Why we shouldn't disregard care worker expertise in care

Last week I attended a day long session as part of my social work course titled "working in partnership" and included lectures and discussion about how social workers can work more effectively with service users, carers and other professionals. At the end of the day we had a safeguarding role play which assigned the roles of social work manager, social worker, CPN, care manager and day centre manager to students and asked them to consider the fictional case of an elderly gentleman, about whom safeguarding concerns had been raised. The "meeting" continued as might be expected with students assuming their roles and discussing the case appropriately. The issue came at the end of the session when we discussed the fact that "Mr Grant" had not been present and how this could have affected proceedings.

One of the students made the point that although Mr Grant had not wished to attend, it might have been helpful for the carer who had been visiting his home to attend the meeting in his stead. This idea was immediately brushed off by the academics present who questioned if the worker would have wanted to attend. They also questioned whether this was a suitable environment for the worker to be present in and seemed to imply they wouldn't have understood the "high level" discussion being made. This struck a number of students in the room who had been working as carers before taking up the course as extremely dismissive and seemed to embody precisely the stigma we had been taught not to avoid throughout the day.

Disregarding the personal views of a few academics, this was not the first time I've felt that care workers aren't seen as an important part of advocating for service users. In the past I worked at a residential school for autistic children. When social workers would visit they would spend a long time speaking with managers, a short amount of time speaking to the unit team leader but no time talking to the support workers. While I accept that some discussions wouldn't need to involve "frontline staff," it always seemed bizarre to me that the social workers wouldn't want to consult with the people who spent the most time with the children they were supposed to be caring for. Similarly in a mental health setting, it was the managers who would be consulted at length, whereas health care assistants were seen as unimportant. 

Attention has been drawn in the media lately to the role of carers and the importance they have to the advocacy and empowerment process, but this seems to have passed by the role of paid, professional carers. In reality paid carers, where there are no relations to advocate and where the service user is unable to self advocate, should be given primacy as it is these workers who spend the most time with the service user who needs the help. All too often care workers get written off as "unqualified" - a by word for "doesn't have a clue," but this disrespects the worker and wastes their valuable contribution. It also disrespects the everyday experience of the service user as it ignores the fact that they probably spend more time (15 minute visits aside!) with the care worker than anyone else. Effective "Partnership working" must include every part of the partnership, to ignore one part of it doesn't help anyone, least of all the service user. 

The centre is there for the taking. Is Clegg the man to seize it?

James Forsyth's suggestion in the Spectator that Nick Clegg might be angling his party for a vacant cenntre ground is an interesting one. Since the recession and the dawn of "austerity" politics has become more polarised. The Conservatives have been pushed towards the Right to calm the grassroots who feel their party has been hijacked by a soft hoodie hugging green agenda. Likewise, Labour have been pushed Left (despite attempts by Ed Miliband to distance himself from the Unions). This has left a void at the centre between a party that blames our current malaise on a "benefits culture" and a party which berates the rich for being unfairly wealthy. If Clegg was able to establish the Liberal Democrats as a party truly of the centre, he might have a chance of capturing some Tory and Labour strays who don't agree with the all or nothing rhetoric of the Left and Right. It does feel like there is a centre ground to be captured, however Clegg is playing a risky game if he believes the Lib Dems truly are the party capable of capturing it:

1. A centre might exist but it is unclear how popular it actually is with the voters. Though it seems that the two main parties have shifted further outwards it is perfectly possible this has created a void rather than a space at the centre. If this is the case then the centre is actually a fairly unpopular place to be and one which there might be little electoral sense in trying to capture. 

2. The Lib Dems are still an extremely divided party. As Forsyth states possibly 3m Lib Dem voters have been lost due to the coalition. These voters are almost certainly of the Social Democrat persuasion. It is extremely unlikely that Clegg would be able to get them back. However figures such as Vince Cable recognise this and will resist any agenda which seemingly accommodates Conservative policy. 

3. Due to the polarised nature of politics currently, Clegg's "centrist" policy runs the risk of appearing like a "Tory lite" strategy which has too much similarity to basic austerity and benefits bashing. While his conference speech does seem to point to relatively clearly defined differences between his policies and those of the Conservatives, he needs to be careful to ensure he makes these fully clear by election day. Any vagueness will be punished by the electorate. 

4. "Add Yellow get Green" certainly appeals to alienated Conservative voters who voted Blue but got booted. There is little on offer from the other parties when it comes to Green issues and they have largely fallen off the agenda since the recession hit. The Conservatives certainly seem to feel that Green does not mean growth and Labour have been silent on the issue meaning there is space for someone to step in and offer a real alternative. The issue is whether this is really enough given current circumstances. Green growth is persuasive but unproven. It also runs the risk of seeming remote and irrelevant to people struggling to make ends meet. If Clegg can pull off orientating the Green agenda as a way to save money for individuals, while also promoting it as a way to kick start the economy then he might be onto a winner. Then he just has to hope enough people listen and care enough for it to get him the votes he desperately needs. 

5. Europe. This is the exact antithesis of the Green strategy for the Lib Dems. Nationally, escaping from Europe is being portrayed as a true solution to the economic crisis and it is winning over voters. I'm not convinced that it is a really answer and probably owes its prominence in the media to the fact that UKIP have campaigned more effectively than the Green Party, however it is certainly something toxic to the Liberals. There is no way for Clegg to escape his pro-European credentials (even a divorce wouldn't be enough!) and while the troubles in Europe persist it just looks painful for their fortunes. Here Clegg has two options, downplay Europe or fight for its corner. I believe the latter is his only real chance, but while riots continue on the continent, this might just be the issue which prevents him having success in 2015. 

Labels

Reading the blogs Not So Big Society and Being Here over the last few days, both have spoken about perceptions of various mental health problems (Dementia/Alzheimer's and OCD) and it has got me thinking about the labels we put on things and what they come to mean. It is a fact that humans like to label things and throughout our language development (especially in the English language) we have been relentless in our pursuit of finding more and more names to call more and more things. This progression has reached its height with modern branding techniques, where a carefully chosen name can be the different between financial success of failure. Similarly in the medical field, as more viruses, syndromes, ailments and bacteria have been discovered, so too has the language used to describe them. Sometimes a name change reflects a progression in the understanding of a disease, for example when someone is exhibiting extreme and unusual behaviour we no longer say that someone has been possessed by demons or evil spirits, but more likely describe it as a form psychosis or perhaps a virus which targets the central nervous system. At other times a name change has been as simple as a shortening of a term, for example from influenza to flu, or a more specific description of a similar virus from "common" flu to H1N1. 

However any name change, no matter how seemingly small and insignificant carries a burden of meaning and perception for those who read and use it. In the example of flu, to my untrained medical brain it sounds considerably less serious and life threatening than something as horrific as INFLUENZA! Of course this is completely illogical and flies in the face of the facts: that they are one and the same disease, however I cannot deny the feeling that bubbles up inside me when people refer to influenza rather than flu. The longer, more archaic term carries with it a more serious connotation and so my perception is changed. Tell me you have influenza and I might fear for your life, tell me you have flu and I'll send you to bed with a cup of hot cocoa. The point is that these name games are risky (people die from "just flu" every year) and constantly muddy the waters of the process of accurately "labelling" things.

So what does this have to do with mental health? Well with mental health we have a real issue of definition. Our understanding of the human brain is still far from complete and thus any ailments associated with it must therefore also lack a degree of understanding. Doctors and researchers try and pin a label to behaviours they observe but these labels have extreme and potentially dangerous limits. As was the case when demons plagued the mind, a case of mis-labelling can lead to a subsequent misdiagnosis. An exorcism of a non-existent evil spirit will certainly never cure a psychotic episode, though it might do permanent damage to the individual suffering from it. 

Applying this logic to a modern situation, trying to pin a label on a behaviour which has an element of compulsion and an element of obsession and calling it a disorder, doesn't necessarily help us to help the individual with the observed characteristics. By applying a definition of OCD you automatically apply a character to that person, you lose the individual and replace them with a medical term, an acronym and a set of "symptoms". Indeed as Being Here reveals, she has experience of a number of people who have a label of OCD but who clearly do not actually fit what she recognises to be the "real" definition. Outside severe mental health diagnoses but on a similar track from my own experience, one of my students has a diagnosis of ADHD and does indeed have a lot of energy and can't concentrate for a long time. He is a handful to teach but I was told from the outset not to really bother or try to control his behaviour because "his parents say he has a diagnosis of ADHD". However lo and behold, when his father came to watch a class he was a perfect student. Now it could be argued he was just trying hard and successfully fighting any urges to run about and be his normal hyperactive self on this particular occasion, however this hour of complete serenity seems to cast some doubt on the prudence of "not bothering". Whether he was trying hard or not, he was able to improve and we had a good class as a result, thus the label of ADHD did a lot to pass the buck of responsibility for improving his behaviour, but did little to actually help the poor kid learn some English!

Seemingly the need to find a label is often an excuse finding process, as much as it is a naming process, which is clearly misguided and unhelpful to the individual. As Ermintrude2 argues in a post about Dementia:

"the importance is the ability of services – as with all mental illness – to respond to the person and not to the diagnosis."

Thus, society has a duty to focus on the individual and not get caught up in definitions. A label, no matter how well intentioned, shapes the object in our minds and when that "object" is a person, this really changes that person too, potentially unfairly. It also changes the way we respond to that person and try to help them. Grouping, or often more accurately "lumping" similar but always different people together under one diagnosis umbrella, might be very neat and tidy from a spreadsheet perspective, but from a people perspective it can be downright useless. Labels are helpful, but they must be used with caution.

The Government’s latest Welfare Plans Prove That A Fairness Agenda Is No Longer At the Forefront of Government Policy.

When David Cameron was elected leader of the Conservative Party he worked hard to remove the party’s image as the “nasty party”. During this transformation he pushed a more liberal “nicey-nice” image, promoted environmentalism and escaped much of the stigma the party had suffered with since Thatcher who, whether justifiable in her aims or not, did alienate half the country. This agenda seemingly appealed to younger voters, myself included, who might traditionally vote Labour or Libdem, however since then he has meandered through issues, veering to the left and the right with seemingly no logic or overall plan. This began from the off with “huskie hugging Cameron” dropping “vote blue go green” before the grass roots had even sprung. The tree might have remained (much to the disgust of traditional “torch carrying” Conservatives) but Conservative environmental policy has never regained its original primacy and other more liberal policies have subsequently been lost or watered down. However despite this policy pruning Cameron had (mostly) remained true to some devotion to fairness. Welfare cuts were made to “reward taxpayers with value for money”, the international development budget was maintained to ensure international commitments weren’t forgotten. Unfortunately over this weekend this “fairness agenda” has been tarnished by a thoroughly unfair and barefacedly populist policy suggestion – removing housing benefit from the under 25s.

One of the main objectives of Cameron’s plan for the country has been to reduce people’s lifelong reliance on the welfare state. Given the deficit, this was both a pragmatic and ideological mission, but a course which seemed to still hold onto a sentiment of fairness. Policy might have been a medicine which wasn’t very appetising, but it was one that needed to be taken. It was in this spirit that benefits were capped at £26,000, which was both a pragmatic and popular policy to take. It felt fair that people who were working should not be penalised with more tax, in order to fund others who did not work as much as they did. Moreover it was a limit placed on everyone, regardless of circumstance, a notice that the government will support you, but only if you manage not to get yourself into too much of a mess. Of course this policy had problems and would never be 100% fair, but it seemed to chime in with people and convince them that it was something tough, but not too harsh.

Today some people feel the same about the latest idea of capping under 25’s housing benefits. Cameron himself said that young people should be living at home, under the care of the Bank of Mum and Dad, not leeching off other people. “Other people” might find this attractive, however this measure doesn’t just miss sight of the case for fairness, it throws it off a cliff into the flaming abyss below. Cameron has often been derided for being posh and out of touch. How much ammunition does he give to his critics by assuming that everyone between the age of 18 and 25 has somewhere to go to? I am very lucky that between moving jobs or house I can bunk at home in the interim. Of course Cameron could have expected the same but many thousands of young adults in the UK cannot.

Furthermore, the policy itself will save only 2bn, not a meagre sum, but for these people the only thing keeping them off the streets. Since being without a permanent address can have massively damaging implications for people and leaves the vulnerable to exploitation, violence and abuse this measure seems to be extremely short term opportunistic, rather than looking at the bigger picture. How much money will these people cost the government in increased crime, drug use, health problems and unemployment? This measure is far from fair but it simply targets a vulnerable group and tells them they should do better, when in many cases they can’t. How can they with youth unemployment running persistently over 20%. These problems all seems self-evident to me but the government hasn’t seemed to acknowledge that any of this might be a problem.

The dangerous populism inherent in this proposal reflects an innate problem in Cameron’s modernisation agenda. Notice that it is the young who are being penalised here, not the prominently Conservative grey vote. I cannot believe that liberal Cameron can really be in favour of pursuing such an agenda, the same as I can't believe he has ever been that happy dropping "green conservstism". This all feels like a prod from the right who are unhappy with the libdems and feel the need to assert their right wing credentials. However it is Cameron who spoke for it. This is not some tirade from a disgruntled backbencher, this is the PM himself coming out for an inherently unfair, and in my opinion uncharacteristic proposal.

Another explanation which might (but I don't think does) exonerate Cameron, appealing to the grass roots. While the young are told they cannot get help from the state to live, that they must move in with their parents, whether they like it or not, the old are given free TV licenses, free bus travel and free prescriptions, not to mention their pensions.  Why isn’t it them who are being told they must move in with their children, use their tv, get them to drive them about rather than taking the bus and stop drawing a pension? Some people (like the despicable Edwina Currie on Twitter today) might claim the young have made their own bed by being disengaged and refusing to vote (not that this was to be seen anywhere in the manifesto of course) but cynics could, quite fairly say that this is just a vote grabber and ask why should the party care about a group who’d be unlikely to vote for them anyway. 

Regardless of the reason, there is no doubt this proposal is unfair and might spell the end of the Nice Guy act for David Cameron. 

The European Union's Leadership Woes Are A Result Of The Democratic Defecit It Created.

Throughout this crisis people in the UK and abroad have been crying out for strong leadership from their politicians, however it has not been forthcoming. This is no surprise, since a leader needs know which people they are leading in order to properly lead them. However, in the world of the EU, national boundaries have become all but meaningless, because the curse of the bond yield rise affects Eurozone countries regardless of which countries name is written at the top, making it difficult for EU leaders to know whether to represent their own nation or some wider European agenda. The economic crisis dictates that politicians are must work together to come to a mutual solution, but they are bound by their own electoral mandates, meaning that they cannot do what is best for Europe as a whole. Angela Merkel has done her best to work for a solution in the best interests of the entire Eurozone by refusing to issue Eurobonds (though she may be reducing her opposition now) but has been barracked by her own countrymen, and other European leaders for doing so. In private, as intelligent, rational people these leaders might see the logic in a less nationally selfish course of action, but they are at the mercy of their own electorates, precluding them from acting as sense dictates in public.

One might look to the EU parliament to provide leadership in such a situation. Its power and mandate should elevate it above the petty squabbles and confines of national electorates, however it lacks the power to be able to react in such a way, primarily because of the democratic deficit it has created for itself. Since its creation the EU has been in a catch 22 of self-identity. It was created to avoid one country becoming predominant, however through this struggle it became predominant itself, both because its constituent countries were vying for power (thereby increasing its stretch to indirectly boost theirs), and because it took on an ambitious quest of its own with the hope of rivalling rising behemoths in the East. Conversely, while people recognised the benefits of curtailing the conflict in central Europe, and the potential fruits of the single market, they did not specifically ask for a second government to rule their lives (neither in the founding referenda, nor in the more recent Lisbon “treaties”). This can be seen in the reluctance to adopt a European army and opposition to pan-European police powers. Without the necessary existential purpose EU bureaucrats did what bureaucrats do best, legislate. Lacking an overall plan, (which became even more an issue after the demise of Communism) tranches of legislation spewed forth from Brussels (not forgetting Strasbourg) with some hope that this would give legitimacy and purpose to the parliament. As a result, we have a situation where the government isn’t wanted and does little to arouse any democratic feelings among the people it claims to represent. Thus, the parliament has created a pseudo-purpose for itself, but purpose alone does not confer legitimacy. And without legitimacy the parliament can never hope to provide leadership in a time of crisis.

In light of the need for legitimacy the single market did require a democratic mandate, but this regime would always feel remote, unfamiliar and untrustworthy, while it did not fulfil the true intended role of a government – giving a voice to the people. Furthermore, it could never hope to become this voice in an area as diverse as Europe in the time scale it attempted to. Democracy and national identity took hundreds of years to develop among humans but the fathers of the EU thought that because they could understand each other, then there was little reason why shop workers in Burnley and fishermen in the south of Spain couldn’t be friends too.  

And so we come to today. The EU parliament cannot hope to provide the leadership the people ask of it, but because of the way people now perceive Europe, they expect that the national leaders of Europe can speak for both them and the whole EU together. The EU is often criticised in the UK for being a usurper of national power and undercutting UK legislation. In fact the EU does the same to European leaders. It undercuts national power by seemingly providing a platform for cooperation which is toothless, while at the same time what power it does have is meaningless compared to the pressures placed on national leaders by their own electorates.