he had captured all the information appropriately and accurately and so that everyone’s views were incorporated. Sheila stopped the meeting and said ‘Can I tell you something? I work for a bank and I’ve studied commerce. You know mini banks? Cash machines? When you put your card in and you want to withdraw cash, what happens? Take me through that process’ Uncomfortable silence ensued. No-one spoke, everyone looked down not wanting to make eye contact with either me or her. After a few moments of awkward silence, she continued ‘Ok. I’ll tell you. You type your PIN in and then you issue your instructions to the machine. It asks you if you want information about your balance, receipt and then finally you get cash options. You choose what amount of cash you want. But the crucial thing is that the machine doesn’t give you cash straight away. First it gives you back your card and then and only then it gives you your cash. That’s deliberate. Does anyone know why?‘ Again, nothing from the stunned MDT. ‘It’s because you’ll forget your bank card once you see the money because that’s what you came for. You will take the money from the machine and turn and walk away and you’ve forgotten about the process because it’s not important. The card will then come out of the machine and the machine will bleep loudly to remind you to take it. If it didn’t you would be down the road counting your money and planning on what you’re going to do with it. We have research in commerce that evidences that this happens on 90% of transactions we’ve tested it. The product is always the thing, not the process. You’re assessment is a process but it doesn’t mean a thing to my son or me. We want action‘.

Sheila went on to explain that the ‘action’ for her son was the care and support, that was the outcome. The process (the assessment), as she saw it, was for us not her and absolutely not something for her son. This observation had quite a profound effect on me. I reflected on earlier that week I had been to see my GP. Although I recalled answering the GPs questions and listening to the GPs observations about what I told her, it was her diagnosis and her intervention that really mattered to me. That’s what I was there for. That was the action. Whether I was there for the prescription, or the referral on or the sick note or the something else, I was there for outcome and not really that interested in the process about how she got there. The GPs assessment was just that – the GPs. I didn’t need her for an analysis of my life to date and the environment I lived in. I was the expert of my life and my circumstances, I’d lived it! I just needed her to make the next step happen to help me stay healthy.

By this point in my career I had been schooled in assessment and genuinely believed in their merit. Even in my first qualified social work post I had the job title Social Care Assessor. I had showed off to colleagues at the hospital team that as Social Care Assessor covering older people’s mental health wards. In a typical week, I brought 6 cases to funding panel for placements in care homes. I worked hard on producing the assessments. I learned to write lots. They were huge. They covered everything. I wanted to show just how person centred I was so in every assessment I included a pen picture of the person making clear how much research I had done on to understand their younger days, their likes, their culture. The assessments were approved at panel. The CCG had copies. Prospective care homes received copies. And eventually when the person went to the Care home the assessment accompanied the person. As a Social Care Assessor, I would then see the person again in six weeks to see if they had ‘settled in’, which is essentially Social Care code for ‘have they given in and accepted the Care home and all it entails’….

But faced with Sheila I found my faith in my assessment wobble. I went home that night and couldn’t sleep, my mind churning with questions:

  • Who cares about the consequences of the product when we’ve got the process to do?
  • Were the assessments I undertook as a Social Care Assessor ever read again?
  • Did anyone other than me read the carefully researched person centred pen picture?
  • In processing the person through a conveyor belt of assessments was I really being person centred?
  • Did any of my assessments lead to anyone being better off?

I didn’t sleep well for weeks after meeting Sheila.

My assessments were produced after a huge amount of input, but in reality they consistently resulted in a very simple to arrange outcome – the Care home says yes, they’ll take him, send them the Care plan we can settle him in ready for the evening meal round. Ultimately the success of the product was invariably what the care provider made of made of the person I had processed towards their final resting place. The long term happiness of the person entirely dependent on the quality of the individual provider, my assessment recording a point in time which faded into the past as it was superseded by a plethora of new documents to process – support plans, med charts, meal charts, visitor logs.

I genuinely cannot recall a single 40 odd page assessment that ever genuinely informed my view on things like eligibility, need and what the right support would be. The skill of the social worker is in recognising the value of a cuppa and a chat, a frown or a joke, the mention of a relationship, a loving glance between family members. Social Workers shine for me when they celebrate that they are experts in human interaction.

So, let’s embrace our humanity and the humanity of the people we serve such as Sheila and her son. Sheila and her son were the experts of their lives. We are there to understand environmental and sociological issues and place those in a context of their human rights. That’s our role. Let’s stop wasting time spending days in the office typing up pages and pages of assessment forms and case notes which no one will read. We are the PIN number, the bleep in the machine, the questions about balance on screen and whether receipts are wanted. We are the action, not the assessment.

Advertisements

Happiness

Where do you start in the search to define happiness?  Why would you even try?  How arrogant must you be to think you could make a determination as to what constitutes the basis on which another person would be happy?

The World Health Organisation has been exploring ideas about social and economic progress being measured in terms of nations “happiness” levels for some time –  see the report of the Commission on the Measurement of Economic Performance and Social Progress which proposed that states should shift from measuring economic production to measuring the well being of citizens as the key measure of how sustainable their economic and social policies were.  Recommendation 2 in the report is that social policy should emphasise “the household perspective”.  The UK benchmarks above average for most well being measures, however performance is below average for mental well being (20th of 27) and child self-reported health (24th of 38).

Happiness

Reading about the search for a sustainable home for his son Steven from @MarkNeary1 this last month has emphasised just how important that household perspective is.  Reading a day in the life of Mr Neary however is more than that, it is also a reminder that happiness and mental well being are found in the small things, the stuff that you often take for granted.  That being able to go to the pub and have a pint is definitely in Mark’s best interest and therefore in the best interests of his son Steven.

Which takes us to the question, if social care policy and law is about well being and happiness, is social care in the happiness business?  See this from digital story teller @JohnPopham who visited an older people’s care home earlier this week.

 

Improving subjective well being has been a focus for UK social care policy leading up to the Care Act (2014) which introduced the legal duty that Local Authorities are responsible for promoting well being, that people being happy is in their best interest:

“The general duty of a local authority, … in the case of an individual, is to promote that individual’s wellbeing”.

The first legal challenge to how well Council’s are meeting this new general duty is due in Court this autumn, following Luke Davey and his mother having won the right to bring a judicial review of changes made by Oxfordshire Council to his support.  Luke defines well being in terms of being able to get a drink and go to the toilet without the need of his mum having to assist.  What is striking is how far away such ambitions are from the lofty, ambitions of those who believe that they can at scale and pace transform the system of health and social care.

When we forget that it’s the small things define happiness and mental well being, do we start the slide that leads us away from seeing people as being fully human, is it that moment of loosing sight on what constitutes happiness which leads to unhappiness, captured so distressingly in extract from Tony Osgood writing about “serviceland” that strange place where commissioners think they know better than people about what they want and need in their lives:

jane isn't happy

Service land makes for uncomfortable reading.  It leaves commissioners of “care and support” facing a series of uncomfortable questions.  Do we sometimes get confused in social care about the limitations of our legal powers? Do we confuse the role of Social Workers as being a form of “soft police”, dressing up interference in people’s lives as being a form of safeguarding of people’s well being.  Do we focus on physical aspects of safety to the detriment of mental well being?  And in doing so, do we create the conditions which lead to unhappiness, which lead in a self-perpetuating cycle to more “challenging behaviour” which leads to us thinking we need to commission yet more services to meet the very needs we have created? Service land is a place of unhappiness. How typical is it of people’s experience?

LJ Munby in the case Local Authority X v MM & Anor (No. 1) [2007] EWHC 2003 (Fam) reminded us that in keeping with our positive obligations to uphold the UN Convention on the Rights of Persons with Disabilities, people’s wishes, feelings and beliefs must be taken into account when determining what is in their best interests (para 121).

“The fact is that all life involves risk, and the young, the elderly and the vulnerable, are exposed to additional risks and to risks they are less well equipped than others to cope with. But just as wise parents resist the temptation to keep their children metaphorically wrapped up in cotton wool, so too we must avoid the temptation always to put the physical health and safety of the elderly and the vulnerable before everything else. Often it will be appropriate to do so, but not always. Physical health and safety can sometimes be bought at too high a price in happiness and emotional welfare. The emphasis must be on sensible risk appraisal, not striving to avoid all risk, whatever the price, but instead seeking a proper balance and being willing to tolerate manageable or acceptable risks as the price appropriately to be paid in order to achieve some other good – in particular to achieve the vital good of the elderly or vulnerable person’s happiness.

What good is it making someone safer if it merely makes them miserable?”

The #7DaysofAction campaign is exposing that unhappiness is the experience of many within the health and social care “system”.   36 families have now come forwards to tell their story.  The campaign will be telling these stories in October, and as social care professionals we will be listening.  There is a social care commissioner and social worker involved in each and every story, but crucially, will we be able to detect the social work or will we be hearing something else?

We will be supporting the campaign.  Please join us.

Picture is “Things that make me laugh”. Artist Will Turner aged 9.