My favourite mornings start with a coffee. I’m a member of the coffee club at work. Gossiping with others over that first cup is a ritual that grounds the day. There’s something about the feeling of belonging that being part of the coffee club brings. I can’t imagine how it would feel to have that removed from me.
The gossip which goes with the first cup of the day often drifts into speculation about big ideas. Social work naturally draws people in who are interested in big ideas about people, community, society. So, it’s no surprise that the speculation over a morning cuppa at the moment is about the content of two big papers on social care which are due this summer:
- The green paper due this summer on the future of care and support for older people which is looking at how people pay for their care
- And perhaps more significantly for practitioners on the ground the Care Quality Commission report on their findings from 20 Health and Social Care System Peer Reviews.
There are big headlines coming out of the CQC led reviews. The focus on the person is uncompromising. If care and support isn’t person-centred – it isn’t high quality. And being person-centred mean upholding the 5 statutory principles of the Mental Capacity Act through every decision.
- The person has the right for it be assumed that they should be in control of whether they want support at all, and if they do how their support is arranged.
- All practicable steps must be taken to enable them to make the decision including reasonable adjustment to enable them to communicate how they want their support arranging.
- If they want to arrange their support in a way that doesn’t fit the views of professionals – the social workers job is to advocate for them and use the law to enable them to take risks, challenging where professionals and others argue that the risk is unwise and therefore questions the original assumption that the person has the capacity to be in control of how their support is arranged.
- Any decision taken on behalf of a person who does lack the capacity to make the specific decision must be taken in their best interest. Section 5 of the Mental Capacity Act provides a defence against liability if the statutory principles are applied. The bar is much lower than most professionals realise when it comes to capacity. The latest analysis shows a 95% increase in the number of requests for the Deprivation of Liberty Safeguards not granted. This includes people who have died since the request was made, but it also includes people who the MDT deemed lacked capacity to be involved in the decision whether to go home or whether to move to a care home, who have subsequently been found to have had the capacity to understand, retain, weigh up and communicate their view once a social worker trained to a higher standard of legal literacy as a Best Interest Assessor has met the person.
- Any decision taken must be the least restrictive. Rarely will 24-hour settings, such as a care home, a supported living house, a hospital be the least restrictive.
When it’s understood well, the Mental Capacity Act is the most powerful tool in the social work tool box. It defines a unique role for social workers of knowing legislation, understanding advocacy and the ability to interpret and enact keeping power and control with people. Person-centred enshrined in law.
Lizzie’s social worker is also a coffee drinker. When she met Lizzie, they shared their love of coffee. Over coffee Lizzie shared a secret, she had a lover. Her sons didn’t know. She didn’t want to upset them. She used to meet him in a coffee house. But now she was in a care home she wasn’t allowed to go out, she didn’t have her own phone, she couldn’t speak to him or see him. Lizzie couldn’t go home, her sons had sold her house. Her heart was slowly breaking. She just wanted her life to end so she could meet him again in heaven.
Lizzie’s social worker spoke to the nurse who had arranged for Lizzie to be moved into the care home when she’d been in hospital. She was very worried about the suggestion that Lizzie leave the care home to walk to the local coffee house, she wouldn’t be safe, she might get confused and lost.
But nothing is too difficult if you want to make it happen. The social worker was upset for Lizzie. They wanted her to be happy. The social worker made contact with her lover. He was alive and missed her deeply. He wanted her to live with him. A meeting was arranged between Lizzie and her lover in the coffee house.
Lizzie’s sons were furious. They thought he would steal her money. They wanted her to stay in the care home where they thought she was safe. The social worker used the MCA to uphold Lizzie’s right to make the decision about where she lived. She arranged a family meeting where Lizzie told her sons that her decision was to move to live with her lover. The sons wanted other professionals there. Lizzie was quiet upset listening to the nurse and her sons tell her why she needed to stay in the care home. But the social worker was brave and stayed clear that Lizzie had retained and understood what they were worried about and had weighed up the risks of staying in the care home over the risks of moving in with her lover. Lizzie clearly communicated that she wanted to move. The social worker made it happen.
There’s a hashtag at the moment #socialcarefuture where bloggers are speculating big ideas. It’s worth a look. But it seems to me that being drawn to big ideas misses the point. High quality care is person-centred. Being person-centred means being drawn to the small places – the coffee houses where real social care is happening.
Speculating about big ideas is the realm of professionals who are looking to find their place in people’s lives who may not want them there at all. A mature health and social care system is one that recognises and critically reflects on its need to exist at all. Our systems are remain stubbornly determined by historic models of investing in ill health. Debates about how to work within the system will do little more than incremental gains. Perhaps this is enough, it certainly worls for athletes. But if we are to achieve a genuine shift to upholding people’s right to live healthy, happy lives as active citizens free from unwanted state intervention it will require braver shifts from the system controlling resources to people being in control. It requires professionals to be open to challenging their professionally taken for granted assumptions that their involvement in people’s lives is helpful. Being a member of the health and social care coffee club is a comfortable place to be, but being a bystander in a coffee house, walking away from Lizzie as she gets on with her life is a far more person-centred place.