By Alex Fox OBE, CEO of Shared Lives Plus and Vice Chair of Think Local, Act Personal.

The people with learning disabilities who work at the human rights organisation CHANGE pointed out to me once that people who have a learning disability are the only group of oppressed people who are routinely excluded from what should be their own civil rights movement.

 

I am keeping this in mind while thinking about what I and Shared Lives Pluscan contribute to Social Care Futures, which will run in parallel to the annual National Children and Adult Services Conference in Manchester this year.

Fully coproduced events start with a blank sheet of paper. That’s the best way to produce something like a neighbourhood plan, where the resources to be used are largely those that the participants bring themselves. It can be problematic, though, for making plans to change services and systems, because there can be a disconnect between what emerges on the blank sheet of paper, and what is already written in seemingly indelible ink on the spreadsheets produced by those systems. Conversely, if you start with the services and try to rethink them, it’s hard to get further than a few tweaks, because those pre-existing conditions seem so restrictive.

The Total Transformation model published by SCIE, PPL, Nesta and Shared Lives Plus includes an approach to local change which attempts to find a middle way between pure coproduction and narrow service redesign. The tool identifies five areas in which support and health services impact upon people’s lives and for each, identifies at least one innovative model which can demonstrate good outcomes and lower costs. The five areas of work are:

  • Support in your own home
  • Support with accommodation
  • Day activities and employment related-support
  • Support with leaving hospital
  • Whole-community work

The model suggests having a conversation with citizens about each of the five, which starts with ‘What does a good life look like for people using support of this kind?’, which is honest about the state money currently being used and what those budgets are expected to be in coming years, and which looks at what people like and don’t like about current local approaches, as well drawing no the models with a national evidence base. To be useful, any conversation of this kind needs to arrive at decisions about what share of resources (state money, other kinds of funding, people’s time and energy, community resources) will be put into which kinds of model. This will usually include agreement about reducing time and money spend on some things, to increase it in others.

Think Local, Act Personal’s ‘Asset Based Area’ approach broadens things even further: looking well beyond social care or even services in general, to suggest ten changes that local areas would need to pursue to become ‘asset-focused’ in everything they do.

We need, I think, to have those kinds of conversations at national level too. Could those areas which have started to use the Total Transformation or Asset-Based Area approaches, or other change approaches which have similar goals, share their experiences and their decisions at Social Care Futures? Could we identify the features of future support services and systems which we want and don’t want?

In my new book, A new health and care system: escaping the invisible asylum, I argue that we spend so much time tinkering with the big organisations we already have, that we ignore what I see as the most pressing question about the services they provide: what kind of relationship should people who access support and people who offer support have with each other? At present, I think it’s the wrong relationship: starting with proving one party’s needs and dependency, whilst often assuming the other party can do more than any paid professional really can. Not really a relationship at all: a series of brief transactions between a stream of strangers. That can be ok if you have a very specific problem which is quickly and easily fixed, but most people approaching services don’t: they are trying to live well with one or often more long term support needs. They are looking for mutually-respectful and trusting supportive relationships with a small group of people who are in it for the long haul. They want those support relationships to fit with the long-term relationships they already have with family and friends. Models like Shared Lives and Homeshare, which we support and develop at Shared Lives Plus, work in that way by enabling people to choose and build long-term relationships as part of building family and community life. Other models share that approach and I believe that nearly all parts of the health and social care system could try to work in that way.

So perhaps Social Care Futures could help us identify not just ‘good’ models to grow (and perhaps some failing models we would like to see less of), but also the behaviours and relationships we expect of every kind of support service. In turn, we would have to identify what we (citizens, families, communities and community organisations) are willing to invest in making that social care future a reality.

@alexsharedlives

By Rich Watts

Much debate in public policy focuses on the “why” and the “what”. Why is this issue important? Why should it be prioritised over something else? What should be in place that isn’t? What needs to change for this to happen?

Comparatively little focus is placed on “how” – the practicalities of putting the why and what into action. The “how” follows once the “why” and the “what” have been largely agreed, and is important because it’s in this space that all of people’s experiences are generated. It’s also where good ideas can turn into bad delivery.

But below the “how” is a question even less attention is given to: “who?” Rarely is it considered: who is asking for this change? Who is the change being asked of? What are the motivations of these respective groups?

It is too easy to lament how poor commissioning and commissioners are; or how it would be so much better if only senior leaders recognised the radical difference that x or y would make. But this is to fall into the trap of “what’s the matter with these people?” rather than thinking, familiarly enough, “what matters to these people?”

This thought came home to me when, for around three years, I was simultaneously on both “sides” of a policy argument. For around half of my time I was working in a disabled people’s user-led organisation (DPULO), advocating for disabled people’s equality and rights, delivering user-led services and promoting choice and control through personalisation in social care. The other half of my time was in, of all places, the Office for Disability issues within the Department for Work and Pensions (DWP_.

What was fascinating about this was, even though I would say exactly the same things when wearing my DPULO or DWP hat, people would receive a message considerably differently depending on how they perceived me in that moment. Disability rights campaigners would broadly be ok with my thoughts when shared from a DPULO perspective. But the exact same thoughts wouldn’t be acceptable if I expressed them from a DWP platform.

In neither situation was the idea that disabled people’s equality and rights mattered to me. Nor was it recognised I was consciously choosing different means to others by which to achieve what was, in fact, a common goal.

This leads to two connected conclusions relevant for #socialcarefuture.

The first is to understand that what matters to people, matters. Motivations for engaging in an issue will differ. There will be a junior minister who wants to be promoted; there will be lifelong advocates who have dedicated themselves for 25 years to a certain change; there will be civil servants who want a pragmatic solution to a pressing problem they are facing. But all of these different motivations are as present as each other, and can be skilfully aligned to achieve a common change that works for all.

The second is to recognise that such a broad coalition of people with different motivations will be located across a wide range of organisations. Indeed, the coalition has to be widely distributed if it has any chance of succeeding: each participant will have access to something others don’t, and that is needed for the overall change. As a result, some coalition members will be “inside” the system. Some will be outside (possibly literally, chained to railings or waving placards). Some will be in the grey area that is neither inside nor outside (the voluntary sector is most often found in this space). Some may not even know they’re in the coalition.

What leads to change is consciously acknowledging and valuing the existence of such a broad coalition across motivations and organisations. Each participant – each “who”, with their all too human motivations and positions – makes a needed contribution, and it is only through this coalition that successful change will come about.

(For those interested in the public policy theory that underpins such coalitions, this primer on Advocacy Coalition Frameworks https://paulcairney.wordpress.com/2013/10/30/policy-concepts-in-1000-words-the-advocacy-coalition-framework/ is excellent.)

@rich_w

By William Case, EO of Your Support Matters and associate of In Control

In the last 12 months there has been a lot of talk about transforming social care and working more closely with health care. Social care is still on the cliff edge, with local authorities trying to meet the needs of their residents who require social care support. Each year, council tax is increased to help meet the growing need for social care.

If we look back to the general election, the government didn’t once mention young people or those below retirement age receiving social care support. It was focused on the very old and the debate of being forced to sell their homes in order to pay for support costs in later life. In the UK there is a great number of people who are not receiving adult social care support and who are being isolated from their communities, limiting the possibilities to create connections with new friends and neighbours. We should also recognise that those people who do have good quality support are still somewhat isolated from their communities. Through no fault of their own, and due to local authorities’ shoe-string resources, they cannot fully meet the support needs of all individuals.

As we build the social care of the future, national government must recognise the full value of individuals being truly in control of their own support. I also urge the government to fully recognise the role of a personal assistant in health and social care. It isn’t just a stop gap job, but to be recognised as a career, and the salary should reflect as much. Creeping above minimum wage does not do the career justice and undervalues the quality of life a good PA can support someone to have. The salary should include pay rises for recognition of good work and length of service, increased pay on bank holidays, and not be determined by which local authority the funding comes from. The level of support needs and training might also be considered.

We must be more creative with how we support individuals to access a personal budget. The time has come to be more creative with limited recourses if we are to make the future of social care really work. We don’t want to be part of system; we just want our support to work for our lives.

Local authorities and national government must value not-for-profit organisations which support individuals to live an interdependent life, such as Your Support Matters.

My final thoughts: future social care must be creative and diverse so people like me, who require extra support to live a good quality of life, can continue to make a valuable contribution to society.

@willcase100

By Professor Bob Hudson, Centre for Health Services Studies, University of Kent, Canterbury

The outsourcing of public services to non-statutory providers, especially the private sector, has been the delivery model of choice in the UK for around thirty years. The budget devoted to such contracts is hard to estimate but is reckoned to be in excess of £100bn (Walker and Tizard, 2018), equivalent to about 8% of Gross Domestic Product. The model has also changed in nature over the years, moving beyond back-office functions and into front-line service delivery.

 

A number of high profile problems and outright failures, from Carillion to rail franchising, have brought the model into more prominent view, but much less interest has been paid to the longer-standing privatisation of adult social care (ASC). This is a large market worth in excess of £22bn and rising as the care needs of adults intensify and become more complex (King’s Fund/Nuffield Trust, 2016). This blog explores the reasons for this relative lack of interest in the issue of ownership and considers the issues involved in attempting to secure a different balance of provision that better fits the circumstances of those who need services and support.

Adult Social Care: An Intractable Privatisation?

The relative absence of policy interest in revisiting the ownership structure of ASC may be due to three related factors – market penetration, market fragmentation and market fragility. Together these make the prospect of some ‘big bang’ change in market structure seem unlikely and impractical.

Market Penetration: The longer the period over which outsourcing has taken place and the greater the penetration of the market, the more difficult it is likely to be to reverse the situation. This is the position with ASC where the process has been in train for over thirty years and the current structure is deeply embedded. In 1979, 64% of residential and nursing home beds were still provided by local authorities or the NHS; by 2012 it was 6%. In the case of domiciliary care, 95% was directly provided by local authorities as late as 1993; by 2012 it was just 11% (Centre for Health and the Public Interest, 2013).

Market Fragmentation: There is no compact ASC service that can be easily repatriated into public sector ownership. Rather the sector is characterised by a multiplicity of fragmented, competing providers. The care home sector supports around 410,000 residents across 11,300 homes from 5,500 different providers (Competition and Markets Authority, 2017). The situation in home care is even more diverse with almost 900,000 people receiving help from over 10,000 regulated providers. Nor is it any longer the case that the state is even the dominant commissioner of these services – tighter access to local-authority-funded care has resulted in a large growth of self-funding ‘customers’.

Market Fragility: The third complicating feature of the ASC market is its fragility and the politically toxic consequences of market failure. The first major casualty was Southern Cross in 2011 – a large national care home provider which had 9% of the market nationally, but a much greater share in certain regional areas. Much of the Southern Cross provision was eventually taken over by another major provider, Four Seasons, which is itself now at high risk of going under. Whether through financial collapse or strategic withdrawal, the market model is widely considered to be at tipping point.

This is an unenviable policy dilemma. Unlike some other services and utilities there is no simple way of shifting such a dominant and entrenched model of provision. Nor is there any reason to think that the ‘purchaser-provider split’ will be removed in the foreseeable future. Better and fairer funding is a prerequisite for improvement and has been exhaustively explored elsewhere (Barker Report, 2014), but in addition to this, the local state (as the biggest commissioner of services) and national government (as policy-maker) can also act in ways that could create better care quality and reshape the provider mix. The key to this is a different approach to the way support and services are commissioned.

Currently, commissioning is too often a hand-to-mouth process devoid of a wider purpose. Any sustainable alternative model has to go beyond the notion that the role of the state is to ‘fix’ or somehow forestall market failure (Hudson 2014); rather it is to act as a catalyst for innovation. One variant here is that promoted by Mazzucato (2012) with her proposal for ‘mission-oriented’ public investments where the task of the state is to determine the direction of change by ‘transforming landscapes and creating and shaping markets’. It is worth exploring what this might look like in the case of ASC. Four dimensions can be identified: commission local and small; commission holistically; commission individually; and commission ethically.

Commission Local and Small

The trend in the residential sector is for small operators to be replaced by large provider chains with more than fifty care homes. Recent building of new homes in a standard format with sixty or more en-suite beds has been dominated by chain operators, while many of the remaining smaller businesses are likely to exit the market in the next decade by selling homes which are valuable property. Industry estimates (Knight Frank, 2017) indicate that as care homes grow in size they become more profitable, with the highest margin for those with over a hundred beds. The paradox here is that while the market is moving towards large-scale provision, the evidence from the social care regulator is that smaller facilities tend to receive better ratings for quality of care (Care Quality Commission, 2017).

A focus on smaller and more local commissioning is needed to counteract this trend – a challenge for public sector commissioners who generally favour larger, less complicated organisations. This fits in with ideas around Asset-Based Community Development (King’s Fund, 2018; Coalition for Collaborative Care, 2018) – a focus on interdependence as people share skills and support – and on supporting communities to rebuild their own social infrastructure by harnessing community businesses (Power to Change, 2017).

Complementary to this level of ‘micro support’ is the concept of Local Wealth Building (DCLG/Cooperatives UK, 2017), a growing movement in Europe and the USA based on the principle that ‘places’ hold significant financial, physical and social assets of local institutions and people. The key is local ‘anchor’ institutions (public, social, academic, commercial) and their procurement role in supporting the local supply chain. This will include opening markets to local small and medium enterprises rather than looking to national and international chains. The experience of Preston, Lancashire, in the UK is seen as an exemplar (Chakrabortty, 2018). Through the Public Services (Social Value) Act, public authorities can also embed social value into the design of services and decision-making criteria rather than fixating on cost and efficiencies.

Commission Holistically

It no longer makes sense to think of social care commissioning in isolation; rather the focus is upon ‘holistic’ or ‘place-based’ commissioning. Most social care is commissioned separately from other place-based interventions. The most frequent concerns about potential intersections are those with the NHS, where accessing social care is felt to be adversely affecting transfers of care from hospital. However, market-shaping is a much broader strategic task spanning several council departments and other partners – social care, planning, transport, housing, economic development, health, education, criminal justice, community safety, training providers and more. Coordination on this scale would require significant investment in capacity, skills and structures – in effect the reinvention of robust municipal governance at several levels. Britain is the most centralised country in the Western world, and in this respect the reform of social care has to be considered as part of a much broader shift in the way decisions are made and resources are allocated.

Commission Personally

Policies on access to social care support have created two groups of ‘personal’ commissioners’ – those who fund their own care and those whose care is funded via an ‘individual budget’. Both are in need of greater support. A market requires consumers who seek and digest information to inform their choice of product. From this perspective the care home market in particular has some characteristics of an inefficient market (National Audit Office, 2011) – entry is often unplanned, made in response to a personal crisis and with very low rates of switching to a different provider in the event of dissatisfaction.

The obstacles facing those who fund their own support have been comprehensively identified by the Competition and Markets Authority (op cit) which notes: most individuals and families are poorly informed and have done little or no planning or research; they struggle with the notion of exercising choice and rarely move between providers; there are low levels of complaints, fears of retaliation in the event of a complaint; and lack of understanding of the formal procedure. In addition there is a litany of malpractices including: lack of information about prices; demands for substantial deposits and other upfront payments; a raft of hidden extra charges and surcharges; demands for top-up payments without local authority agreement; and fees charged after death.

It is not entirely clear how this situation can be easily transformed. The CMA report raises the prospect of enforcing consumer law, but others will take the view that it is simply not possible to replicate a market in the social care sector. However one option that can work for some people is that of personal budgets (House of Commons Public Accounts Committee, 2017) and more recently personal health budgets (Jones et al, 2017), though here too there are issues to be resolved around issues like making choices and decisions; receiving information and advice; understanding allowance and spend; budget management, monitoring and review; and risk management and contingency planning.

Commission Ethically

The imperative to commission ethically is implicit in all approaches. It could encompass the following dimensions.

Commission from ethical employers: Commissioners need to be able to distinguish between the workforce practices of different providers and prioritise those acting as ‘good employers’. This might have several components such as prioritising providers that comply with minimum standards around workforce terms and conditions, have effective training, staff development and supervision, comply with ethical care charters and encourage staff to participate in collective bargaining (Burns et al, 2016; Hendry 2014).

Commission from transparent providers: A ‘transparency test’ could stipulate that where a public body has a legal contract with a private provider, that contract must ensure full openness and transparency with no ‘commercial confidentiality’ outside of the procurement process. All providers of public services should – at a minimum – publish details of the funding they receive, performance against contractual obligations, the suppliers to whom they subcontract services, the value of these contracts and their performance, and user satisfaction levels (Gash et al, 2013).

Commission from tax compliant providers: The ownership of all companies providing public services under contract to the public sector, including those with offshore or trust ownership, should be available on the public record. At the same time, a taxation test could require private companies in receipt of public services contracts to demonstrate that they are domiciled in the UK and subject to UK taxation law (Corporate Watch, 2012).

Commission from not-for-profit providers: A fresh approach to adult social care offers the opportunity to rethink the role of other sectors. Whilst wholesale renationalisation seems unlikely there is every reason to encourage local authorities to begin to build up their own in-house provision and to support all organisations with a social purpose, whether in the public, private or voluntary sector. This could include encouragement for user-led organisations, social enterprises, mutuals and others to recruit and train service users in innovative ways.

Conclusion

The privatisation of ASC in the UK exhibits an unusual policy narrative compared with other sectors. Devoid of any real debate or stated purpose, a thirty year process of outsourcing – predominantly to private companies – has continued unabated and unchecked. The scale of penetration and the dismantling of alternative providers have resulted in a situation that fails to meet ordinary market standards around choice and control. And now, as a result of austerity politics, there is every chance that the private sector will lose interest and leave the market with dire immediate consequences for those in need of services and support. Whilst it is not feasible to simply eliminate a model that has become so deeply embedded, a combination of better funding and smarter commissioning could, over time, reshape ownership structures, increase provider stability, focus on ethics rather than cost, connect people more fully to their local communities and enhance the quality of care.

@Bob__Hudson

References

Barker Report (2014), A new settlement for health and social care: Final report

Burns, Diane., Hyde, Paula and Killett, Anne, (2016), ‘How financial cutbacks affect job quality and care of the elderly.’ Work and Employment Relations in Healthcare. Industrial Labour Relations Review

Care Quality Commission (2017), The State of the Adult Social Care Services, 2014-17

Centre for Health and the Public Interest (2013), The future of the NHS? Lessons from the market in social care in England, pp. 10-11

Chakrabortty, A (2017), https://www.theguardian.com/commentisfree/2018/jan/31/preston-hit-rock-bottom-took-back-control

Coalition for Collaborative Care (2018), Commissioning Community Development for Health.

Competition and Markets Authority (2017), Care Homes Market Study, Final Report

Corporate Watch (2012), An unhealthy business: major healthcare companies use tax havens to avoid millions in UK tax

DCLG/Cooperatives UK (2017), Community Economic Development: Lessons from two years’ action research

Gash, T, Panchamia, N, Sims, S and Hotson, L (2013), Making public service markets work, Institute for Government

Hendry, J (2014), Reconstruction after the crisis: a manifesto for collective bargaining, Institute of Employment Rights

House of Commons Public Accounts Committee (2017), Personal Budgets in Social Care: 2nd Report of Session 2017-17

Hudson, B (2014), Dealing with market failure: a new dilemma in UK health and social care policy, Critical Social Policy, 35(2) pp281-292

Jones, K et al (2017), Personal Health Budgets: Process and context following the national pilot programme (PSSRU, University of Kent)

King’s Fund/Nuffield Trust (2016), Social Care for Older People: Home Truths

King’s Fund (2018), Reimagining Community Services: Making the most of our assets

Knight Frank (2017), Care Homes Trading Performance Review, 2015-16

Mazzucato, M (2012), The entrepreneurial state: debunking private v public sector myths. London: Anthem

National Audit Office (2011), Oversight of User Choice and Provider Competition on Care Markets.

Power to Change (2017), http://www.powertochange.org.uk/what-is-community-business/

Walker D and Tizard, J (2018), Out of Control (London: Smith Institute)

By Alan Rosenbach

Social Care has always been and always will be political and so about money and power. To see how we might shape the future for social care we best understand the recent past. “The rise of the welfare state in the late 19thCentury was in response to the growing popularity of left-wing politics, especially among the working class. Conservatives and Liberals in the late 19th early 20thcenturies could see no greater threat to their political position than that posed by socialism[1]“. The socialist aims were for a much greater role by the state in tackling poverty, poor health and inequality between rich and poor. The response by the ruling elites was to cede ground on meeting health needs in the early 20th century through voluntary hospitals meeting acute care needs and a means tested pension for older people by 1908.

Then, as now, the majority of carers were family members looking after their older or disabled relatives. We should not romanticise this idea. High rates of death in children, families moving away, immigration and war meant many disabled and elderly people had no support.

Left-wing politics in the middle of the 20th Century shifted the debate from the deserving and undeserving poor to the setting up of the National Health Service, free at the point of use, and the National Assistance Act at the same time in 1948, which means tested social care. The concept of the state supporting you from cradle to grave was established. So successful has this system become that we are all living longer, which may or may not be a good outcome.

We have learnt along the way that support in or closer to people’s homes and in communities rather than in institutions leads to improved health and well-being. We have shifted from local government running services to the development of less than perfect public service markets for care and support. We shifted from:

  • Professionals deciding what is best to
  • Central government targets to
  • Voice of the consumer to
  • Choice of the person using service

being the driving factor in market design. Voice and choice are still somewhat limited and there is a gap between rhetoric and reality. We have the not-for-profit sector, the public sector, voluntary and private sector all contributing to care and support. There are debates about small being beautiful, particularly if it is not-for-profit, versus large being less than satisfactory, particularly where the for profit sector is the provider. These are features of imperfect public service markets.

So, what of the future for social care? It looks bleak not least because we would need to double run the funding of care and support from the ‘as is now’ to where ‘we want to be’. Unfortunately, ‘we’ don’t have a consensus about where we want to be and how we might get there. I have great faith in experts, but we don’t have a determined evidence base about what works best for older people’s support or for working age adults in terms of service configuration and interventions, or a requirement where we do have the evidence that these must be implemented. We also have a significant problem with workforce shortages.

Let’s scenario plan here in summing up. We are designing a sustainable system for care and support that would help us to shift from our current broken system to one that works for individuals and families. What do we need?

Funding a care and support system that is:

  • Funded by general taxation for working age adults;
  • Funds through general taxation dementia care;
  • Funds through general taxation end of life care;
  • Abolishes the role of local government as a conduit for funding;
  • Makes financial resources directly available to citizens through the benefits system;
  • Extended investment relief for companies developing new technologies including artificial intelligence capability to improve care and support;
  • Enhancing tax and housing benefits specifically for those choosing a career in care and support;
  • Defining and implementing integration between health and care where the evidence supports an initiative of this type.

We have regressed back to the idea of the deserving and undeserving poor and we have come to see the welfare state as a burden. We have allowed the poor to carry the burden of economic failure, privatised the profits and nationalised the failures in economic policy. The most recent analysis of satisfaction with social services makes for grim reading. Satisfaction was 23% in 2017. The change from the previous year was not statistically significant. At the same time, dissatisfaction with social care services increased by 6 percentage points in 2017 to 41%[2].

What might services look like that meet need?

There are today aspects of care and support that meet the needs of individuals, families and parts of communities. These are all predicated on managing the asymmetry of power. In these circumstances, the state and its institutions are prepared to cede power determinedly and purposefully back to the individual, the family and communities. Importantly they come in all shapes and sizes. This series of blogs have highlighted the work of Community Catalysts, Shared Lives Plus, Local Area Co-ordination and community well-being teams. I know from my experience of working with the voluntary and for-profit sector that these services too cede power away from the staff to individuals.

Social care must find a coherent and articulate political voice that spells out the inequities of the asymmetry of power between state its institutions and citizens; highlight the positive approaches of services ceding power back to communities. It must do so in such a way that it threatens the status quo and so drives the positive change.

@AlanRosenbach


[1] Richard J Evans, The pursuit of power; Europe 1815 -1914.

[2] Kings Fund: Public satisfaction with the NHS and social care in 2017 Results and trends from the British Social Attitudes survey.
https://www.kingsfund.org.uk/sites/default/files/2018-02/NUT_KF_BSA_2018_WEB.pdf

By Jenny Pitts

There are many reasons to be pessimistic about the future of adult social care and social work services at the moment; is it, as Chris Hatton says, fundamentally broken? Well documented statistics such as the difficulties in recruitment and retention of social work staff, the continual gaping hole of the funding gap etc. don’t need repeating here.  We know that doing nothing isn’t an option – something has to change and that change has to be quite radical and deep; we can no longer tinker around the edges while expecting real and sustaining change – waiting lists to reduce, person-centred and community-based solutions to flourish, people’s experience of services to improve, etc. Achieving these things and more is only possible if those leading change work very differently and are prepared to put everything on the table in terms of questioning what needs to change and, importantly, to let the people who know best about what will work drive those changes at a local level.

I talk to many social work teams across the country and all too often hear that they strive to put the person at the heart of practice but that they often feel constrained by the burden of the internal and cross-organisational bureaucracy. With pressure on teams as intense as we have known it, we are using up our greatest asset – the staff – to carry out laborious and often unnecessary process and form filling.  The answer doesn’t lie in a new IT care management system but in many areas the system is dictating practice and tying up hard pressed practitioners to spend significantly more time inputting a person’s notes on the system and processing the next steps than they spent talking with the person in question – this is not good for people they support and serves to damage the motivation of practitioners. Systems which have a ‘one size fits all’ approach mean there is no room for proportionality. An assessment has become defined as a document and a stage in the IT system that is needed to unlock other stages, not a rich process that seeks to really understand what’s going on in a person’s life.  Changing this is part of the solution but not a solution in itself.

A system that is process-heavy is fundamentally predicated on a culture of mistrust and this works against any desire to be creative and it fuels the urge to cover one’s back in the event of there being any legal challenge, let alone a challenge from panel.  Funding panels generally only add to the bureaucratic burden and serve to further damage morale within practitioner teams. Fragile resilience and confidence can be obliterated by the experience of “going to panel”. There are better ways to make decisions about allocating limited resources that don’t ride a coach and horses through the worker’s professional self-esteem and that ultimately better serve the interests of people they’re supporting.

The challenge is complex and if the solutions were easy we would be in a different place. There is no blueprint, no quick fix nor magic bullet but there is a great deal of commitment, knowledge, expertise and learning within social work teams and within the communities they serve. Harnessing this is the key. I would suggest that we already know what we need to do – it’s the doing it that’s the challenge. For decades practitioners have said that we need to reduce bureaucracy so that time is freed up from the ever increasing form filling and process, we need to be more preventative and find ways people can talk to someone before they’re in crisis, we need to reach out and collaborate with all the organisations and community groups who are working to achieve the same end – no organisation has all the resources needed but pooling resources at a community level and people coming together to agree how they can genuinely collaborate as equal partners around a shared vision is powerful.

We’re privileged in the NDTi to work with a host of people within services and across communities who are doing just this and there is a rich body of learning and experience from that preparedness to share. When change starts to happen locally the momentum develops a life of its own and more and more people want to get on board because they see that it works. So we know that it is possible to not have waiting lists, for people to see someone within a week, to have a good conversation that focuses on what matters to them, what they want to achieve and to identify solutions, for practitioners not to be overburdened by paperwork and process and for decision-making to sit at a local level. Morale increases, practitioners feel valued and trusted and empowered to use that thing that has been fragile and wafer thin for too long – their professional judgement. Confidence increases as teams support each other through peer support, reflective practice and shared decision-making. Moving towards a culture of trust and empowerment, within services and across organisations is, in my view, essential but this takes time and it takes bold leadership.

Is this a return to “good old-fashioned community social work”? Maybe. People talk fondly of days when they used to go out with a notepad and pen to conduct their assessment. Did it feel any more risky? Not at all. Did they feel they were using their skills? Yes. Practitioners talk about how they’ve lost sight of the reason they came into the profession – to make a difference in people’s lives, to use their skills in working with people in listening and understanding what matters. This passion and dedication hasn’t gone away but I would suggest that the more we overburden practitioners with process and bureaucracy and rely on IT care management systems that don’t allow them to use their judgement, we run the risk of losing that most precious resource.

Those areas implementing Community Led Support have found that many people benefit from having an appointment with a social care practitioner in a welcoming community venue where they can find out what’s going on locally, what support might be available. These ‘hubs’ often involve community groups and volunteers and can take place in libraries, town halls, community centres, voluntary run cafes, GP surgeries, church rooms and even fire stations, to name but a few. They offer a valuable experience for the person who is offered an appointment usually within two weeks, often days, and mean that with proportionate recording, the practitioner can be far more efficient and have time to follow up any actions.  Not everyone needs a home visit but if they do they are therefore able to experience that much more quickly than they would otherwise.

These hubs are one of the ways that services can be far more responsive but are not an end in themselves, they need to be underpinned by skill of the worker to have an effective and strengths based conversation, to have permission to record what matters and to be trusted and supported in that judgement, to have time to connect with the organisations in that community to understand what they offer and work together better. It requires the entire experience of the person to be smooth and joined up – this includes working with customer services teams who so often do a fantastic job in beginning that conversation and understanding what matters and the outcome the person requires.  The good conversation, the language that doesn’t confuse or mislead, needs to start as early as possible and be followed through, including that bit of customer service that social care is so poor at – finding out how useful the person found it, did it make a difference, how they can talk to someone again in the future if they need to. Only then we can really understand how effective services are.

There’s a lot of talk about asset-based social work at present but this shouldn’t be some new thing; this is what social work practice should be all about – but we need to allow it to flourish and enable creativity and flexibility and allow people who work in services to do what I believe they do best and what they came into the job to do.  If we address that people are more likely to stay and to invest in a career in an underrated but so vitally important a profession.

@JennyPittsNDTi

By Jenny Morris

I haven’t been able to blog for a while but recently two key questions have got me thinking…

 

The first was a challenge from Catherine Hale, who leads the Chronic Illness Inclusion Project, put to me and a few others: “The term Independent Living” she said, “does not seem to have resonance for people with chronic illness and has been corrupted by those implementing Care Act in the service of cutting costs”.

The second was a blogpost by Chris Hatton posted as part of the #socialcarefuture debate.  He asked: Is social care as we know it fundamentally bust?

Linking the two challenges has led me to ask: Is it time for us to admit defeat and abandon the term ‘independent living’ to describe our aspirations as disabled people?  If so, how can we articulate these aspirations in a way which addresses the current problems with social care?  And what would that mean for what we now call ‘social care’?

I don’t want to focus on the question of whether the term ‘independent living’ is particularly problematic for people with chronic illness, partly because it deserves consideration completely separate from the question of the current state of social care. However, the second reason Catherine gives for questioning its continuing relevance – the way the term has been corrupted by those implementing the Care Act – is relevant to all groups of disabled people and is directly related to Chris Hatton’s challenge.

So to start by addressing the challenge to the term ‘independent living’ (but emphasising this is just my attempt to open up debate rather than my firm conclusion):

1. Maybe we have to admit that talking about ‘independent living’ is not useful to us at this point because we have failed to achieve general acceptance for our insistence that it should mean ‘having choice and control over the support needed to go about daily life’.  Instead, many working in health and social care, and also the general public, still take these words to mean ‘doing things for yourself’.  Moreover, too often it seems the terms ‘independent living’ and ‘independence’ are used to deny the reality of someone’s support needs. The rationing of services goes along with an unequal power relationship between the person who needs support and those responsible for funding and delivering it, and can result in a denial of needed assistance in the guise of encouraging ‘independence’.

2. At the same time, we need to recognise that independent living was never just about social care.  Yes, its origins were in replacing institutional and institutionalising services with direct payments, which enabled people to employ their own support workers, but this didn’t deliver what we meant by independent living unless other barriers were addressed: the barriers to accessible, affordable housing, transport, to employment, to participating in family and community life and so on.  This wider vision is reflected in the last Labour Government’s Independent Living Strategy which defined independent living as:

Having choice and control over the assistance and/or equipment needed to go about your daily life; and

Having equal access to housing, transport and mobility, health, employment and education and training opportunities.

That Strategy envisaged:

a single community based support system which focuses on all aspects of what people [of all ages] need to maximise their health and wellbeing and to participate in family and community life. The right of the individual disabled person to determine the kinds of services and support that they need will be at the heart of this reformed system.

3. We need to return to the roots of what disabled people in the 1970s and 1980s were trying to achieve. When I was carrying out research on independent living in the early 1990s, I consulted with the British Council of Disabled People about what the term meant.  The first principle they identified was that “all human life is of value”.  This echoes the UN Declaration of Human Rights: “All human beings are born equal in dignity and rights and all life is of equal worth” which is also, of course, the starting point for Article 19 of the UN Convention on the Rights of Persons with Disabilities (CRPD), the right to independent living.

As the UN’s Committee on the CRPD pointed out, “The foundation [of Article 19] is the core human rights principle that all human beings are born equal in dignity and rights and all life is of equal worth”.  Article 19, they explains:

has its roots in civil and political as well as economic, social and cultural rights: The right to liberty of movement and freedom to choose one’s residence (art. 12 of the International Covenant on Civil and Political Rights) and the right to an adequate standard of living, including adequate clothing, food and housing (art. 11 of the International Covenant on Economic, Social and Cultural Rights) and to basic communication rights form the basis for the right to live independently and be included in the community. Liberty of movement, an adequate standard of living as well as the ability to understand and have one’s preferences, choices and decisions understood, form indispensable conditions for human dignity and the free development of a person.

This makes clear both how comprehensive the concept of independent living is within the international human rights framework, and also how a denial of independent living is a denial of human rights.

4. In the current context, where the term independent living has – as Catherine Hale says – been corrupted by those responsible for implementing the Care Act, perhaps we need to frame our aspirations and our demands in terms of human rights. Articulating our aspirations in terms of our human rights would enable us, for example, to see the rationing of support to a level which prevents people from even going outside their own home, or which forces them into residential care, as a human rights abuse.  It would also enable us to see a failure to recognise how someone communicates as a human rights abuse.  Segregation and isolation from family and community would be seen as a human rights abuse as would many other features of the current broken system of social care.

5.  The answer to Chris Hatton’s question is that, yes, social care is fundamentally bust.  This is partly because our society has not chosen to put enough resources into what is currently called ‘social care’. We used to talk about how the question was not so much the level of resources put into such services but how the money was used. But we are now in the situation where there is widespread agreement that not enough money is going into social care.  The problem is that this is only being brought home to politicians and the public because of the impact on the NHS and the danger is this agenda will only identify solutions in terms of what social care can do to prevent hospital admissions and delayed discharge.  Instead, we need to ensure that this political and public debate includes a wider vision of community support which enables people, whatever their age, impairment or circumstances, to access their full human rights.

6. But it is not just about the level of resources, important though this is. Social care is also fundamentally bust because we have constructed methods of rationing and of delivering such services which mean they cannot be relied upon to protect and promote older and disabled people’s human rights.  Direct payments, the original mechanism which aimed to deliver choice and control, were intended to place decision-making powers in the hands of people who needed support to go about their daily lives.  Personal budgets were similarly intended to empower people who did not want to employ their own support workers but who – through being able to control how the resources to which they were entitled were spent – would thereby have choice and control.  Neither have fully delivered on this vision, partly because it is hard to change the local authority culture which relies on bureaucratic processes to maintain control – and this even harder when budgets are cut back so significantly. And partly because the so-called ‘market’ in social care is dysfunctional – there isn’t a real choice of service provider for either local authorities or self-funders, and one in four social care providers do not even provide ‘safe’ care, according to the CQC.  Social care is just another privatisation which hasn’t delivered.

7. But, as I wrote in a previous blogpost, the answer is not to go back to state provided services – that doesn’t address the power imbalance.  Instead, the answer is to develop new ways of delivering support services, such as user-led services and co-operatives – not old style charities run by the great and the good with the values of ‘doing unto people’ but non-profit community-led organisations which are truly accountable to those to whom they provide a service: support which is designed and delivered for the community by the community. Vidhya Alakeson, Chief Executive of Power to Change, gave some examples of this in her blogpost – and incidentally, Vidhya mentioned that some communities no longer even have a cafe where they can meet “to plan a different, better future”; but my community now does thanks to Power to Change part-funding our new community shop and community cafe.

8. New ways of both delivering and commissioning services also require some fundamental changes to how we make decisions about how to raise resources and what level of resources should be put into community-led services. In that previous blogpost I argued that the current system of means-testing social care is unjust because it is a matter of luck as to who needs a substantial amount of care for themselves or a family member. The NHS is funded on John Rawls’ principle of the ‘veil of ignorance’ – in other words no-one knows whether they are going to be struck down by serious illness and it is therefore in all our interests that healthcare is funded by a progressive taxation system to ensure that health care is there if and when we need it.  This is the same basis on which community support services should be funded. Community-led, not-for-profit services should therefore be funded out of our society’s collective resources, free at the point of use.

9. However, decisions would still need to be made about how to allocate those resources.  We therefore need to think about developing new and more democratic ways of commissioning services. Chris Hatton mentioned participatory budgeting in his blogpost, and there certainly seems enormous potential for promoting deliberative democratic decision-making in both the allocation of resources and in the delivery of support. But we haven’t been bold enough yet in this country; instead we have only tried to make gains within existing systems and there is inevitably a limit to which this can bring about real change. We have talked about co-production but even where this enables genuine participation it does not enable control over resources and thus does not tackle much deeper issues about democratic decision-making.  We need to be experimenting with mechanisms which “give people real power to effect change in their lives, communities and beyond“. We need to use an idea like participatory budgeting to give local communities real power to determine how resources are used.

10.  So my answer to both the challenges posed by Catherine Hale and Chris Hatton, is: let’s frame our aspirations in terms of our human rights and let’s redesign and properly resource a system which is collectively funded, free at the point of use, and where resources are democratically allocated to forms of support which are designed and delivered by and for local communities.

@jennifermor