Posts Tagged ‘Public Services and the Welfare State’

The future and quality of mental health services: the organising challenge ahead

Despite being in decline, the quality of mental health services is largely absent from public debate. One of the reasons is the silencing of those delivering services, writes Elizabeth Cotton. She draws on data about conditions and wages to explain that there is a clear trend towards precarious work in the sector, and concludes by suggesting how to challenge the current system.

The Budget announcement that mental health will receive an additional £2 billion funding was met with a surprisingly unenthusiastic response from the main stakeholders. The total amount spent on mental health is unknown as funding systems have undergone large-scale reform and monitoring of the thousands of private contracts issued to providers go largely unmonitored. We know that attempts to ring-fence mental health funding have failed, particularly in relation to Child and Adolescent Mental Health Services, and it is estimated that ‘additional’ NHS funding has only contributed to a 1.4% budget increase in mental health funding.

The other reason for this lack of enthusiasm relates to what that funding is likely to be spent on. Despite the cultural shift in thinking about mental health issues in the UK, and all the recent debates about the same, we are still failing to protect both the services or the people who deliver them. One central reason for current problems is the overwhelming focus of the service on Increased Access to Psychological Therapies (IAPT), the NHS’s largest mental health programme. IAPT has been offered as a silver bullet to the mental health crisis, yet has also been a central driver of an unfolding workforce and political crisis, one that remains largely hidden from public view. For many people working in and accessing these services, IAPT is considered a threat rather than an expansion of decent care.

IAPT provides short-term, results-oriented cognitive and behavioural therapy, and has been introduced as a ‘talking therapy’ that efficiently addresses individual psychological states. Because of the relative low cost of IAPT services, in comparison to the long-term talking therapies and specialist services that require experienced clinicians, the economic argument for rolling out IAPT has prevailed across UK mental health policy. As a result, despite the genuine concerns about the ethics and quality of care being provided that have been expressed, this downgraded model of ‘talking therapy’ now dominates across the UK’s mental health service. The ‘evidence base’ for its effectiveness has been established through the widespread use of performance data, drawn from a system that has itself become highly contested – in terms both of the relevance of what it measures (such as waiting times) and of the accuracy of its claims (such as a 50% recovery rate).

IAPT is also a central part of the political crisis that is emerging for mental health services as a result of its positioning as a key component within the government’s plans for changes to welfare benefits. There has been a merging of mental health services with the DWP’s programme of welfare reform, such that people who are ‘cured’ are then disqualified from benefits. Although mental health providers such as Mind campaign against Universal Credit and have recently responded aggressively to Esther McVey’s claims that they support welfare reform, it is true to say that IAPT is the largest source of contracts and jobs in the sector and as a result the two are profoundly linked.

One of the reasons that the recent decline in mental health services is so absent from public debate is the silence of the people delivering services, in part motivated by the growth in precarity of jobs in the sector and the fear of victimisation for raising concerns. The insecurity of mental health workers lies in the invisible but strategic downgrading of jobs and working conditions. In response to a lack of data about conditions and wages within mental health services, during 2016-17 I carried out the Surviving Work Survey. Our results indicated that although it is true to say that working life in mental health is diverse, there is a clear trend towards precarious work right across the UK.

A growing majority of people were working in multiple settings using different modalities, increasingly providing generic rather than specialist care. Although 74% of respondents said they worked for the NHS, many reported that they worked on short-term contracts, and many were working for multiple employers, as direct employees of third-sector or private providers, or as self-employed representing 30% of workers. A striking 21% of workers are involved in unwaged work, 15% as part of their training and professional registration. Most reported a strategic downgrading of clinical roles, lack of promotion, and the impact of rigid performance management systems, combining to put workers in ethically and financially precarious positions.

Respondents also raised clear concerns about the quality of IAPT services. The principal concern was the decline in number of sessions offered to patients, and the rigidity of the model of cognitive behavioural therapy that is offered. Additionally, respondents reported high case-loads which ranged between five and eight patients per day. As a result of these concerns, there was a significantly higher propensity for IAPT workers to raise concerns about working conditions (55% as compared to a sample average of 36%) and patient care (58% as compared to a sample average of 38%).

Given the almost universal criticism of the direction of mental health services on the part of clinicians and service users, the question has to be asked: who benefits from the uncritical continuation and expansion of the IAPT model? Despite a number of recent mental health inquiries and workforce reviews, there has yet to be any genuine engagement with the emerging crisis in the sector. It may be that one explanation as to why the expansion of IAPT services has not been subject to public inquiry is the vested and financial interests of the individuals and organisations involved in all the reviews.

In the context of downgraded mental health services, the fact that workers are unorganised and silenced is a matter for both professional and personal ethical concern. One way to change the current system is to campaign for an inclusive inquiry into the IAPT model and the nature of the ‘evidence base’ for mental health services – not to be led by the organisations and bodies with a vested interest in delivering services. Another is to explore the potential for developing a new negotiating platform to address workforce issues in the service, including wages, working conditions, and standards of care. The proposal is to establish a body that is not populated by employers’ organisations or private providers, but by the professional, trade union, service-user and political networks that have an interest in mobilising mental health workers to defend services.

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The above draws on the author’s article available here. and the workforce survey results discussed are available here.

About the Author

Elizabeth Cotton is Senior Lecturer at Middlesex University.

 

 

 

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science. Featured image credit: Pixabay (Public Domain).

 

 

To meaningfully support carers, we must rethink their purpose and contribution

What does supporting carers mean in practice, and how can the government fulfil this mandate? Building on recent research commissioned by NHS England, Melanie Henwood, Mary Larkin, and Alisoun Milne explain that the narrative around carer support needs to be reframed.

Much of the prevailing discourse around ’supporting carers’ is presented in terms of enabling people to keep caring and prevent ‘additional demands’ being placed on health and social care services. But for carers and those they support this may not be the most helpful approach. Indeed, the narrative may need to be reframed to address what people really want from services and what ‘support’ means to them. Recent work commissioned by NHS England as part of their ‘Commitment to Carers’ programme, sheds light on support for older carers, and carers of people with dementia. The findings from this work have implications for carer support more widely, and for challenging the models labelled as such.

Supporting carers – the story so far

A commitment to supporting carers has rightly been part of the care and health policy context for some time. However, this is often addressed at a level of considerable abstraction. Operationalising support to carers and defining how this might translate into strategies or interventions is more complex; it also requires resources. If supporting carers is to be effective, we need to apply some critical scrutiny to the debate.

The importance of supporting carers has been recognised explicitly in policy since the first National Carers Strategy was introduced in 1999 (and in legislation since the Carers Recognition and Services Act of 1995). The 2014 Care Act was intended to create parity of esteem between carers and those they support, strengthening carers’ rights to an assessment and introducing a new duty on local authorities to meet carers’ eligible needs. The duties of the NHS are less explicit, but both the NHS Five Year Forward View and the Next Steps iteration underlined the importance of a new relationship with patients and communities. Thus, the Forward View referred to the need “to find new ways to support carers”, particularly the most vulnerable, while the Next Steps document highlighted the need to identify and support carers, particularly to reduce carer breakdown and improve health-related quality of life for carers.

These are objectives that attract broad support, but moving from aspiration to delivery is a different matter. Finding new ways of supporting carers is not just about innovation for its own sake, but rather about looking at the way the caring relationship is understood and developing a model that addresses both carers and those they support.

The evidence base is relatively thin; two meta-reviews in recent years have concluded that the best evidence is around interventions that enhance carers’ knowledge and skills. Most models of support have not been evaluated, but the findings on ‘what makes a difference’ to carers points to the value of having contacts with people outside their usual networks. Others have found that the recurrent feature of a variety of interventions judged to be of value by carers is how they contribute to strengthening carer resilience (including extending social assets; maintaining physical health; quality of life; availability of external resources, and strengthening psychological resources).

What actually matters to carers

When looking at models of support valued by carers we found that what matters most is often not the nature of an intervention or support, but the style of that service and the way in which it is delivered. In other words the process of service delivery. Getting appropriate and timely information were recurrent themes, and for some carers there were easier pathways than for others. When caring develops slowly and over a period of time, the information response is often less developed than for someone who is thrust into caring following a crisis event (such as a stroke, for example). Lack of information can also be due to the response of healthcare professionals following a diagnosis of dementia and an underlying belief that ‘nothing can be done’. Supporting people to have a life beyond diagnosis, particularly for those with younger onset who might have many years ahead of them of living with the condition, is critical.

Many older carers are caring for people with dementia, but not all carers of people with dementia are elderly. The NHS England project uncovered the substantial impact on entire families associated with early onset dementia, particularly where there may still be dependent children in the household, or additional caring responsibilities such as for an elderly parent, and where the person diagnosed and their carer are still of working age with all the accompanying financial commitments.

Ensuring that local support services are appropriate requires commissioners to challenge many assumptions about ‘carer support’. Establishing carer support groups, for example, may not be what carers actually want if it means they have to make alternative arrangements for the care of a person while they are at the group. The research found enthusiasm for groups that were open to both carers and those they support, but with opportunities for the group to split for some or all of the session, giving people the chance for social contact and peer support.

What constitutes ‘respite’ is also an area that requires some critical rethinking. If respite is essentially about a break from the usual routine for both carers and those they care for, there is enormous scope for developing imaginative and meaningful activity and engagement, but this is rarely in evidence. Some of the more innovative approaches we identified had developed around age-appropriate models of support for younger people with dementia who would not generally be interested in accessing standard day-care opportunities. The activity and social interaction which participation facilitated would be likely to be valued by many other carers desperate for a change of place and company.

A challenge for all providers, but particularly those in the third sector, concerns the impact that austerity has had on public services and on funding for commissioned services. Many of those we interviewed highlighted the difficulties of not knowing if people would have a contract in the next financial year or if the service would continue. With the NHS typically commissioning services on an annual basis, the lack of security for staff is a recurrent problem. Commissioning over a longer timeframe is required if people are to have some security of funding and the space and scope to expand and develop their model.

Needing to demonstrate outcomes and value is problematic both for commissioners and providers. While it is relatively rare for services to articulate a clear theory of change and to follow this through with demonstrable outcomes, the level of monitoring and reporting required by commissioners is often a hindrance. Counting activity rarely reveals much about the nature of a service or its outcomes, and both commissioners and providers need to develop more sophisticated and relevant measures of evidencing effectiveness in both quantitative and qualitative dimensions.

As we await the green paper on social care, and its promised attention to carers as an integral part of future plans, the messages from this research are highly relevant. The value of supporting carers is not just about ensuring the NHS can function properly and avoid delayed discharges because carers are unable to pick up the pieces. A proper strategy for carers needs to address carer resilience for the benefits this will bring to carers’ quality of life and wellbeing, and to those they support. It is not just the language of ‘carer support’ that needs to be reframed, but the understanding of the purpose and contribution of support to dynamic and fragile caring relationships.

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About the Authors

Melanie Henwood is an independent health and social care research consultant.

 

 

 

Mary Larkin is Senior Lecturer in Health and Social Care at the Open University.

 

 

 

Alisoun Milne is Professor in Social Gerontology and Social Work at the University of Kent.

 

 

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science. Featured image credit: Pixabay (Public Domain).

 

Despite the government’s U-turn on work allowances, Universal Credit still has major problems

While the 2018 Budget proposals mitigate some of the risks of Universal Credit implementation and may help certain groups eligible for work allowances, they overall do little to offset the erosion in household incomes caused by welfare reforms, explains Dan Finn.

Universal Credit (UC) aims to simplify and modernise the income and employment support system for millions of households. The system’s implementation has, however, been punctuated by controversy over missed deadlines, botched IT development, and poor project management. It has also been directly associated with increased debt, rent arrears, hardship, sanctions, and food bank use. Despite the significant problems that remain the National Audit Office recently concluded there is no practical alternative but to continue with UC implementation.

Ministers claim that the difficulties are exaggerated, and in the 2018 Budget the Chancellor announced that UC was ‘here to stay’ and will help ‘drive’ future ‘growth and employment’. He sought to deflect mounting criticism by injecting extra resources into ‘work allowances’ and measures to support the transition of some 2.8 million working age existing claimants onto UC. Concerns about this ‘managed migration’ process had already caused the Department for Work and Pensions to announce a delay in its migration timetable. This process will now be tested on 10,000 claimants in 2019 with fuller migration to start later in 2020.

Work allowances and the 2018 Budget

Work allowances are integral to the work incentive effect of UC. They are a set amount that a claimant in receipt of UC can earn from employment after which their benefit entitlement is reduced at a rate of 63%. The Budget increased the work allowance by £1,000 but only for claimants with a disability or who have children. The Office for Budget Responsibility estimates that it reverses only half the savings associated with the cuts made in the 2015 Budget. These cuts abolished the work allowance – then worth over £1,300 – for non-disabled and childless claimants, and cut it back severely for other groups. At the time it was estimated that just over three million families would lose an average of about £1,000 per year, saving £3.4 billion in 2020-21. By contrast the £1,000 increase will help some 2.4 million families keep an extra £630 of income each year at a cost to the Treasury of £0.5 billion in 2019-20, rising to just under £1.7 billion in 2023-24.

The government’s original vision for UC emphasised the increased generosity of work allowances and the lower withdrawal rate compared to the equivalent income thresholds in ‘legacy’ benefits. This was true for out-of-work benefits, such as Jobseekers Allowance. It remains a false claim, however, when compared with working tax credits that have an income threshold of £6,420, followed by a 41% withdrawal rate (the threshold for those claiming only Child Tax Credit is significantly higher). The number of working families receiving tax credits has fallen from 4.85 million in 2010-11 to 2.86 million in 2016-17.  UC further contracts the poverty-reducing in-work income support system that existed in 2010.

UC payments, Jobcentre support, and the extension of benefit conditionality to around a million low paid workers are expected to encourage more claimants to take up employment and increase their earnings. There is a risk, however, that rather than support ‘progression’, UC will encourage the growth of ‘mini jobs’ and further underpin the dramatic growth in part-time and low paid employment and also fuel in-work poverty.

The unaddressed problems

The other measures in the 2018 Budget add to a patchwork of changes introduced to offset some unanticipated, albeit predicted by critics, effects of paying UC monthly in arrears, that will also ease the forthcoming passage of the ‘managed migration’ regulations that Parliament must approve. Until 2016 most UC claimants were unemployed, often single or childless, and claimed only for a short period. This caseload profile is changing and after ‘managed migration’ UC claimants are more likely to be families in low paid work, the self-employed, and long-term claimants with disabilities or work-limiting health conditions.

Currently, UC applies only to people making a new claim for benefit, or existing claimant households who through ‘natural migration’ must make a new claim because of a change in circumstances. The ‘full’ digital service through which UC is delivered will cover all Jobcentre areas at the end of 2018, after which no new claims will be accepted for ‘legacy’ benefits. The promise of transitional protection has muted criticism of reduced entitlements under UC. This guarantees that claimant households transferred to UC through managed migration will suffer no immediate reduction in income should their entitlement be lower. This protected payment lasts until it is extinguished by a change in circumstances or subsequent increases in benefit rates.

Draft regulations on ‘managed migration’, published in June 2018, raised concerns about the DWP requirement that all existing claimants must make a new claim for UC. The regulations propose a campaign of ‘warm up’ messages advising claimants to prepare for change, for example, by ensuring they have evidence of identification and proof of their right to residence (creating potential for another Windrush scandal). This will be followed by a formal one month notice period for claimants that their current benefit claim will be terminated and that they must make a new online claim for UC and agree a claimant commitment. If someone fails to make a claim on time they risk not only an immediate loss of income but when they do apply they may lose their transitional protection.

Safeguards are proposed for ‘vulnerable and complex’ cases, but concerns have been raised about the likelihood that large numbers of ‘migrated’ claimants will miss their deadline and lose transitional protection. The Work and Pensions Committee has highlighted the problems of a significant minority of claimants when navigating the application process. The Committee recommend that migration should proceed only when the Universal Support system has a much improved provision to assist this group of claimants in developing their online, budgeting, and debt management skills.

The transition to UC risks pushing ‘migrated households’ into debt. New UC claimants must cover their living expenses and much of their rent for up to five weeks before receiving their first payment (if the claim goes smoothly). Claimants can apply for earlier assistance but ‘advance payments’ are a loan which is recovered, along with any other benefit debts, from subsequent UC payments.

Some of the problems experienced by UC claimants were ameliorated in the 2017 Budget. It reduced the initial UC waiting period from six to five weeks, made access to advance payments easier, and rolled on rent support for two weeks for new UC claimants already receiving Housing Benefit. The measures in Budget 2018, which will cost ‘£1 billion over 5 years’, provide further mitigations. They extend two weeks rent support to those migrating from legacy benefits from July 2020. From October 2019, the government will reduce the maximum rate at which debt deductions can be made from a UC award, from 40% to 30% of the standard individual allowance, and will increase the period over which advances will be recovered, from 12 to 16 months. Other mitigations include extending to two years the grace period for self-employed people and ensuring that people receiving Severe Disability Premium have transitional protection.

Anyone who thought that the Budget might end austerity for benefit claimants has been disappointed. It mitigates some of the risks of UC implementation and the increased work allowances will help those eligible and employed enough hours to use them. Most UC claimants are not working, however, and the Budget has done little to offset the erosion in their household incomes caused by welfare reforms and the four-year freeze in benefit rates which continues in 2019-2020.

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About the Author

Dan Finn is Emeritus Professor of Social Inclusion at the University of Portsmouth.

 

 

 

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science. Featured image credit: Pixabay (Public Domain).

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