Politicians Seem Clueless About Social Care

It seems evident that politicians do not know what to do about social care. The predominant method over the last few years appears to be simply to avoid doing anything substantial by having endless consultations and a constant tinkering around the edges (e.g. we are on the third regulator since 2003). It is not a political party specific phenomenon as all three main parties seem to be struck by the same malaise.

But why? Political parties are, generally, very sure of the best ways to do things (whether the public agree with them or not) and will forcefully set out their agenda to improve aspects of public policy for the greater good. Education, Welfare & Health, for example, have all been dealt with by the current Government and dealt with early in the terms of previous administrations yet social care has, and continues to be, something that eludes substantive action.

One of the reasons for this is, simplistically, the time factor. At the inception of the ‘welfare state’ post World War Two social care was a small consideration to those in power. After all in 1950 life expectancy was around 68, therefore those who drew from the state pension scheme aged 65 were only expected to draw on the state for three years or so. Similarly the impact of older people on the National Health Service was much more limited. In addition those with physical and learning disabilities were not expected to have much impact on the state because of their poor life expectancy.

So, in essence, social policy has largely focused on the under 65 population and political parties have, and continue to, have that as their primary focus.

Unfortunately for them the real world has crept up on them and now they seem at a loss how to respond.

Life expectancy today is around 79 years of age and rising. The life expectancy of people with disabilities has risen even more dramatically and we now have a greater need to support and care for people with age related illnesses, diseases such as dementia and provide suitable care and support for people with disabilities to meet their needs as they age.

In fact figures suggest that the UK has (or will soon have) more people over the age of 65 than under 16. Something that politicians have not quite grasped yet and something society has not yet come to terms with, as, it seems, we need to gear our society towards the needs of older people.

Society has changed and social policy needs to change with it but all politicians seem to be clueless in how to achieve this and afraid to make bold policy decisions. Now, obviously they are afraid that such boldness may cost them precious votes but until bold measures are taken, and social care bought to the fore of social policy the people who will suffer are the people who most need societies help.

Personalisation: Structure and Agency

A basic common debate within social sciences is the question of structure versus agency, how the social structures of society impact on us as individuals and how our individual choices and freedoms are constrained by those social structures.

These arguments need to be considered in relation to social care, particularly personalisation.

The Social Care Institute for Excellence give us the following definition for personalisation;

"Personalisation means thinking about care and support services in an entirely different way. It means starting with the person as an individual with strengths, preferences and aspirations, and putting them at the centre of the process of identifying their needs and making choices about how and when they are supported to live their lives. It requires a significant transformation of adult social care so that all systems, processes, staff and services are geared up to put people first"

This shows the intrinsic link between structure and agency within delivering personalisation. It could also be argued that it demonstrates why personalisation has been difficult to achieve and why personalisation will never be truly personal unless there is a major change in the way social care is structured.

The SCIE definition describes the individual as being at the centre of the process of identifying their needs and making choices about how and when they are supported to live their lives.

In other words, the person is at the centre of the structure! But, how much is their individual agency constrained by that structure.

Unfortunately that structure is one that limits those choices available for personalised care and support and it is a multi-layered structure, each layer filled with bureaucracy and each layer with, at times, competing agendas.

The big, over-arching layer of structure in social care is, of course, Westminster. Parliament set out the laws and regulations under which social care is practiced in England, it sets out how social care is funded and it sets the structure under which personalisation can operate. This is all administered by the Department of Health who, as is its name suggests, has a primary focus on health and while many aspects of social care may overlap with health there are many other areas, such as housing and welfare, that do not.

The next layer in the structure is the most diverse and, perhaps, Weberian in its nature and that is the delegated bureaucracy. The role of implementing and enforcing the dictates of Westminster is handed down to a myriad of Quango’s (e.g. CQC, NICE etc) who have their own structures for implementing the written law handed down to them and of course, 152 local authorities with responsibility for commissioning state funded care and again with their own structures and political leadership which may vary from that sitting in Westminster.

The next layer surrounding the individual is the providers of care services. This is not just care homes or home carers, it also includes Social Workers who provide a service on behalf of the local authorities, providers of advocacy services, services which provide employment opportunities etc.

Eventually we reach the person needing care and support services.

Whichever way you look at it, as a top down structure or a circle with the individual at the centre, the layers of structure hamper the ideals of personalisation.

Those who provide services can only do so in controlled circumstances, they must be appropriately registered or have an appropriate contract and the services must be provided within the budget available. For those who need to choose services the choice becomes limited by these structural constraints, even those who have personal budgets or direct payments have the budgetary implications to consider. Whatever an individual’s strengths, preferences and aspiration, services can only operate within the structure dictated by the layers that surround care provision and the rules and regulations imposed on them.

This is not to argue that such constraints should be removed but that the structure should be revisited if we are to improve social care services and increase the opportunities for greater personalisation.

We are trying to move from a top down structure to one that has the individual at the centre yet the actual structure remains the same and has the same constraints on agency. If we want to change the outcomes for individuals we need to take a real look at the structure within which social care operates.

Registering the Professional Social Care Workers

If you found yourself in need of social care services, perhaps in need of someone to help you with your incontinence or perhaps someone to help you through your day and support you in making sense of the world when your mind has been attacked by dementia, wouldn’t you want to be assured that person is a professional, qualified and registered with an appropriate authoritative body.

In the same way as nurses are registered, doctors are registered, and even, in the last few years, social workers are registered.

Registration means that those practising are more accountable, not just to the body they are working for but also to a national professional organisation who set out the standards and code of conduct as well as taking action against those who fail to meet these standards, with the option of preventing the worst offenders from being able to practice again.

One of the advantages of professional registration is that it gives the individual personal responsibility for their work, conduct and professional development. Personal responsibility is an important motivator to continued professional development as well as being an important factor overall job satisfaction.

There has been a trend, in public services, over the last twenty or so years to move away from this professional accountability by creating another layer of workers below the established professionals, Community Support Officers have been introduced into policing, Teaching assistants in schools have been given greater responsibilities for supervising classes, healthcare assistants have been introduced into the NHS and care managers (or social work assistants) into social services.

One of the key elements of this new level of workers is that they do not need to be registered with professional bodies.

Whether you agree with this trend or not there is an important difference between these unregistered workers and the unregistered workers in social care and that is they sit below the established layer of registered professionals who, in the eyes of the public, take an element of personal responsibility for the particular service provided.

As social care braces itself for another example of abuse in care from Panorama we need to look at the registration of social care workers again.

The idea of registration has been floated about for a decade now with the implementation being off and on so many times I have lost count but we need to seriously take steps toward achieving it.

Of course, being a registered professional does not eliminate bad practice, there a plenty of examples from the General Medical Council or Nursing and Midwifery Council to demonstrate that, but it does give the general public a sense that when things go wrong there is a layer of justice in the system that does not only blame ‘the system’ but tackles the individual. This also helps the professionals in question, the system of personal responsibility allows those who do good work to distance themselves, professionally, from those who fail.

There are many thousands of social care workers in the country who will, it seems, be tarnished by the actions of a few rouge individuals. Professional regulation would, to a certain degree, mitigate this a little. It would help to demonstrate that these heinous individuals are the exception rather than the rule and that, when they are discovered, they will be unable to practice again.

The logistics of professional registration for social care workers are a minefield, which is why it has been constantly delayed, but with more and more people needing some form of social care services surely it is more important than ever. It is also important that social care workers can be recognised as professionals who are providing personal services for the most vulnerable in society.

Let’s start recognising the professional work of the many to counteract the hideous acts of the few

Being Gay is Wicked: Language, Leadership & Social Care

"Being Gay is Wicked”

What does that phrase mean? Fifty or sixty years ago it would mean “being happy is sinful” today it would mean “being in a same sex relationship is a really good thing”.

What this illustrates is that the language we use can change meaning quite drastically is a relatively short period of time and while the example above is quite extreme in nature more subtle changes exist that impact on our understanding of everyday things and social care is not immune to this.

Take, for example, the discourse of institutions. The current social care system was created out of a  desire  to get people out of institutions, at that point institutes were the large, impersonal, usually Victorian, buildings that held people with learning disabilities or age related conditions that impacted capacity. These places were notorious for their lack of privacy, dignity and respect where people were treated as objects of pity rather than as individuals with their own personalities, preferences and rights. The people incarcerated in these institutions had no control over their lives, no chances to participate in how their lives were being run and little opportunity for any decision making.

It is no wonder then that the term ‘institution’ developed an extremely negative meaning.

The answer was, of course, to close these institutions and develop smaller care homes for the elderly and frail and those more severely disabled whilst promoting care in the community for the more able.

Yet, just a few decades on, the term ‘institution’ is used to describe those care homes which grew up out of the  desire  to rid the country of those old institutions!

Because of that, and the negative connotations of the word, care homes are seen by the public at large as bad places where the practices of old institutions still take place. Obviously there are bad care homes where institutional practices still take place but, in general, care homes have considerably improved the level of care from the dark days of the institutions.

The principle reasons for painting care homes as bad places is to promote the agenda of more community care and this is a perfectly normal way we operate in language. If we want to show that something is better we contrast it with something that is not as good but there are implications in doing this with social care.

For many there is no alternative to living in a care home. Those with advanced dementia, for example, may need the 24 hour care and support that their families (if they have one) are no longer able to provide. Some, with severe and profound learning disabilities, may benefit from the community setting of a care home rather than the potential isolation of living alone and for other elderly people a care home setting may free them from loneliness.

The negative image of care homes also impacts on the hundreds of thousands of care workers in the country, the majority of who deliver the best possible care they can. Being associated with the impersonal, autocratic staff of the old institutions is hardly a basis for improving moral in the sector!

This is where effective leadership across social care is so important.

To promote social care and to raise the standards those who lead must  present a positive image  of the sector. Being positive does not mean ignoring the deficits and problems of care homes nor does it mean painting a false picture.

Truth and honesty are important traits in leadership as they generate trust as does a recognition that things are not as good as they could be. But the important things is that those deficits are accompanied by visions and goals to show a way to correct those deficits in an achievable way.

Leadership is also about working with what you have got. So there has to be a recognition in social care that care homes are a part of the system, there also has to be a recognition that care homes have changed dramatically over the last few years. The average age of entering a care home has risen and, more often than not, care homes are the final stage of the care process when home care is no longer appropriate for the safety of the individual.

Leadership is about using language that is positive but honest and realising that using stereotypical labels may do more harm than good.

Why Prof Robert Winston Saddened Me

A few people may have noticed that I had an issue with Professor Robert Winston’s Party Political Broadcast on Wednesday night on behalf of the Labour Party.

As the restrictive limit of Twitter means it is difficult to fully express issues I thought I would take the opportunity to set out why I think the broadcast was misleading and why Professor Winston’s role was ingenuous.

The main thrust of the broadcast was the broken promises on the NHS by David Cameron and the Coalition, the ‘top-down’ reform imposed on the NHS by the Health and Social Care Act, the loss of nursing jobs and the cuts in NHS services in general. I have no disagreement with any of this and it is the normal cut and thrust of politics.

What I did disagree with was the implication that voting Labour in the forthcoming Local elections would help improve the NHS.

The fact is Local Councils have no executive power when it comes to the NHS, Councils cannot reverse cuts, Councils cannot employ more nurses in the NHS and Councils do not have the power to initiate any reforms of the NHS.

If you read the Health and Social Care Act (which I have) there is a significant increase in local council involvement in Health, particularly in terms of public health, integrated services (e.g. social care) and through Health & Well Being boards, but none of this gives local councils power over the NHS.

Now if Ed Milliband had been touting that voting Labour in May the NHS would be improved in the areas where Labour held the council I probably would not have batted an eyelid. I (and I expect many people) expect politicians to try and mislead me in order to  seduce me  to vote for them.

However when a well-respected, well-known figure of authority does this, it should be of major concern. I spoke to someone today who saw the broadcast and asked them what it meant, and they told me that if Labour won the council elections they would make changes to improve the NHS. When I pointed out that, actually, that would not happen I was told I was wrong because Robert Winston had said it.

It is somewhat ironic that the Party Political Broadcast that complained about the broken promises by one politician was actually implying promises that it could not keep!

Political spin will always exist but I am saddened when figures of authority indulge in it as it will, inevitably, diminish that authority.

Cut Out the Middle Man: Do we need Local Councils in Social Care?

So there isn’t a pot of gold for social care (http://www.bbc.co.uk/news/health-17740832)

So we need to find new ways of making certain that the money that is available goes directly to those who need care services.

I am not an economist and I do not have the figures to hand but it seems to me that  the best way forward  is to take a radical look at the social care system and make wholesale changes that increase the funds at the front line.

We all know the way the current system works, money from central government filtered through Local Authorities to front line care provision.

So how about cutting out the middle man?

There are 152 Councils with Social Services Responsibilities (CSSRs) and, therefore, 152 directors of Adult Social Services (or whichever name they currently go by!), similarly there are 152 different administration systems that have to be paid for and 152 systems of line management.

It is said that this system creates a postcode lottery it which where you live can be important in the level of care you receive.

What if we eliminate that?

Have just one Director of Adult Social Services (there is one already in situ at the Department of Health), have one administration and assessment system that provides the same level of care across England and a system that allows more money to be directed at front line services.

Such a system will, of course, still have localism at its heart. Obviously social work remains in local offices and local services will meet the needs of local people but does such a thing really need director level involvement local level and does localism need variation when it comes to who is entitled to what service?

This would not necessarily mean that Local Authorities have no impact on local social care services. The Health & Well-Being boards could exist as a monitor to services and are still important in providing an oversight to ensure integration between services.

I have admitted I don’t have the figures for what the savings actually would be but I think it is an exercise that needs to be undertaken. Money is tight and we need what money is available to provide support and care for the people who need it and if that means 152 Directors of Adult Social Services losing their jobs isn’t that worth it in the long run?

Social Care - What's that then?

What is social care?

To those of us who work in the sector that is probably an easy question to answer, although I suspect many of those answers will actually be slightly different, but what does it mean to the general public and the mainstream media?

It is perhaps the vaguest of all social policy areas after all most social policy is easily understood. Housing refers to where people live and the links between poor housing, welfare and deprivation are fairly easy to see to the average person (obviously to specialists things are much more complicated than that). Education means teaching our children to learn and, while there may be arguments on the best way to do this, when politicians talk about education the general public knows it is about schools, colleges and universities. Employment is about getting people to work and ensuring that the conditions of work protect employers and workers. Welfare is about the State supporting those in need, yes they is a debate about how you define that need but we all understand what is meant by welfare.

Health is also an easy issue to understand, it is about our physical and mental well-being. If we are ill we see a doctor, the type of doctor we see depends on what is wrong with us. We would expect our G.P. to refer us to the appropriate specialist in either physical or psychological issues and then expect to be treated by them, and that the system that the general public expect social policy to support. One of the reasons for the animosity toward the Health & Social Care Bill is the worry that changes may make this system different and more difficult to achieve the best possible results for our own health.

But what about social care? How easy is it for the average person to understand what social care means when politicians and professionals talk about it?

In 2006 the Department of Health described social care as “the wide range of services designed to support people to maintain their independence, enable them to play a fuller part in society, protect them in vulnerable situations and manage complex relationships” (DH (2006) Our health, our care, our say: a new direction for community services.)

Yet does that really mean anything to the average person?

Take, for example, services to support people to “enable them to play a fuller part in society”. The majority of people tend to think of social care as services for the elderly, something not helped by politicians who insist on focusing on how elderly care is paid for, and would find it hard to see what playing a fuller part in society would actually mean. After all for most people life does not involve “society”, it just revolves around work and home life (yes I know that is society but how many people think of it like that).

Social care does, naturally, support people to play a part in society, beyond supporting older people, support for people with disabilities involves trying to enable people to getting employment and if that is not possible ensuring that they receive their full entitlement of benefits (but, says the average person, isn’t that employment & welfare policy?)

Social is, or should be, about promoting and maintaining independence and enabling people to live where they want to live and ensure they are living in accommodation that is most appropriate to their needs. It is about ensuring that people have the adaptations and support in their home or, if their needs are greater that they can find accommodation in a home that will allow them to be as independent as possible whilst minimising potential risk (but, says the average person, isn’t that housing policy?)

Perhaps the mainstay of social care is providing personal support for people who are no longer able to support themselves. The reason for not being able to support themselves is generally down to physical or mental deterioration, age related conditions can be physically disabling and diseases, such as dementia, impact on the mind. The role of social care is to ensure that these people have support in maintaining their physical and mental well-being (but, says the average person, isn’t that health policy?)

There has been a lot of talk about integration in social care but the real fact is that social care is the integrating service.

Social care should be about bringing all other policy areas together for the benefit of those who need them. Social care should be seen as the umbrella under which all other policy areas sit because all of the areas could may need social care intervention. This is especially true if we include children’s as well as adult services in our overall definition, education, housing, welfare, employment and health all have an impact on the “social” and where they fail it is down to social care to step in to aid the individual, whether vulnerable child or adult, and support them to achieve the best possible outcome.

To raise awareness of social care we need to be able to define it in a way that the general population can understand and that definition should be one that shows the importance of social care as a policy area that embraces and sits above m

Are we too focused on service user involvement?

Are we too focused on service user involvement in care services?

I know that is a controversial question but make no apologies for it because I think it is a debate worth having because while we  focus  on that we may be missing some of the essential ingredients to  truly personalised  care and support provision.

The idea of service user involvement is a natural extension of the theory of Social Role Valorization (or normalisation or an ‘ordinary life’ which ever term you choose to use). The idea behind this is that all people with disabilities should have the same conditions in life as are offered to the general public and that they should have the same should have the same opportunities in housing, education, health and freedom of choice. It does not mean that we should try to make everyone ‘normal’ but it does mean the same conditions of life should allowed to occur.

So why could we be too focused on service user involvement? Let’s take two areas where it is touted as a good thing for users to be involved in, recruitment and supervision.

The aim is to create an ordinary life, the same as the general population but at what point do the general public get involved in the recruitment and supervision of people in the services that they use? When was the last time you were given the opportunity to sit in on the recruitment process of your bank, your G.P. or your local NHS Trust or, indeed, have the opportunity to sit in a supervision session at your local council, supermarket or energy supplier?

The fact of the matter is we are all service users in one way or another, the principle difference being the majority do not use care services but if people are to be given the opportunity of an ordinary life then, surely, care services (in this sense) should be treated the same as any other service.

This is where the true difference occurs and where social care fails in providing the opportunity for an ordinary life. What do the general population do if they are really unhappy with a service they receive? Simple, they change the suppliers if they are able to or, if not (as in NHS services), they will challenge the quality of the service.

What many service users lack is the opportunity of freedom of choice in the service they receive and it is the denial of freedom of choice that needs to be addressed.

How much choice to service users get in the social worker ‘allocated’ to them to assist them in sorting out their care package? An unfair question because we would not expect any other service to give us the choice yet if we were unhappy we would be able to move to a different provider, something not available to care service users or we would be able to make a specific request about the type of person we wanted to help us – how many service users are given that choice?

And what about the choice of actual care services? Is there a real choice or are service users again ‘allocated’ the approved local authority contractor? Given that we are talking about vulnerable adults, is there really an adequate mechanism for challenging the quality of the service and a choice of care provider available?

Service users should be involved in their care but rather than the somewhat tokenistic concept of involvement in recruitment, supervisions etc. the real involvement should be in the choice of services they receive in order that they can have the ordinary life opportunities available to the rest of us.

The Voice of the Vulnerable

The Guardian’s Social Care Network has recently asked the question “How do we give service users a voice?” yet the fact that the question needs to be asked does, perhaps, highlight what is wrong with the current social care system and why we need wholesale reform to achieve social care that meets the needs of those who need it.

The most obvious answer to the question is, simply, that we ask those who use the services and, more importantly listen to what they say. But, unfortunately we have such a fragmented and somewhat territorialised system that any messages have to pass, in the manner of Chinese Whispers, upwards towards those who make policy decisions via the agendas of the various parties involved.

If we start with the individual the person who will listen to them the most and who probably has the best rapport with them is the frontline care worker. There may be occasional contact with a social worker but my general experience this will only happen once or twice a year at reviews, obviously families will probably also be involved in listening to what the individual thinks about their care package.

The route for the care worker is obviously their own line management but that would require the care worker be given the time (and be paid for it!) to sit down with the manager to outline their discussions with the care user, how things could be done differently to meet their needs and how the care service an improve their overall care delivery.

From there the route upwards means the care provider talking to the local authority funding the care to pass on the individual’s views and what they want from their care package. Yet there are probably very few opportunities to do this except where reviews take place and there is almost certainly not enough time to discuss everything the user may have said over the intervening period and be more focused on the care plan in place. It is also at this point the Chinese Whispers can begin with the agenda of the provider being set.

For example a care user might have said they would prefer to have their care at a particular time and the care worker would have passed this on, but if the care provider was unable to facilitate this because of staffing levels etc then would they necessarily pass this on to the local authority, especially if they feared the contract could be passed to another company who could accommodate that.

Once the care provider has passed on the views of the care user to the social worker then it will get passed along the upward line of the local authority where, to be brutally frank, it is likely to get lost or transform from the voice of an individual into a statistic aimed at proving why the authority should get more money from central Government. Of course the message may have to go through the NHS route and that is equally convoluted.

So by the time that the voice of the care service user gets to the Department of Health it has changed beyond recognition ceasing to be a voice and just one of many numbers that are processed by the bureaucracy of Westminster.

How do we stop this? Well the simply way is to ensure that all user comments about their care service are written down. This may seem a little old fashioned but it achieves one thing – the original message retains its value, unadulterated, on the way to the top. Yes it would generate a lot of paperwork (or e-paperwork!) but at least in Westminster they would have access to the qualitative data in addition to just the quantitative stuff!

In reality the problem is a fundamental one, the distance between the person using a service and the policy makers deciding what is best for individuals is an immense chasm with a rickety bridge connecting the two. The change in social care needs to address this, it needs to ensure there is a smoother, undistorted route for the users of care service to move up the line towards those who make the policy and hold the cash.

Not easy by any means but worthwhile it we are to achieve the best social care for those who need it.

Hard or Soft! Actually we need both

I recently heard a debate about the “soft skills” and “hard skills” needed to lead and manage social care and the importance of focusing on each but perhaps the principal argument is the need to understand these labels, consider what is the most  desirable  and question whether they are somewhat misleading.

The ‘soft skills’ in question are the ones usually associated with leadership, particularly communication. The soft skills are usually associated with ‘Emotional Intelligence’ (I would certainly recommend to work of Daniel Goleman if you have not already  read  it) which focus on personality traits, the use of language etc. and in terms of leadership it is about the way in which the leader acts, interacts and inspires those around them.

The ‘hard skills’ focus on the tasks usually associated with management, the practical skills of how we achieve a task, the steps needed to achieve a goal or target and the day to day housekeeping associated with any work role.

In recent years the  focus  in social care has been on the hard skills, training in the core skills such as infection control, health & safety etc. and while there are excellent courses on such things as communication skills these have been less important to the regulatory framework and, therefore, of less importance to the care providers.

But in the real world what are really the harder skills?

For example, what is harder, working out the level of cover you need to provide the right level of care or persuading staff members to work the shifts needed to implement that level of cover?

Imagine  the care worker who has told support an individual in dealing with incontinence. The practical skills of assisting them to clean themselves and applying appropriate infection control procedures are surely a lot easier than the task of reassuring a person who may feel shame and embarrassment and developing an empathy with the individual told help them understand that such things are not their fault.

The above also illustrates that while I have talked about leadership and management skill sets these actually apply at all levels of care provision. Front line care workers need the ‘soft skills’ to be able to provide effective personalised care to individuals. The skills of empathy and effective communication are essential in discovering what really matters to the person and what they want from their care package and life in general.

I have blogged before on the need for both leadership and management skills (Thoughts on Leadership & Management) and the  importance  of both but there is also a need to recognise  that these skills apply across the spectrum of care delivery.

Commissioning, for example, needs to be more than the management process of ‘tick box’ contracts with care providers and commissioners need the soft skills to work with providers in an effective way that benefits the individual receiving care, equally providers need to work with commissioners in the way that most business sector would deal with customers (after all it is the commissioners who are paying your wages!).

Effective social care needs both the soft skills and hard skills in balance in order to provide effective social care to the ever growing numbers who need it and we need to ensure that the regulatory framework recognises that both sets of skills are equally important.  

Building Social Care

Social care is full of concepts and the problem with concepts is that there are difficult to get across to the wider population as it is difficult to grasp what something actually means, especially when those espousing the concepts of put different interpretations on what they mean.

Take for instance the Social Care Institute of  Excellence   definition: "Personalisation means thinking about public services and social care in a different way – starting with the person and their individual circumstances rather than the service" 

Compared with the Department of Health version: "every person who receives support, whether provided by statutory services or funded by themselves, will have choice and control over the shape of that support in all care settings" 

Broadly similar but the first takes personalisation as being outside the care service where the latter stresses that personalisation occurs within the care settings.

That is, of course, pure semantics but it serves to illustrate how talking about social care is open to interpretation both by the organisations delivering the message and those listening to it and why listeners may simply switch off if they cannot fully understand the message being delivered.

To add to the general woolliness of social care speak many of the more recent concepts, such as personalisation, are being inserted into a system established 20 odd years ago and may not always be totally compatible without significant change to the system.

To illustrate in more, literally, concrete terms.

Most people agree that personalisation needs to underpin social care (and other public services), it needs to be the foundation on which such services are built. Yet if you can imagine social care as being a house exactly how easy is it to change the foundations without tearing the house down and rebuilding it? But, I hear some people cry, surely personalisation could be used to underpin the subsiding house of social care that is sinking rapidly yet is this a wise move using personalisation to simply prop up a house that is no longer fit for the ever growing family that is needs to accommodate.

We can extend the metaphor to the forthcoming white paper. Will it be an instrument that simply attempts to paper of the cracks in the social care house? One that replaces the odd rotten beam rather than tackle the endemic rot in the system, maybe it will knock through a few walls to allow for more space to accommodate prevention or even add an extension out the back to allow room for the ever growing number of people who will need social care over the next few years.

Or will it be a white paper that recognises that the house is no longer fit for purpose and tear the whole thing down in order to build a bigger   higher   social care house with firm foundations on personalisation and one that has personalisation insulating all the walls. A new,   desirable,   house that has more than enough capacity for social care to grow, has wide corridors making it easier for those who live in it to move from one room to another and, perhaps, even adjoin the Health Services house with a single door through which people can move with ease.

To  engage   the public in the importance of social care and   build   public awareness we need to ensure that the language we use is accessible to all and that the message being sent is consistent, whether we undertake extensive repairs to the social care house or rebuild a shining new ‘des res’ the important thing is to get the planning permission through with the support of the general population and the millions who will need to live in the house in the future.