Can you dig it?

wine bottle

I often see guidance for those completing mental capacity assessments which suggest that, while the person may appear to be lucid and capacitous at first blush, if the assessor “drills down” or “digs deeper” they will be able to show that actually the person lacks capacity to make the decision. Yet as the guidance from 39 Essex Chambers tells us, “the presumption that P has capacity is fundamental to the Act. It is important to remember that P has to ‘prove’ nothing.

It reminds me of the criticism of the way some professionals use the MCA; that people with a mental impairment often have to demonstrate a degree of understanding in decision making that people without a mental impairment don’t.

Consider this scenario. I know it’s daft, but please put yourself in the shoes of say a person with a learning disability wanting to go to the pub on their own;

You are a social worker, it’s a Monday evening and you have had one hell of a day. It started with back-to-back meetings, the first one at 0830 (who arranges a meeting at 8.30 on a Monday?). In the afternoon a crisis developed regarding someone and by the time you get back in your car for the drive home, it’s gone 7 o’clock. It has been a stressful day.

On the drive back home, you stop at the off licence for a bottle of wine. You know you shouldn’t, it’s a school night, you have to be back on the road the following morning but nothing winds you down like a bottle of wine.

You tell all this to the guy behind the counter, maybe feeling a bit guilty for having a drink on a Monday night. The shopkeeper says to you,

“Are you sure you should be drinking tonight?”

“Excuse me?” you say.

“Are you sure you should be drinking tonight? You just told me you have to be back on the road in the morning; did you know that 23% of all drink-driving convictions are where the person was still over the limit the day after?”

“Oh, don’t worry, I’ll be fine. But thank you for your concern.”

“Well, I’m not sure I should be selling you alcohol. The effects of alcohol wear off differently depending of the age, gender, weight of the person. It can take over twelve hours for the alcohol units in that bottle of wine to wear off.”

“Well, I’m not sure it’s any of your business. I’ll be fine, I’ll just take the wine and pass on the advice, but thanks all the same. Anyway, I have one of those breathalysers at home, I can check in the morning if I am over the limit”

“What make and model is it”?

“What?!”

“You just said you have a breathalyser. What make and model is it? I need to be sure you are going to be safe. And it’s not just you I am worried about, supposing you hit a pedestrian? I have a duty of care…”

Ok, that conversation would never happen and if it did, you would tell the shopkeeper where to stick his bottle of wine and go elsewhere.

But it does happen all the time for people with disabilities. Last night I was at a gig in Bradford to raise money for musicians with learning disabilities to fund a music tour of Norway.  Brian Mitchell (social work lecturer at Bradford University and lead singer of The White Ribbons) pointed out that we all go out on a Friday night and take it for granted – no risk assessments, no best interests decisions, no risk management plans. But people with learning disabilities and autism, or people with a brain injury, mental health needs, dementia etc all have many hoops to jump through before they can do what we all do without question.

So by ‘drilling down’ or ‘digging deeper’, an assessor will eventually be able to prove any person could not make a decision, and then with a few typed words, easily link that inability to the mental impairment. And sadly, it is unlikely that assessment will ever be challenged. (By the way, it remains the case that since 2007, while I have been challenged many times about the outcome of my capacity assessments, not once has that been when I concluded the person lacked capacity; everyone agrees when I say that, I am only challenged when I say the person is able to make the decision).

Many readers will be wondering about the first Principle of the 2005 Act, that we have to assume the person has capacity unless proven otherwise? I wonder the same. I also wonder what efforts those professionals challenging me about my assessments made themselves without success? I ask to see their assessment in which they will have demonstrated they did all they could to help the person make the decision without success. Nine times out of ten, there is no assessment, and when there is, it is usually so poor it’s not worth the paper it is written on. For example, I saw one recently by a consultant on an acute ward, it said “Mrs Miggins has dementia and therefore lacks capacity to make wise decisions.”

But back to drilling down, digging deeper and raising the bar; the law and policy guidance does not tell us to do this. It is possible that a practitioner can so want a person to be autonomous and make the decision that they don’t ensure the person is truly making a capacitous decision. But that’s rare compared with people simply wanting the person to be incapacitous so they can then go on to make a decision for them and invariably it is a decision contrary to what the person wants, which is often what initiated the capacity assessment in the first place.

However, I met a man once who appeared lucid and able to make the decision but during the assessment it became evident that he did not understand his limitations, he thought he could walk and climb the stairs at home and that if he fell over, he would be able to pick himself up again. No matter how much I showed him the evidence he could not do that, including inviting him to demonstrate his mobility to me, he wouldn’t have it. But that was not determined by digging deeper, it was simply that I applied the MCA and found that he could not understand the relevant information and that on a balance of probabilities, it was because of his dementia.

Of course, it could have been that the man was afraid of admitting to me his limitations, fearing I would make a decision for him. It is a massive judgement call we have to make. As Lucy Series tells us, “Capacity assessment is not some kind of scientific process where capacity is ‘measured’, it’s a social interaction – often with hugely high stakes for the person being assessed. If I were having a conversation with a person and something I desperately wanted hinged on it, I think I would probably try to convince them that it was a good idea and minimise the risks. That’s how some people argue. That’s a pretty standard persuasive tactic when arguing a point. It may not mean that a person doesn’t understand the risks – it might mean they don’t want to hand a person they regard as powerful any more ammunition to deny that it’s a good idea.

So it was a judgment call, and I hope I got it right when I concluded the man did not have the mental capacity to decide to go home. But we must reflect continually on our practice, on our values and on our competence and prejudices.

I undertook a capacity assessment recently where the woman had a speech impediment. She struggled to get her words out, she sometimes lost track of what she was trying to say, such was her anxiety. In my mind, I was thinking she was incapacitous, but when I looked down at my notes, her responses were all logical and reasoned.  I had to allow for her being nervous and anxious. She asked me what the consequences of the assessment were, she said, “What happens if I fail?” and I wondered; Who gave me this power and why does she think I have power over her? The answer of course was no-one, I don’t have a power at all; a capacity assessment provides a defence, not an authority.

So no digging deep, no drilling down, no raising the bar higher and higher or judging people because they cannot remember your name from a previous visit. We just need to follow the process as described in the MCA, in the Code of Practice and in the subsequent caselaw. If the person is capacitous, and I have followed the process, what the person goes on to do is no more my business than it is the business of a shopkeeper whether or not you have a bottle of wine on a Monday evening.

39 Essex Chambers, “A Brief Guide to Carrying Out Mental Capacity Assessments”, March 2019

https://www.39essex.com/mental-capacity-guidance-note-brief-guide-carrying-capacity-assessments/

Lucy Series, The Small Places, “A serendipitous judgment”, September 2012

http://thesmallplaces.blogspot.com/2012/09/a-serendipitous-judgment.html

 

 

 

 

 

 

 

 

Telling us what we want to hear

A guest blog by @DickyBiscuit

In this blog post, I will consider a particular phrase I’ve come across, which is used sometimes by a minority of professionals in assessment records.  When used however, it has huge implications for the person being assessed as it assumes the status of evidence which demonstrates or proves that a person lacks the requisite capacity to make a certain decision, and therefore may be subjected to whatever the professional and others think is in the person’s best interests. I am considering the use of the phrase, “She will tell you what you want to hear” or “He will tell you what he thinks you want to hear.”

This is worthy of analysis; the person is telling the assessor what the assessor wants to hear, rather than what they actually believe, and that, therefore, is evidence of incapacity? What degree of proof must be provided to support such a claim? Certainly, I have read that phrase many times in capacity assessment forms but have never seen it supported by any evidence, the statement just sits there on the report, a value judgement against the person. It is a peculiar thing to read, because the person is at once vulnerable and needing to be cared for, and at the same time devious and trying to pull the wool over the assessor’s eyes.

So, is there a legal test referred to in case law and professional agreement captured in guidance which shows that if indeed the person is telling professionals what they want to hear, that this is appropriate to use as evidence of incapacity?

Well the short answer is – no.

Maybe instead it is mentioned in the legislation itself? Section 1(4) of the Mental Capacity Act says;

A person is not to be treated as unable to make a decision merely because he makes an unwise decision.

Further, at section 2(1);

…a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.

And at section 2(3);

A lack of capacity cannot be established merely by reference to —

(a) a person’s age or appearance, or

(b) a condition of his, or an aspect of his behaviour, which might lead others to make unjustified assumptions about his capacity.

And finally at section 3(1);

…a person is unable to make a decision for himself if he is unable —

(a) to understand the information relevant to the decision,

(b) to retain that information,

(c) to use or weigh that information as part of the process of making the decision, or

(d) to communicate his decision (whether by talking, using sign language or any other means).

I don’t see anything in there about a person telling others what they want to hear being legal grounds to asses they lack capacity.

One might also consider that a person telling professionals what the professional wants to hear that would require the person to have the skills of Derren Brown? And logically, if a person can work out what the assessor wants to hear, and can then tell the assessor what they want to hear in order to secure a particular outcome, then surely that would evidence a very high degree of cognitive functioning, thus making a claim that the person lacks capacity look increasingly silly?

Forgive my cynicism. We must consider; do people tell professionals what they want to hear? I would suggest the evidence is strongly that they do, because we all do it from time to time.

Here’s an example. Nearly 30 years ago, I went to see my then GP for a routine appointment. He asked if I smoked and I admitted that yes, I would smoke about fifteen Marlboro Lights a day. I loved ciggies. I can still hear the incredulity rising in his voice as he leaned across the desk, almost pleading with me, “Mr Biscuit, do you realise the lunacy of what you are doing to yourself?”

I was unhappy as I left the surgery. I did not want to be called a ‘lunatic’ so six months later when I went back, I lied and told him I had quit. He was very pleased with me. I don’t think he gave me a Chupa Chups lolly for being such a good boy, but I enjoyed the visit more than I had the previous one. I told the doctor what he wanted to hear, he didn’t criticise me as a consequence, and so I lit a celebratory fag as soon as I had left the surgery.

You take my point. I was telling the GP what he wanted to hear because I did not want to admit to having the breaking strain of a KitKat when it came to quitting smoking, or to have him lose his patience with me. I knew smoking was bad for me, of course I did, but still I smoked.

So how many of us tell GPs the truth when they ask us how much we drink, how much exercise we do? Or when the dentist asks, “Do you brush twice a day and floss and use mouthwash?” Yes of course! Every day!

We tell people what they want to hear all the time. It’s called lying.

The people having their mental capacity assessed will tell the assessor what he or she wants to hear but probably for different reasons, and crucially it is not evidence of incapacity.

I believe it is about power. Since starting the social work degree course at university in 1998, I repeatedly heard inspiring things about social workers giving power back to ‘service users’ – and then there would inevitably be a comment about how the power was never ours to give back and we would all agree.

But in practice this plainly is not always true. The person telling the social worker or psychiatrist what they want to hear, may be doing so, as I did with the GP, because they don’t want to appear daft or lacking in will power. But more likely, the person is afraid that if they admit to doing something risky (like not living in a care home or going to the pub on their own) then the assessor will stop them from doing it.

And why should the person not lie to their social worker? Who are health and social care workers to question people as if they are children and we their parents?

So this, more than any other reason, is I believe why people lie to professionals. It is not because of their mental impairment, it is because of the power imbalance between the assessor and the assessed, and the likely outcome of that imbalance (e.g. the person is that evening prevented from going to the pub by the professional who knocks off at five and goes to the pub).

There is the phenomenon of those who, as 39 Essex Chambers describe in their excellent guidance in assessing capacity, “can talk the talk, but not walk the walk, especially if they have had numerous prior capacity assessments.”

39 Essex Chambers refer to people with brain injuries who might say one thing but do another. It may be the case that a person will tell the assessor that yes, going out alone at night to the pub (for example) might make them vulnerable to attack by bad people and that they won’t do it, only to later go to the pub. The assessor then leaps on this as evidence of incapacity.

As the 39 Essex Chambers guidance suggests, we should put that repeated mismatch to the person. That detail – that the person says they won’t but the assessor can prove they have done more than once and will do again – is relevant information. That relevant information should be put to the person, and as the law says, it must be provided in a way that will enable him or her to understand it.

But assessors must still show the causative nexus – that it is the person’s mental impairment that causes the person to not be able to understand, retain or use or weigh that relevant information and not some other reason, such as the person being afraid to admit the truth about what they want to do or intend to do (and how sad is it that most of these decisions are just the things that the rest of us do without being hindered or having to explain our behaviour or seek permission?)

In other words, assessors must show that if they think the person is telling them what they want to hear, the assessor must provide evidence of what they have done to make the person confident that they are not going to use what they say against them, that the assessor has taken all necessary steps to enable the person to make the decision – even if it is an unwise one. Assessors should try to gain some trust between themselves and the person, and sometimes, as I have done in the past, that might mean recognising that the assessor is not necessarily the best person to do the assessment if that relationship is not conducive to effective communication.

References;

The Mental Capacity Act 2005

https://www.legislation.gov.uk/ukpga/2005/9/contents

39 Essex Chambers, A Brief Guide to Carrying Out Capacity Assessments, March 2019

https://1f2ca7mxjow42e65q49871m1-wpengine.netdna-ssl.com/wp-content/uploads/2017/11/Mental-Capacity-Guidance-Note-Capacity-Assessment-March-2019.pdf

Is Social Work Rocket Science?

hope

Is social work complex, like rocket science? I am still not sure. I’ve heard social work be described as being harder than rocket science (which I suppose isn’t hard if you are an actual rocket scientist) and I’ve heard it described as being simple common sense (which I am always sceptical about). I think I have come to the conclusion that social work practice isn’t really complex but as the Chief Executive of the British Association of Social Workers said in 2018, it is working with complexity. Social work is deep in the messy stuff, the grey areas of life which is then fused with primary legislation and mixed with the social workers interpretation of what we think we see in the smallest snapshot glimpse of someone’s life. And like all our lives its murky, confused, confusing, laced with double standards and things that you just can’t properly explain to anyone.

Despite the million and one different variables in peoples lives we experience, I do think as social workers we can identify much of what we hear and see in terms of peoples well-being & security (which equals happiness maybe?) into four outcomes that Neil Crowther brilliantly blogged about recently – https://socialcarefuture.blog/2018/12/13/a-million-dreams/amp/

Love, Work, Home and Hope.

People don’t tend to want more than these four things. Complexity might attract the ‘professional’ (those who are also drawn to blue lights, rushing into the Big Cases ready to be the Decision Maker), however the genuine complexity (i.e. the messy stuff which isn’t easily solved with a set of pink papers or a court order) is usually left to someone else to sort as the blue light professional moves on to their next case, never looking back to check on how the person’s life continues.

In my experience, of the four outcomes Hope is first among equals. Hope is about ambition, a belief in a better future not only for ourselves but for our families and others. Hope should be about ambitions without ever been dismissed as over ambitious. For social workers, I feel that working with people to enhance hope and opportunity, means that we need to be able to critically evaluate everything and mostly ourselves and our own worth to the person and their family and friends. Do we enhance the outcomes that people want? Do we enable relationships to thrive regardless of the difficulties they may cause us (anyone wish to displace this troublesome Nearest Relative?). Do we take a risk enabling approach to enhance relationships and help provide loving relationships to replace us? Do we genuinely strive to support people to achieve social status? To evaluate everything means to evaluate ourselves.

We are at our best when we believe in people. We are the only profession who is taught to do that. We believe that people are good and where they are not we work to alter factors around them to facilitate change and ensure good. To believe in people is to believe in hope. If the outcome is a nursing home what is our approach to hope and ambition within that? Do you remember this blog? https://lastquangoinhalifax.wordpress.com/2018/07/29/to-be-in-among-the-crowd/

If Andrew actually needed something to provide for occupancy of his mind, and it wasn’t just that others thought he did, perhaps our job was to recognise and respect that he loved football. Not to dismiss what his voice, his wishes, feelings and beliefs and instead confer onto him our solution of restrictive day centres and so called ‘supported’ housing. If people want to scale an active volcano, or become prime minister, or race high speed cars, is it not our job to hear their voices and positively engage with their wishes, feelings and beliefs to help them construct the world they want for themselves? One in which they can experience happiness?

Maybe it’s time for us to slightly reframe ourselves as social workers. I have felt I have peddled a worn-out bag of care management tricks for years and generally the tricks don’t work. The very things we do to keep people ‘safe’ are the very things that expose them to classical health risks for dull, restricted and inactive lifestyles. Our illusion and box of tricks is seen through (just ask people with learning disabilities and their families), the tricks may be disappearing, but we remain – social workers laid bare without the tricks and care plans (including the less than visible ‘fairer’ charges’). Social work reclaiming its purpose, upholding social justice by advocating for values of inherent dignity, equality, democracy and freedom.

So, are we ready to stand beside people and their families now without claiming we have a bag of magic tricks?. Can we talk honestly about the illusion that are and instead be clear there are no complex short cuts to life and no day care or home care or care home that’s likely to mend the broken heart or fulfil potential or lead to a world of things that we might have? And if there are 4 things that people want and need, Love, Work, Home. Hope, what’s our role? These things are messy and will involve us exercising humility. We are not the professional expert. People and their families are the experts of their own lives that we really know so very little about. Our unique professional role may be keeping the hope alive.

The only way is ethics

Ethics

Conflict between the lived experience of practicing as a social worker for a social work employer and trying to fit in to the bigger organisation with your social work values is possibly a big source of stress for social workers. Social workers are employed by lots of different types of employer. Housing associations, community health trusts, charities, inspectorates and regulators, hospitals including private treatment centres. Each with different priorities, accountability and ways of working. You won’t know what the cultural norms are until you start.

Social work is a global profession, with a shared, global definition. Through embracing the power of collectivist action, social workers can positively influence employers and reshape organisational culture to fit with social work values. Social work’s mission, as described in the British Association of Social Workers code of ethical practice, is to uphold respect for the inherent dignity, equality and worth of all people. Social workers can live this mission by encouraging their employers to recognise positive obligations to base practice around the United Nations Declaration of Human Rights (1948). Social workers who are encouraged by employers to promote social justice, through upholding the natural rights of the individual, and through taking positive action to strengthen families and communities will give back far more than the basic job description requires.

Social workers are natural agitators for positive change, whose values have public service running through them like words in a the middle of a stick of rock. And the Courts are encouraging social workers to remember and reclaim their unique contribution to public service:

“The Local Authority is a servant, not a master… vulnerable adults… do not seek to be ‘controlled’ by the State, … ‘working together’ involves something more, much more, than merely requiring carers to agree with a local authority’s decision even if, let alone because, it is backed by professional opinion” (Munby, 2011).

The contentious point for social workers is that you can only be a servant not a master if your employers supports you to be able practice in a way which enables you to spend time with people, taking all practicable steps to find out what they want from you and why. Working for a social work employer with a relational and rights-based ethos makes it much easier to live the values of an ethical practitioner than being in a highly ridged care management environment where your core function is to broker packages and move the person on to the next setting as quickly as possible.

Rights-based employers encourage what O’Donnell et al. (2008) termed as being a form of ethical activism. Ethical activism is a more radical approach to social work, with social workers positioned as being more than allies working within a network of support around people, but rather assuming the role of accomplice in subverting the status quo enough to disrupt and effect positive change.

You will know if you are working for a social work employer whose cultural norms support rights-based, ethical activism if you find yourself in the middle of ethical deliberations with people, their families and/or carers and other professionals on a regular basis. Usually over a cup of tea, reflecting on how the week is going, ethically activist social work employers have a culture where every day brings a new debate about the ethics of any given intervention or approach, always centred on upholding the rights of the person social workers are supporting. Ethically activist social workers respect autonomy as the first principle to uphold in practice (Gillon 2003), upholding people’s wishes and feelings through tackling oppressive power dynamics which push for unnecessarily disproportionate, restrictive interventions.

An example of the type of disproportionate, restrictive practice ethical practice avoids, can be observed in the ruling on the Wye Valley NHS Trust v Mr B (2015), which was about a 73-year-old gentleman with a long history of mental health needs and poorly controlled diabetes. Following the death of his partner, Mr B lived on his own. He developed a leg ulcer, which did not heal over time, leading to a hospital admission in 2014. During a long stay in hospital, Mr B resisted treatment for his diabetes and his ulcer which led to his leg becoming seriously infected. In 2015, the NHS trust who were caring for Mr B applied to the Court of Protection asserting that Mr B needed to have his leg amputated to save his life but lacked the capacity to make the decision, so they wanted Court authorisation to proceed. The evidence presented to the court made it clear that Mr B was likely to die within days from the infection if not action was taken, however if his leg was amputated, he had a positive life expectancy in excess of three years. Most people just remember it as the Wye Valley case, forgetting Mr B, the appellant. However, Justice Peter Jackson did not make such a crude error. Entirely centred on Mr B, and his views, the ruling upheld that whilst Mr B lacked capacity, this did not negate his known wishes, feelings, beliefs and values. In paragraph 11 of the ruling Peter Jackson noted that:

“This is not an academic issue, but a necessary protection for the rights of people with disabilities. As the Act and the European Convention make clear, a conclusion that a person lacks decision-making capacity is not an ‘off-switch’ for his rights and freedoms. To state the obvious, the wishes and feelings, beliefs and values of people with a mental disability are as important to them as they are to anyone else and may even be more important. It would therefore be wrong in principle to apply any automatic discount to their point of view.”

Given these considerations, the Judge ruled that it was not in Mr B’s best interests to undergo an enforced amputation and ruled against the NHS Trust. This is what makes the Wye Valley case ruling so important for social workers, this emphasis on the person’s wishes and feelings when constructing a best interest decision. It is a simple message; the person’s views are central. Ethically activist social work practice centres on respect of autonomy.

Gillon, R. (2003). Ethics needs Principles – four can encompass the rest – and respect for autonomy should be “first among equals”, British Medical Journal, Vol. 29, No. 5. https://jme.bmj.com/content/29/5/307

Munby, L. J. (2011). Safeguarding and Dignity: When is Safeguarding Abuse’. Keynote Address by Lord Justice Munby to the Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust’s Approved Mental Health Professional and Social Care Conference.

O’Donnell, P., Farrar, A., BrintzenhofeSzoc, K., Conrad, A. P., Danis, M., Grady, C., Taylor, C. and Ulrich, C. M. (2008). Predictors of Ethical Stress, Moral Action and Job Satisfaction in Health Care Social Workers, Social Work Health Care, Vol. 46 No. 3, pp. 29–51.

Clouds in my Coffee

latte-art-kak-delat-risunki-na-kofe-foto-7

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:

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.

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

For the Valentines I never knew

Valentine

There’s a song by a band called the Wedding Present which like so many other songs is about falling in love.  It’s called A Million Miles.  It’s about that moment when you meet someone for the first time. The moment when your stomach spins. You can’t eat, you can’t sleep and yet despite this, as the song goes, you ‘can’t even remember the colour of her eyes’. The song connects with that first fleeting moment when a returned smile and a burst of shared laughter on the walk home together means everything. When your world is filled with subsequent endless telephone calls to each other (it was written in the mid 80s before text). It’s about that mad bit. The bit where the massive risk has paid off, even if it’s only momentarily.

I know it’s different for everybody but that song has always resonated with me because that’s how it feels when it happens. It’s a kind of prolonged Christmas Eve of anticipation. It’s mystifying, scary and the most exhilarating experience that you can have. Its the 1000-1 off-chance of a new human relationship that may lead to love and will involve lust and desire alongside, hopefully, some happiness on the journey. The risk you’ve taken was huge. The smile that might be unrequited, the humiliation of a misread signal, the shocking discomfort of a blind date from hell, the deeply personal hurt that comes from rejection if, as may be likely, a rejection is just around the corner. Yet despite that, despite all of that, we felt it was risk worth taking.

Love and falling in love. Seeing people fall in and out of love. Beginning and endings to relationships plays a huge part of our lives. I’ve completed two three year courses on issues around humanity and social care and I’ve completed countless additional training courses but I genuinely cannot recall ever being asked to write about love in any assignment that I competed. I have definitely never written the word love in an exam. I can’t remember a single lecture on love or certainly not one that didn’t medicalise it, or quickly move towards framing love in terms of ‘attachment’ or ‘obsession’. But love and relationships appear to be one clear thing that drives us. We don’t get to choose who we love or we can not prevent unrequited love. It is part of who we are, and can at times lead to terrible sadness. It is the essence of humanity. And yet, it is something that health and social care isn’t comfortable with.

As social workers you would think that our profession would be there when people needed help and support with love – it’s sort of in our job title. But in my career, I have found the most significant block in terms of our thinking about supporting people to experience the love, with all the risk it brings.  I can recall on one hand the number of conversations I have had with people where there has been a positive approach to helping someone with any aspect of having that ‘Wedding Present song’ feeling.

It is particularly stark when it comes to people with a learning disability. Instead of love, I hear about sex a lot. And sexually transmitted infections. And grooming. The words sex and relationships in social care are invariably linked to risk and danger and professional worry, rarely love. I worked with a young man some years ago who according to his allocated learning disabilities nurse had had sex with his boyfriend who also had a learning disability after an evening party at the day centre. Within the course of that day over 20 professionals were made aware of what had happened. We knew what had happened in forensic detail and more or less where it happened. The police were mentioned. No crime had taken place but someone thought something needed to be done. What about the risks? What about consent? What about protection? Everyone focused on the sex. No one of course said anything about love. Whilst I find the term ‘making love’ a bit toe-curling, it was safe to say that none of the people who got to hear the intimate details of whatever happened between that loving couple stopped for one moment to consider it to be anything other than a physical act. The couple are still together. They are still upsetting people by having sex. No-one is mentioning that they love each other and may get married. No one is talking about how their lives have been enhanced through love. They often skip their allocated day centre to spend the day together travelling on buses. The fact that as a couple they want to stay in each other’s company all day every day, seemed to worry and upset professionals rather than be celebrated. But surely that’s what love does, it puts everything else outside of that relationship into context. For them, love is the answer, not social care.

Social care, day centres, endless games of ten pin bowling, coffee and cake in Merry England for ten people and two carers – all makes sense when there’s nothing in your life other than people who are paid to care for you. Especially  so if you also do not have the comfort of love from your family. Add love into the mix and suddenly ‘outcomes’ and ‘achievable goals’ and ‘support plans’ find their context – in the bin. Love between two people makes sense of everything.  Leaving the question – why don’t we embrace the possibility of love for the people we support rather than reframing relationships in terms of worry, risk and danger; The pain from love is a risk that we are willing to take ourselves, and not infrequently do so. Yet by worrying about others feeling pain from those very risks we embrace for ourselves, we inadvertently ensure love remains always just outside of reach and relevance of those we support.

Perhaps, as professionals we find this so difficult as it calls into question our professionally taken for granted assumption that our interventions are wanted and helpful. If we properly understood love and humanity we would have to understand our place in a person’s life is somewhere much father down in the pecking order. Our rules, our say so, our plans for you suddenly lose gravitas when competing with forces like love. What always strikes me about Mark & Steven Neary’s powerful account about ‘Getting Steven Home’ is that via the Court of Protection the Local Authority seem to very late in the day to be forced into having to grudgingly accept the fact that there is a relationship between Mark and Steven which must be respected and upheld in law (Article 8) but never really seem to get close to understanding that it is the love between them that drives everything about their words, actions and motives. It’s as if love is quite literally an emotion beyond us. We’ve typed ‘love’ into our health and social care computers and it’s come back with an error message and then crashes.

So we tend to stick with what we know and what keeps us safe as professionals. We’ve sort of come up with a fudged thing in assessments which is about relationships. This means that we don’t really have to talk about love but we can talk about other people – significant others, next of kin, nearest relatives and relevant persons. And we’ve got a form and a process for every relationship. Some relationships (nearest relative and relevant person) even come with special powers. Whether nearest or relevant relationship is loving never really crosses our minds. Love becomes relationships. Relationships become processes. Processes get processed. Health and social care box ticked. Love don’t live here anymore. Not that it ever did.