Comprehensive spending review: little for social care

The months of rumours, leaks and speculation are over; the Comprehensive Spending Review has finally been announced. As expected, for social care, it does not make for fun reading.

Here are some of my immediate thoughts, based on Chancellor George Osborne’s speech and a (very) swift look at the spending review document. While the review obviously affects everyone in some way, I’m going to try to focus on the impact it could have on people with mental health issues and/or learning disabilities.

Firstly, it should be noted that there is very little geared specifically to people with learning disabilities and/or mental health issues. For instance, specific mentions of ‘learning disability’ (or disabilities) does not get one mention and ‘mental health’ only 2. I didn’t expect there to be; today is the day for grand statements, with the detail to come at a later date.

In terms of what was said, while Osborne promised an extra £2 billion for social care in the next five years, including £1 billion to aid joint working between health and social care, he mentioned that this would help older people – no mention of adults with disabilities.

Also, BBC health reporter Nick Triggle worries this could be more or less cancelled out by the increasing demand of the aging population.

Meanwhile, benefit reform will ensure that it “always pay to work”, according to Osborne. Benefits are to be capped at no more than the average net wage from 2013 – which will work out to about £500 per week for couple/lone parent household and £350 per week for single adult households – although people receiving Disability Living Allowance are exempt from this.

However, this may well hit people on incapacity benefit/Employment and Support Allowance and other benefits, especially those who are moved onto Jobseeker’s Allowance from ESA. The focus of the welfare reform is evidently on people getting jobs, with benefits cut to make it more of an incentive to work.

There is also a new 12-month time limit proposed for the one million people on ESA in the Work Related Activity Group to find work or face having their benefits cut.

But surely this will be dependent on the jobs being out there for people to take? Many people on ESA would like to take up jobs – part or full-time – but with many businesses not looking to take on employees, and the public sector set to shed 490,000 jobs, there are precious few available and competition for them will be fierce.

The reforms to housing benefit will also hit many people with learning disabilities and/or mental health issues, especially those living in London and the southeast, where property prices are generally higher than in the rest of the UK.

Potentially, the adverse impact of money worries on people with mental health issues or learning disabilities could be immense, as could the upheaval of having to move, if they now cannot afford the rent on their homes. For someone to have to move away from an area they know – including a network of informal support – to somewhere new could have a disastrous effect on a person.

Not all bad news

But the CSR wasn’t all bad for social care; there were a couple of positive notes from the Chancellor.

Firstly, personal budgets are to be extended to people with long-term health conditions, children with disabilities and special educational needs and adult social care. The commitment to personalisation is welcome and, for some people, personal budgets have made a tangible positive difference to their lives. Giving more people the option to do this is a good thing. Whether their budget will be enough to do this is another matter.

Likewise, the commitment to increase talking therapies for people with mental health issues is also to be welcomed.

The government is also going to take forward proposals to invest nationally in mental health liaison services at police stations and courts to intervene at an early stage, diverting mentally ill offenders away from the justice system and into treatment. However, it does carry the caveat ‘subject to business case approval’.

Nevertheless, this is a good move. Far too many people with mental health problems get stuck in the justice system and opportunities for them to access treatment are often lost.

Conclusion

From an initial assessment, people with learning disabilities and/or mental health issues do not fare well out of the CSR, especially in terms of welfare and housing reform. However, I don’t think anyone – regardless of who they are – fares well out of this review.

But there are some crumbs of comfort, especially with expanding personal budgets and talking therapies, although they are probably outweighed by the cuts.

However, to paraphrase Winston Churchill, this is not the end, it is not the beginning of the end, it is the end of the beginning. Next month, government departments will set out business plans to outline how they will implement cuts. This is where the real detailed information about cuts will come at a local level, and we will all find out which departments, services, projects, charities etc will retain funding, be closed, or face hard times.

People with learning disabilities still face discrimination

Discrimination against people with learning disabilities is still rife in the UK, with a third of people still believing that they cannot get a job or live independently, according to a new survey.

Health and social care provider Turning Point has found that 9 out of 10 people believe people with learning disabilities are still discriminated against, with 51% saying they are the most discriminated against group in society.

This is not necessarily a revelation – everyone involved in the sector knows that it is rife – but does show how much still needs to be done if people with learning disabilities are to be truly integrated into society.

OK, while it is a survey of only 1,100 adults and nobody knows whether it was weighted to get certain results etc – I know some people are sceptical of statistics – but taking these on face value from a reputable source it nonetheless provides snapshot that can at least create a debate about the topic.

From looking at the survey results, a lot of this discrimination seems to be down to a lack of public understanding about people with learning disabilities and how they live.

For instance, the survey found that 8% still expect people with learning disabilities to be cared for in a secure out-of-town hospital, while 23% believe they live in care homes.

Whether these views are borne of ignorance or prejudice, all this shows that information campaigns about learning disabilities need to be redoubled. Some of the findings show a basic lack of knowledge – such as identifying mental illness as a learning disability – that needs to be addressed.

Adam Penwarden, Turning Point’s Director of Learning Disability Services, hits the nail on the head: “As a sector, we need to work together to challenge preconceptions and show what a positive contribution to society people with a learning disability can make. This includes working, living independently and playing an active role within the local community.”

There have been high-profile anti-stigma campaigns for mental health in the past couple of years and perhaps the time has come for a similar campaign for people with learning disabilities.

Another way to break down stigma would be to have someone with learning disabilities become a regular member of the cast of one of the major soap operas. While this may sound flippant, it can work – the Stacey Slater bipolar storyline in Eastenders (which I blogged about previously here) has helped to bring the condition into the mainstream and increase understanding.

Yes, I know Billy and Honey Mitchell had baby Janet, who has Down’s syndrome, but that character has all been written out now. I am thinking more of an adult/teenage character.

While better information about learning disabilities would not be a panacea – stopping discrimination is an ideal only – it would at least eat into those statistics and provide a good basis for further work.

NHS reform – impact on social care

Andrew Lansley’s much-vaunted white paper on the future of the NHS was published yesterday afternoon, promising widespread reform, including the abolition of PCTs and SHAs and giving commissioning power to GP consortiums. But what will it mean for social care? Here are a few of my initial thoughts.

Firstly, there are concerns that the reforms focus on general services and that people with learning disabilities, mental health problems and dementia have been largely ignored – this came through strongly on Twitter yesterday, from what I saw.

To test this, I did a quick word search of the white paper to gauge how many times certain phrases were mentioned; mental health is mentioned 8 times in the 61-page document, Alzheimers or dementia receives one mention [as @seetheperson pointed out to me], and learning disability – or learning disabilities – never crops up.

To me, this is shocking. Considering that people with learning disabilities, dementia and mental health issues make up a significant chunk of those that use NHS services, the lack of attention given to them is a worrying omission.

Specialist services are often a lifeline or those who use them and an acknowledgement of this – and preferably a commitment to give them at least some degree of protection – would have been reassuring to the many service users who are already distinctly nervous about what government cuts will mean for services.

Hopefully the government is planning for learning disability and mental health services separately…

Also, do GPs, who will now have power over which services are commissioned in their area, have the specialist knowledge that is often required in MH/LD to be able to give an authoritative view on what sorts of services are needed? Mental health charity Mind’s chief executive Paul Farmer has already questioned this and called on them to talk to experts and “tap in to the personal knowledge of patients and mental health charities about what works.” 

There is also cynicism over whether GP commissioning will work from some within the profession. For example, the GP for hire blog gives a distinctly lukewarm reaction to the proposals, saying it will put more pressure on salaried and locum GPs, and could lead to divided interests for those doctors involved on a consortium.

Also, will GP consortiums not exacerbate the postcode lottery, which was supposed to be got rid of? If commissioning a service depends on the decision of the GP consortium – a group of individuals with their own opinions – surely there is the risk that one consortium would approve it, but the one next door would not.

It hardly improves patient choice if they find that their needs are rejected in one area but available in another.

But there were some good points in the white paper. For instance, it talks of promoting the joining-up of health and social care services and promoting preventative action. I can’t argue with that principle – health and social care are closely linked, so that is a no-brainer and could help to reduce duplication of information and bring about efficiencies. Also, preventative action is generally accepted to reduce the need for costlier, more complex services down the line.

The white paper also says that the government’s vision for adult social care will be outlined later this year, and indicate that it will be a continuation of the current personalisation drive towards choice and control for service users. A white paper will follow next year. Nothing new there, but it is good to have the timeline in place.

In conclusion, the government’s reforms are certainly ambitious, but they are also risky. Social policy think-tank Civitas has warned that considerable resources will be needed to enact the restructuring – I’m not sure how that sits with the aim of saving £20 billion by 2014 – and if it is got wrong it could lead to a dip in the NHS’ performance for at least a year.

That will be the acid test of these reforms – will it make services better for service users? I’m sceptical, but only time will tell, as ever with any reforms.

This white paper provides so many points for discussion so it is more than likely that I will blog on aspects of it again later in the week.

The future for social care programmes?

Last Friday I blogged on the government’s axing of the Caring with Confidence programme, and how on an initial reading it seemed to make little sense. But comments since then from care services minister Paul Burstow have explained more about the decision – and given a hint as to future policy direction.

Burstow, as reported in Community Care has justified the move to end Caring with Confidence by saying: “We were not getting value for money from the delivery. Not enough carers had been through the programme, and there was no evidence that delivery would accelerate significantly.”

Whether that is accurate or not is a moot point. But this statement may tell us more about future policy direction when it comes to social care programmes: if they can demonstrate they are providing value for money, they will be safe, if not – watch out for the axe.

Now, once upon a time I was a business journalist, and I used to regularly interview entrepreneurs who would explain that a project or an arm of a business had been closed because it wasn’t providing value for money. Their priority was the bottom line and if it wasn’t contributing to it, and showed little sign of doing so in the future, then it would be axed, more often than not.

That’s fair enough in business – they exist to make profits – but in social care, it is a whole different ball game.

In social care, investment in a project may not provide demonstrable fiscal returns; it is often a lot more subtle than that. For instance, how do you quantify the value for money for someone taking part in a mental health project? It may aid their recovery and wellbeing but does it provide value for money? How do you judge? Is it whether they are able to get a job at the end of it and therefore can come off benefits and start paying tax?

It’s not an easy call to make; social care projects often provide intangible benefits to those that use them, and in these cases it is generally more important than any financial returns.

In fairness to Burstow, he has added (again according to Community Care) that the money from Caring with Confidence will be reinvested in other carers’ projects, including a training programme to raise GPs’ awareness of their role in supporting carers. He has also said that Caring with Confidence materials will be available free to carers’ centres that want to carry on the work.

Nevertheless, Caring with Confidence will not be the last project to bite the dust in the coming months. The government is making difficult decisions and with the cuts coming – said to be 25% of local authority budgets – it is inevitable that some social care programmes will be axed.

There are projects out there that are not doing what they were set up to do well enough and need to be weeded out, but there are many more that do and should be protected. Government and council leaders will need to examine each one very carefully and assess the benefits it gives to service users before deciding which should be cut and not just make a decision based on financial data.

Incapacity benefits claimants worried by threat of cuts

These are nervous times for incapacity benefits claimants; with more rigorous testing coming for Incapacity Benefit and Disability Living Allowance, there is also the threat of more cuts to come later in the year.

Earlier this week, Chancellor George Osborne hinted that benefits which the government had not given specific commitments to protect would be part of a summer spending review aimed at cutting the deficit – although exactly what form this may take has not been elaborated on and work and pensions secretary Iain Duncan Smith has since tried to play down reports of cuts.

Nevertheless, it all amounts to a worrying time for disabled people. There have been several blogs in the past week by people who fear for their future or are angry at the nature of the changes, such as Emmanuel Smith in The Guardian and Dawn Willis.

Already Incapacity Benefit – and its successor Employment Support Allowance – has been in the firing line for some time, with new claimants having to go through more stringent checks with the work capability assessment since before the election. This is set to be extended to all claimants next year.

The government reckons that about one in 5 people on Incapacity Benefit – about 500,000 – are fit for work.

Some people – the much talked about “benefit scroungers” – who do play the system that will be found out by this, which is good.

But the vast majority of claimants are legitimate – 500,000 erroneous claimants seems high to me – and the Citizens Advice Bureau reported in March that the work capability assessment has found seriously ill and disabled people fit for work, including people with Multiple Sclerosis and severe mental illness.

There are several potential negative effects of taking people off Incapacity Benefit and onto Jobseeker’s Allowance. For instance, not only will income be reduced – and many disabled people are not well off to begin with – but, for people with mental health problems especially, the stress could harm their recovery.

The targeting of DLA is also serious; the new assessment seems designed to get people off it.

Indeed, there is a feeling among some commentators that the government has misinterpreted what DLA is. The Guardian’s Anne Wollenberg pointed to the government’s state of the nation report, which noted that “…around 2.2 million people, including 1.1 million people of working age, have been claiming disability living allowance for over 5 years”.

As Anne says, DLA is not and never has been an unemployment benefit; it is there to support people with the extra costs associated with disability – usually a long-term condition – such as wheelchairs and care services.

For many claimants, DLA is essential to their quality of life and if they were moved off it, life would become very tough very quickly – they will still need the equipment/services DLA enabled them to buy but have less money to do it with.

All these measures are wrapped up in a drive to get people off benefits and into work. While this is a laudable aim, there are problems. For instance, the UK is just coming out of one of the longest recessions of recent times and jobs are scarce, with 2.9 million unemployed and another 1.3 million set to lose theirs due to the measures in the recent Budget, according to news reports today.

The struggle to get work is often magnified for people with disabilities. Even though there is anti-discrimination legislation, I would be willing to bet that many employers would still choose an able-bodied person over someone with disabilities – although few would admit as much and may do it unconsciously.

I could go on. But it is clear is that life could get very tough for some people with disabilities or mental illness in the coming months and years if the government goes ahead with its plans.

Postscript: The government has now announced an independent review of the methods used to assess incapacity benefits claimants’  fitness to work and will report back by the end of the year.

More funding needed for mental health research

While Homer Simpson may have said “people can come up with statistics to prove anything”, there are some occasions when bald numbers do tell their own story. Mental health funding is one of those.

For instance, according to a review by the Medical Research Council, mental health is estimated to cost £77 billion each year in England alone. It accounts for 15% of all disability due to disease and affects 16.7 million people in the UK at any one time. Yet only about 5% – £74 million – of medical research budgets are dedicated to it per year.

Professor Til Wykes from the Institute of Psychiatry at King’s College London hit the nail on the head in a recent BBC piece, saying that mental health research is “incredibly underfunded”

This seems especially so, given that mental health problems affect more people at any one time than cancer or heart disease – both of which receive more funding.

Given the statistics, it is hard to argue with Prof Wykes. Whether this relative lack of funding is down to stigma or the fact that mental health is not a “sexy” illness is debatable, but at least there are moves to challenge the situation.

For example, in its review, the MRC has outlined the priorities for the research community for the next 5-10 years:

• Focus on the prevention of mental disorders based on better understanding of causes, risk levels and new approaches to early preventive measures
• Accelerate research and development to provide new, more effective treatments for mental illness, and implement them more rapidly
• Expand the capacity for research in this area in the UK.

The MRC will work with funding agencies such as the Economic and Social Research Council, the National Institute of Health Research and the Health Departments of the devolved administrations on approaches to take forward these recommendations, but whether more funding will be forthcoming is debatable.

The logic for more funding is hard to argue against – basically, more research would lead to better and more effective ways of preventing and treating mental illness, thus reducing the burden to the country and saving money – but the financial state of the country may dictate what happens.

With the Department of Health looking for savings, research budgets look set to be slashed for many areas of healthcare – although not dementia – so any large increases may be out of the question, although an increase in real terms may be feasible. Whether that is enough is another matter – it may be another case of innovative work having to be done with fewer resources, which could hold back the pace of development – to everyone’s detriment.

Welfare reform plans worry disability groups

As the new government starts to get itself into gear, one of its key policies seems to be welfare reform and getting people into work – but getting it right, especially for people with disabilities or mental health problems will not be easy.

The idea of welfare reform and ending dependency on it is good – and some would say long overdue – but it has to be ensured that it is fair, especially for people with disabilities or mental health problems who are currently receiving Employment and Support Allowance (ESA)/Incapacity Benefit (IB).

While most people with disabilities or mental health problems want to either return to or gain paid employment, some are not capable of it. Others are capable, but only perhaps certain jobs or part-time hours.

However, the Work Capability Assessment, which determines if someone is capable of work – if they are deemed capable, they are moved onto the £25-a-week lower rate Jobseekers Allowance rather than ESA/IB – is flawed, some groups claim.

For instance, Neil Coyle of the Disability Alliance, calls the Work Capability Assessment ‘unfair and ineffective’ in today’s Daily Mirror.

Meanwhile, Paul Farmer, chief executive of mental health charity Mind, says “the current test is not up to the job of measuring whether people with mental health problems are fit for work.”

The test was trialled among new claimants at the end of 2008, and involves rigorous medical assessments carried out by an independent company. Of the 500,000 tested, only 9% remained on ESA. This test is now set to be rolled out to all 2.6 million claimants.

But this worries Farmer, fearing that people with mental health problems will be incorrectly assessed. “We urge our new Government to review the benefit assessment… so that people aren’t deprived of their benefit and forced to look for work they can’t do.

“Work can be good for mental health, but only when it is suited to the individual. The Government has proposed to sanction anyone turning down ‘reasonable offers of employment’, but people should not be forced to accept work that risks damaging their mental health, putting them back on benefits and back at square one. Sanctioning people who can’t secure an appropriate job misses the point about why they are locked out of work in the first place.”

There are other wrinkles in the government’s plan to get people into work; we are just coming out of a long and deep recession and jobs are scarce and very competitive – 2.5 million people are unemployed remember.

Despite all the efforts of various schemes to tackle stigma against people with disabilities, it does still exist; two thirds of employers are unwilling to offer someone with mental health issues a job, according to Farmer.

A solution that is fair for everyone will not be easy, but if the government is to stick to David Cameron’s quote that ‘that those who can should and those who can’t we will always help’, then this needs to be got right and concerns from such groups need to be considered, to avoid the problems that could arise from trying to get people into jobs that are not suited to them.

New Horizons for mental health service users

Continuing the pre-Christmas rush to release big and/or important documents – last week brought us the Social Work Task Force final report and the CQC’s adult social care review – today the government launches its new 10-year strategy for mental health, New Horizons: A Shared Vision for Mental Health.

A quick skim through the 100-page document reveals a few key themes to the strategy, including;

• Improving the mental wellbeing of the entire population. The inclusive nature of this strategy, to me, will help to bring down the stigma of mental health issues, which still looms large. Also, prevention is easier (and cheaper) than cure
• Early intervention, including treating mental health problems in children and adolescents, with such things as counsellors in schools. Many children with depression go undiagnosed and often go on to have mental health problems in adulthood, again, prevention is better than cure
• Getting people with mental health problems back into work – this can really help with self-esteem and bring people back into ‘normal’ society and also reduces the cost to the taxpayer in benefits
• Linked to this is a campaign to tackle mental health stigma. This is needed to help ensure the other 3 points are successful.

Thus far, the response from mental health organisations has been positive. Paul Jenkins, chief executive of Rethink said it could (note: could) ‘revolutionise the quality of life and care available to people affected by severe mental illness’.

Meanwhile, Mind’s chief executive Paul Farmer has described it as a ‘turning point’ for mental health and welcomed the focus on prevention and wellbeing.

However, Farmer also noted that there is, as yet, no action plan for making the vision of New Horizons become a reality. There are action points in the document, but they are light on detail. He also added that in many areas basic mental health services are still lacking and this should not be ignored.

This hits 2 large nails on the head; government strategies often sound impressive and it’s easy to get carried away and think how good things will be, but ignoring how it will get made into reality, and such documents can also distract from what’s happening (or not) on the ground that needs to be addressed urgently.

So, while the strategy has many of the right elements in it to make genuine strides in improving the care and wellbeing of people with mental health problems, only when the action plan is in place – along with guarantees of funding, or at least no cuts to it – will it be worth getting properly excited about.

Breaking sport’s mental health stigma

It is the illness that dare not speak its name. Mental health has traditionally been one of sport’s great taboos; nobody talked about it, and those who did risked ridicule and career suicide.

For instance, footballer Stan Collymore was openly ridiculed by his then manager John Gregory and the press when he sought treatment for depression in 1999. When boxer Frank Bruno was sectioned under the Mental Health Act, the ever-sensitive Sun ran the headline ‘Bonkers Bruno locked up’ – although this was changed in later editions.

It’s no wonder sports stars keep things bottled up. Admitting to a perceived weakness in the macho world of sport is just not done; they could be considered unstable or unreliable by managers, and opposition players and fans would ruthlessly use it against them.

The tragic death of German goalkeeper Robert Enke demonstrates an extreme conclusion of this stigma and the fear of its effects.

But Enke’s death may prove to be a turning point in addressing mental health stigma in sport – and more widely. The story was reported around the world and gave people an insight into the mind of someone with depression.

This was followed last night by an Inside Sport special on BBC1. The programme took a considered look at mental health problems in sport – including high-profile cases such as cricketer Marcus Trescothick and Bruno.

The programme eschewed sensationalism and gave them time to explain how they feel when they are suffering problems and – just as importantly – how they manage it and now lead ‘normal’ lives again.

The fact that these two, and others, such as Serena Williams, Neil Lennon and Ronnie O’Sullivan have ‘come out’ and admitted to having mental health problems is helping to slowly break down the stigma.

It shouldn’t be surprising that sportspeople suffer mental health problems, because the pressures must be intense; coping with the expectations of coaches, fans and the media; trying to be the best in the world; dealing with the highs and lows that sport brings; keeping at the peak of physical fitness, for example.

After all, they aren’t superhuman. While some may be fabulously remunerated for, essentially, playing games for a living, it doesn’t change their basic human nature. Money doesn’t make you happy.

While Robert Enke’s death shows how deeply ingrained the stigma of mental health problems – or fear of stigma – still is, people are beginning to understand more about it and that it is an illness and not simply a case of someone ‘pulling themselves together’. Today, Collymore and Bruno would be viewed much more sympathetically, including by the national media.

Programmes like Inside Sport, and idolised sports stars admitting their problems, will help to change attitudes. It may be a long, slow process, but it is changing and hopefully that will mean that there will not be more cases like Enke in the future.

Big Care Debate – any closer to a solution?

The Big Care Debate closed last Friday (the 13^th, ominously, for those of a superstitious bent) ending the consultation on the government’s green paper, Shaping the future of care together , which set out the government’s options for the future funding of adult social care.

Now, the Department of Health will go away and contemplate the results, before, in theory, coming back with a White Paper, possibly in early 2010.

But with an election looming, I wonder if any of it will actually get through and make it into law.  

A spokesperson from the DH told me earlier in the year that if there is no consensus from the Big Care Debate on the best way forward, then it may go to a further period of consultation.

Looking at the reactions to the green paper from various groups, there seems to be little consensus; there have been criticisms, notably from mental health and learning disability groups, that the green paper focused on too much on older people. Indeed, much of the media focus has been on old age care funding and people not having to sell their homes to pay for residential care costs.

But then, older people’s groups, such as the National Pensioners’ Convention, have also voiced dismay over the government’s dismissal of the option to pay for care from direct taxation.

This option also found favour in a Joseph Rowntree Foundation survey. But then other organisations have supported the partnership and comprehensive models of funding the government suggested, which involve insurance and some state provision or the creation of a National Care Service.

If this is reflected among the wider responses, then we could be in for further consultation, which neatly kicks the debate into election time, when nothing concrete will happen because every politician will be scrapping for votes.

So, it seems like the social care industry will be in limbo for some time to come. And all the while the current regime will continue to creak along, and the problems within it will continue to mount, and – crucially – service users will continue to suffer at the hands of a much-disliked and over-complicated funding system.