This is not the way to develop social care

I was listening this morning to a thoroughly depressing discussion on social care.  A major part of the way the issue has been framed is, apparently, to encourage migration so that migrants can fill the roles that need to be provided.  The other was to point to the supposedly five and a half million people receiving ‘out of work’ benefits, a figure that includes, as far as I can tell, four million people who are either too sick to work, in work on low pay or who already have caring responsibilities, and demand that they provide social care on a minimum wage.  The underlying message seems to be that care is unskilled, and anyone can do it.

If we look at the way that social care is being provided, the picture is very mixed.  The delivery of services has been shaped to match the criteria of commercial markets: individuated services, priced distinctly by activity.  So we get tick-box lists of what needs to be done, masquerading as an assessment: dressing people, cutting their fingernails, brushing their teeth and so on.  Some of the activities are paid for, and counted as nursing care; others are based on reported needs  that, in their nature, are typically out of date.  I’ve argued, in How to Fix the Welfare State, for a different (and admittedly rather more expensive) approach: providing teams of professionals who are paid for blocks of time, rather than specifically costed activities, who within that time can identify and negotiate services with the people who receive them.  To do that, social care needs a professional structure – including training and qualification – and a pay structure that is commensurate with the skills that are required.  We have a long way to go before we get there.

75 years of the NHS

The NHS – and the British Welfare State -are 75 years old today.  I’m not going to try to cover all the issues here, but I did offer a potted summary in my book, How to Fix the Welfare State (Policy Press, 2022).  Here are two of the summaries from that book, for the chapters on the NHS and Social Care.

 

 

The NHS

Key points  

  • The NHS offers a form of insurance, providing medical care to anyone.
  • Despite the dominance of hospitals, general practice is at the heart of what the NHS does.
  • The need for public health has been highlighted by recent experience.
Positive developments  

  • The NHS has moved away from long-stay institutions and focused on medical care.
  • General practice has been greatly improved.
Where policy has gone wrong  

  • Private markets cannot fill the gaps. They depend on producers having choices, and that leads to exclusion.
  • Health is public as well as individual. Reducing everything to the personal level compromises the aims of health services.
What to do instead The health service has to provide different levels of service: decentralised general services, more specialised work for larger areas, and highly specialised centralised provision.

Social care

Key points  

  • The shift from health care has left services that are fragmentary, insecure and often expensive.
  • Residential care has grown because it is an effective way of providing intensive services, but not all residents need that.
  • Domiciliary care has been based in a flawed model of ‘personalisation’ – and a catastrophic assumption that it won’t be sustainable.
  • Care in any setting depends on continuing personal relationships.
Positive developments  

  • This service did not exist when the welfare state was founded.
  • It was created as part of the movement away from long-stay institutions. It has its failings, but at least it has made it possible for some people to continue to live in their own homes.
Where policy has gone wrong  

  • Personalisation has never lived up to its promise; it only works for some.
  • Creating something like a market in social care is no guarantee of choice.
  • Markets offer commodities; people who need care need something different.
What to do instead The clients of social care need people with time and skills, not a shopping list of the tasks that workers will fulfil. Both residential and domiciliary care will need teams of carers who can offer a personal service to clients.

Designing the National Care Service

Common Weal has offered a blistering critique of the process for designing the new National Care Service in Scotland.  They argue that it’s been designed for top-down governance, rather than service delivery, and that pledges to ‘co-design’ the service with users and carers have proved empty.  Their criticism seems to me justified. The design, and the patterns of governance which are being proposed, are both centralised and corporatist.

I don’t know, to be honest, whether a service that is ‘co-designed’ is likely to be better than one that isn’t.  People who have experience of the system are often conditioned by that experience to look for tweaks and minor improvements, rather than thinking how things might be done differently. The needs of older people with limited mobility, adults with mental health problems or people with developmental disabilities are rarely the same, the interests of ‘carers’ and ‘service users’ vary hugely, and we cannot imagine that one set of service users can speak for others.

I have written recently about some of the long-standing problems in social care: fragmentary, insecure and expensive services, the misplaced attempt to create ‘markets’ in disparate fields and the treatment of ‘personalisation’ as if it meant a selection of services from a shopping list.  I argued there that people need flexible forms of provision based on personal relationships, rather than a commoditised response. If a National Care Service is going to work, it needs to be conceived in terms very different from the old models.

More money for residential care? The system needs reform first.

There’s a debate raging about how to pay more for ‘social care’, but it’s mainly a debate about how to pay for the largest cost, which is the price of residential care.  A year in residential care can easily cost £40-50,000. It’s residential care that is most likely to eat up all a persons’s savings, along with the value of their house.

Unfortunately, the finance of residential care has been based in a deeply exploitative model, and the conduct of a few of the largest providers, while legal, is open to question in terms of the use of funds, the stability of the operation, and the quality of the service provided.  I’d recommend a critical report from 2016 by Burns and others, called Where does the money go?  They explain how a complex series of financial transactions have been used to milk the system of money, and most of it finishes in tax havens.  Operational companies, which actually provide the care, are separated from property companies, which charge them rent.  The operational companies are loaded with debt at excessive rates of interest, paid to finance companies.  Management services are subcontracted to other companies within the group.  And so it goes on.  The authors comment:

Putting more money in to the system via higher weekly payments per bed will not produce a robust and sustainable care home sector when the financialised providers are so adept at taking money out.

 

Social care: a tale of two countries

You wait for ages for a review of social care, and two of them come at once.  One is in Matt Hancock’s rather strangely timed proposals for reform of the NHS; the other is the Feeley report for the Scottish government, proposing a National Care Service for Scotland.

The English report has the catchy title, Integration and Innovation: working together to improve health and social care for all – I wonder if  they hired a consultant to come up with that one?  It’s a proposal for legislation on a range of topics, but lots of topics are listed as the subjects of a forthcoming bill, and the topics that are listed are difficult to match to any text that lays out the rationale.   In relation to the integration of health and social care, the main proposal seems to be that there will be a law telling people they will have to collaborate more eagerly. We all know, it seems, that the real problem is that we need a supervisory body to bang heads together.  And that, as far as I can tell, is about it.  Not a word about finance, or budgets, or professional barriers, or liaison, or … much at all, actually.  I can’t help feeling that I’m missing something, but I can’t tell what.

The Feeley report, by contrast, is rather good.  For one thing, it starts by asking people, both service users and professionals, what the issues are it needs to address. It points, for example, to the current arrangements for getting specific services to people: “It’s the equivalent of NHS staff having to make a case for funding every time someone needs a blood test.”  The panels knows that care workers are woefully underpaid.  It recognises, as the Hancock report doesn’t, that there has to be money.  The report argues:

There is a gap, sometimes a chasm, between the intent of that ground-breaking legislation and the lived experience of people who need support. In the improvement world, there is a maxim which reads something like “every system is perfectly designed to get the results it gets”. … We have inherited a system that gets unwarranted local variation, crisis intervention, a focus on inputs, a reliance on the market, and an undervalued workforce. If we want a different set of results, we need a different system.  … We need a transformation of the way in which we plan, commission and procure social care support.

I don’t agree with everything in the report, but that’s what happens if people who know what they’re talking about make their case with a rationale  and evidence.

The reform of social care will take more than money

The House of Lords Economic Affairs committee has called for free personal care in England, on lines similar to the system in Scotland.  “Under free personal care individuals would therefore only receive funding for support with these basic activities of daily living, based on the minimum threshold of eligible needs as defined by the Care Act.” They are recommending a major increase in the funding for social care, so that care can be delivered on much the same terms as health care.  However, they accept that people should pay accommodation costs themselves, with means-tested support, and they recognise that this might entail “catastrophic accommodation costs” which might have to be subject to a cap.

This has been welcomed as a radical proposal, but it doesn’t touch on most of the problems that go with social care.  We’re still thinking of social care as a set of needs which can be satisfied by specific cash payments.  The Lords report explains:

“Personal care means essential help with basic activities of daily living, such as washing and bathing, dressing, continence, mobility and help with eating and drinking. It does not include other areas where support might be needed, such as assistance with housework, laundry or shopping.”

I don’t believe that a system based on this approach can ever deliver what people want to see.  I don’t believe people want, or are comfortable with, successive 15 minute visits from a team of people who bathe them, or dress them, or help them to bed.  I don’t believe that what most people really want in life is to manage a rota.  I don’t think that providing for a series of events, sold as if they were commodities, meets people’s human needs.  What we should be allocating is time with a person, and that calls for a different approach to assessing needs from one that focuses on whether or not someone needs help with brushing their teeth.

Self-directed support makes little headway

Self directed support in Scotland hasn’t exactly shaken the rafters – a report in 2014  called the system “nebulous” – but an Audit Scotland report suggests it “shows many examples of positive progress”.  The vague welcome is hardly justified; this is a system that’s hardly stirred into life at all.  The Social Care (Self Directed Support) (Scotland) Act offers four  “options” for self-directed support:

  • Option 1  Direct payments
  • Option 2  The individual chooses the support and the authority manages it
  • Option 3  The authority chooses the support and arranges it
  • Option 4  A mixture of options 1, 2, and 3.

It’s highly debatable whether option 3 can be thought of as self-directed support at all, and it’s far from clear what qualifies as option 4.

An Audit Scotland report claims that  “at least” 53300 people, out of 208,000 adults receiving non-residential support, are getting SDS.    Of that figure,

  • 11% chose option 1
  • 9 per cent chose option 2
  • 75% chose option 3, and
  • 5% chose option 4.  (para 24)

So out of that 53,300, something between 10600 and 13330 people chose an option.  Direct payments have increased, from 3680 to 7530 people 2010-16,  but as a proportion of more than 200,000 people it’s a very long way from the ‘total control’ supposedly offered by SDS.

It’s also troubling that at this stage the evaluation has not been able to show any clear advantage in personal budgets, even for the selected few who receive them.  A few qualitative comments show that some people support the idea in principle; other comments point to difficulties in knowledge, implementation, resources, restrictions from the local authority and a lack of choice.  My own experience as a carer has been that assessment came cursory and late, with no effective choices at all.  I’ve previously expressed some scepticism about personalisation; developments to date have done nothing to change that view.

Learning about disability provision in France

I spent the back half of last week in Lyon for a forum on the ‘disability sector’.   It was an international conference.  I was there to explain alien aspects of the British system, such as care packages, personalisation and welfare reform; others were there from Norway, Germany and Italy.   I’ve had to learn some new vocabulary – for example, that people with disabilities are no longer personnes handicapées but personnes en situation de handicap, and learning disability is sometimes (but not always) rendered by handicap intellectuel, sometimes by les personnes ayant des difficultés d’apprentissage.    Beyond that, there’s always the problem that professionals in France routinely talk in acronyms, such as the ESMS (établissements et services médico-sociaux) or the CPOM (contrat pluriannuel d’objectifs et de moyens) – I’ve only deciphered that one after coming home and looking it up, and I still don’t know what it really means.  There were interpreters at hand, so I chickened out and spoke in English.

It’s more of a culture shock to understand some of the differences in provision.  None of the agencies represented, in a conference with more than 300 managers attending, dealt with older people.  France still makes heavy use of residential care for younger disabled people.  There was also a moment of incomprehension when the German speaker asked about the  representation of people with disabilities in monitoring groups and got an answer about institutional accountability instead.  However, there’s a level of funding that many people in the UK would find enviable.

The problems with social care

Social care has been unmanageable for some time, and it’s not simply down to the actions of this government, or the one before it, or the one before that.  The problems run much deeper than any quick fix can address, but many of them can be laid at the door of two very long-standing policies, and I can see no way of resolving issues while those two policies stand.

The first failing policy has been in place for more than fifty years.  Circular 2/62, on Development of Local Authority Health and Welfare Services, declared that “Services for the elderly should be designed to help them remain in their own homes for as long as possible.”   The model sounds plausible, but it is based on the highly questionable gamble that people will never need more intensive support.  This is, quite literally, catastrophic – it generates sudden crises.  It means that we leave people in place until there is a catastrophe, usually a fall or hospital admission.  This leads directly to people being trapped in acute hospitals until they can get an emergency admission into residential care, often settling for a third or fourth choice because that’s all there is.   We need people to be settled in lifetime accommodation long before the crisis happens.

The second failing policy stems from the Griffiths report of 1988, which attempted to provide personalised, individuated social care through the creation of a quasi-market.    Provision based on this model has signally and continually failed to provide people with the level of support they need.    It’s not down, as many supporters of the policy claim, to lack of resources.  Market provision can’t work by providing a flexible response – it implies that support will be fragmented, offered in short bursts of time.   Individuated responses are spectacularly inefficient; they’re also desperately expensive.

The push to personalisation has been based in a futile attempt to implement an impossible dream.  Individuated policies only work for people whose needs are more limited.  The more intensive the support has to be, the more has to be provided in a distinct location.  We spend a great deal of time and money pretending that residential care is really a modified form of domiciliary care, with added accommodation: it isn’t.  A greater commitment to residential care is the only way out of this bind, because residential care brings together trained staff, facilities and resources in the places that allow them to be used for people in need to the greatest effect.

Local government and devolved benefits

There’s an intriguing disagreement reported in the Herald between disability organisations and CoSLA, which represents local authorities.  CoSLA has been arguing for building up the role of local authorities in benefits administration.  At present the Scottish Local Authorities administer Housing Benefit, Council Tax Reduction and the  Scottish Welfare Fund; they are also effectively responsible for support in social care, including the fashionable (and misguided) trend to individual budgets.  They stand to lose responsibility for a large slice of the work relating to Housing Benefit (relating to working-age benefits).  That has raised questions about the viability of the operation and the prospects for people working in that field.

Others have expressed concerns about the possibility that disability benefits will be transferred to local authorities.    Tressa Burke, of Glasgow Disability Alliance, is concerned about cuts – a reasonable fear, because the experience of local authority administration to date has been that social care is expected to work within fixed budgets, and benefits don’t work that way.    Sally Witcher, a former director of CPAG who is now CEO for Inclusion Scotland, comments that there will be a ‘postcode lottery’ and points to the problem of people transferring across local authority boundaries.  (As a carer myself, I’m more worried about the discontinuity of care: quite apart from the effect on personal relationships, putting together a fresh care package in Scotland can take months or even years.)

The main concern raised by CoSLA’s statements to date – such as the delivery plan for people with disabilities –  is that they’re based on a narrow concept of disability, dominated by the model of ‘independent living’.    I’ve sat before now through a long presentation arguing for disability benefits  to be unified with social care, a prospect which appals.  It implies  the replacement of entitlements with assessment and bargaining within the constraints of fixed budgets;  a system where assessments of need are geared to what’s available;  and a subordination of all the other objectives of disability benefits – social protection, income smoothing, compensation, rehabilitation, empowerment and so on – to the priorities and demands of the social care budget.

There may be room for compromise.  A CoSLA spokesman is reported as saying that “councils are not suggesting they should make decisions about who gets benefits or how much they get.”  If that’s right, this could be taking as proposal for something very different, focusing on effective benefits administration, and there’s a good case to think about administration at local levels.  One of the first priorities has to be to ensure that benefits are not swallowed up by an misplaced identification with social care.