Flexibilise care – the social care vision

An evaluation of the English government’s ‘Vision for Social Care’

Department of Health (2010) A Vision for Adult Social Care: Capable Communities
and Active Citizens. London: Department of Health

December 14th, 2010 by Malcolm Payne on: http://blogs.stchristophers.org.uk/one

I’ve struggled to respond rationally to the Department of Health’s Social Care Vision.
This is because it’s a brief political statement, without depth of analysis or innovative
policy-making. You could summarise it by saying that the ConDem coalition is going
to carry on much as before but with a stronger ‘big society’ ethos. There’s a big
emphasis on continuing ‘personalisation’, and this is backed up on the Department of
Health website by an interest in personal health budgets as well as pushing on with
personalisation in social care.

How will they implement ‘big society’?

The best way to assess this is not to look at the buzz-words and extremely generalised
statements of big society philosophy, but to ask ourselves: how do they actually
intend to implement this philosophy? Because it’s by how they do it that we will
judge the outcomes. How you evaluate this depends partly on how enthusiastic you
are about personalisation. Keen on personalisation types are relieved there is going to
be no rowing back on the faith. I’m agnostic, not because I don’t see that
personalisation could have many benefits, but because I suspect that, like the arthritic
form of care management that the Conservative and Labour governments have
lumbered us with here in the UK, they will not roll out a decent form of
personalisation.

Especially, that form of personalisation will not be good for older people, who are less
keen on personalisation than young physically disabled people and the parents of
learning disabled people, who have seized and benefited from the opportunities of the
current trend. Older people have more complicated and variable lives, and that’s
harder to manage, and they don’t on the whole want to be social entrepreneurs in the
management of their care packages, they want it done for them. If that’s true of older
people, it’s even more true about people using palliative care (whose needs are
extremely volatile) and end-of-life care (which if it’s happening at all is pretty
minimal).

I also worry about people getting adequate social work from personalisation policy.
I’m sure Con Dems think now that they don’t need to worry about that: what do we
need social workers for? just deliver the services. And, in the new regime, we won’t
need social workers because… the families and neighbours are going to do it, so there
won’t be any services, so we’ll need social workers even less. I’ll hope to show you
that they’re wrong about that, but I think there is good cause to worry about social
work. And I emphasise that I mean social work, like palliative social work, not social
care in the Con Dem and new Labour meaning of the term.
Future big society scenarios

In this regard, the Skills for Care assessment of the state of the social care workforce,
which they do periodically, and which came out earlier this year, is instructive. They
set four future scenarios and looked at the implications for the social care workforce.
The scenarios are:

- A base case, some progression in personalisation which reaches its limits and
stops expanding after a while.
- A maximising choice scenario, where personalisation goes all the way – this is
what the enthusiasts would like to see.
- A contain and community scenario, where the job would be to ease back on
paid care where you can, with professionals assessing more stringently, and
informal care taking the strain.
- A restricted resources scenario, where extensive cutbacks in provision means
vicious (my word) assessment arrangements and more social workers to do it,
extra help for people to move round the system, and most of the strain being
taken by informal care.

As I always say about Conservative policies, although you tend to think they are
against social work because of it being part of the nanny state and so Conservatives
are bad for the future of social work, they tend to cut back the system and then find
that they need more social workers to manage the consequences. This was true
throughout the period of Conservative administration of the 1980s and ‘90s. Social
work actually did rather well, lots more child protection, work on young offenders
and services for disabled and other groups as a result of closing the mental and
learning disability hospitals. After an initial bout of anxiety, leading to the Barclay
Report, when they thought they could get rid of social work (no nannying on our
watch), they found they needed social workers to keep some sort of show on the road.

The Skills for Care contain and community and restricted resources scenarios make
this pattern for the future of the ConDems very clear. If you’re going to cut back on
services, the assessments become more difficult and time-consuming so you need
more professionals to do them. And people will have to be helped to find the peculiar
kinds of help that will emerge from the system, so you need more people to guide
people to the not very good support they can get from community services, instead of
assuming they can get it from health and social care agencies.

This not-very-good help is going to emerge from whatever happens to employment. I

was very heavily involved in unemployment schemes in the 1980s, as most people
were in the voluntary sector. There is this naïve view held by economists and
politicians that if you throw lots of people out of work, they will all put on overalls
and go off to weld rivets in the shipyards, thus developing industry and economic
growth. But of course most of the people they’re going to throw out of work this time
will be local government manual workers and a few bureaucrats who either wouldn’t
be seen dead in overalls or would probably drop a spanner if they were given one.
They’re going to be looking for work in all the government schemes for helping
people into employment, until the economy takes off again. I don’t know what the
schemes will be, but they’ll be there.
And a lot of them will be cheap and shoddy ways of providing care services.
Economists will tell you that demand creates supply, and there’s going to be a lot of
demand for care. Moreover, it’ll be, from the point of view of the Con Dems,
respectable care. Because by cutting back on local authority, prisons and, to a lesser
degree, healthcare, what care is going to be provided will be by small local companies
substituting for local government social care in the new social enterprise economy.
There will be lots of start-up grants to create little local companies to do this, like in
the 1980s there were opportunities to start up little care homes.

The new ‘funny money’

In the 1980s, I was kept busy because in Liverpool, where I was working, by all sorts
of community-type projects funded by unemployment funny money. This time it’s
going to come from:

- Ken Clarke’s funny money for getting tough community projects to keep
people who would otherwise be prisoners busy.
- Andrew Lansley’s funny money to get social workers and nurses to set up
social enterprises to run local health and social services.
- Eric Pickles’s funny money to get local communities to do useful things to
replace local government.
- David Willett’s funny money to think tanks and social enterprise consultancies
to do research and evaluation to prove (unlike the university researchers, who
will likely be too neutral to prove what is required) that the big society is
working.
- And so on (big society schemes yet to be devised).

When the economy gets going again, people will either have got a nice organisation
going that will become part of the system in the future (the ConDems will call this the
success of their big society initiatives), others will sell out to multinationals (as in care
homes after the 1990s) and others will melt back into real government jobs again.

The three principles of the Vision

So, to summarising the Social Care Vision.

The ministerial intro focuses on three principles: freedom, which you get by having
choice, fairness, which we get when stable adult social care funding is sorted through
legislation which covers the Law and Funding Commission recommendations, and
responsibility which lies very clearly not only with the state. They want to enhance
community resilience, reciprocity and responsibility. This will postpone dependency
and promote independence and choice.

The porble with this idea about freedom of choice is that the only freedom available is
the freedom to decide you want what the government wants to organise yourslef to
provide. Choice in this model of service means being able to choose things provided
by yourselves in the way that the government approves. Are we allowed to dissent?
And will they fund the dissenting choosers, or only the ones they prefer?

How will they do it? Carers and community

The main answer is capable communities and responsible citizens, supported by
personalisation. Their approach to personalisation is to speed up its roll out, so that it
is available to more people quicker, and they are going to use the Law Commission
and Funding Commission outcomes to formalise a system that will do this. A lot of
the rhetoric is about choice, with the professionals providing guidance about the
options available; more jobs for social workers then.

It then goes on to ‘plurality and partnership’. Partnership is not so much between

healthcare and social care (as in the Labour use of the term), but more partnership
with service users and carers, who are going to be taking the main responsibility.
Carers organisations have rather liked this emphasis; well beware, is all I can say.
Because the whole Vision is about carers being able to do what they want, provided
they do all the work. If they want some care rathre than them, they’re going to have to
keep on wanting. This responsibility is both for providing the care within the budget
offered, as well as organising it by managing their budget. So it looks as though the
options that the professionals are going to be guiding people through are what they
can do for themselves, not what they can get. As well as this, plurality means freeing
up the system so that there are going to be more small local social care providers –
groups of professionals and relatives getting together for example; more of doing
what you can.

However, there will be partnership between health and social care, because they will
be doing JSNAs (learn this new jargon quickly, please, it’s obviously going to be the
thing) that’s joint strategic needs assessments – deciding what the area needs. They
will then be jointly commissioning what is needed (but of course not necessarily what
people want; plkease udnerstand that needs are what you’re told you have not what
you think you have), and there are going to be new financial devices such as ‘social
impact bonds’ (i.e. funny money to ‘overcome barriers’ in setting up businesses that
will meet people’s needs).

There will then be joint commissioning and aligning of health and social care budgets
to enable them to commission lots of these new local community structures for
providing services. I’m a great supporter of local people being enabled to work
together to respond to local needs; I’ve been doing it all my life. One of the problems
with the commissioning approach to being creative in the community is that
commissioning only pays for what’s there; it acts as a brake on community creativity
and initiative. All the commissioners sit in their offices moaning about the fact that
nobody replies to their internet questionnaires. What they should be doing is finding
local groups and supporting them to decide how they want to respond to local needs.
Unfortunately, they will then make demands that the commissioners can’t afford
because they’re only ready to provide what they’re used to.

I’m against commissioning for this reason. If you want a real big society, you have to
put up with the fact that people will not want that the health and social care
commissioners would like them to want. They might be more creative, but they might
also make demands for more things that they understand and appreciate. Like good
quality residential and home care or support for carers rather than support for new
social enterpirse initiatives.

Safeguarding
There is some whiffle about safeguarding – local communities are going to be making
sure people are safe, building on Neighbourhood Watch and similar initiatives. So
we’re all going to sit around in someone’s front room, decide on where we need to
keep an eye open for any of Ken Clarke’s unbanged-up criminals who aren’t doing
sufficiently tough work programmes and then decide on who’s been beating up their
granny this week. Don’t worry though, there’s going to be local authority leadership,
reinforced by something we know not what from the Law Commission reforms on
adult social care.

Productivity etc

There then a chapter on productivity (an industrial and economic term which is
invading social care), a lot of which is about telecare, cutting back on residential care
to spend more on front-line home care and being strategic about rewarding and
incentivising people at the front line to improve the quality of services. I agree that
telecare is an important way forward, which is appreciated by people because it gives
them independence. Governments have been saying they want to cut back on
residential care in favour of commuunity care for decades; what they mean is cut the
cost of expensive residential care and whittle away at the community care we replace
it with. What this means is that you can be watched by a camera and therefore
safeguarded, instead of a real person coming round twice a week to talk to you.
However, much of the strategic stuff is whiffle squared because it’s about setting up
structures for controlling what people want to do, instead of liberating it. Rewarding
and incentivising people is about spending funny money on staff and service users
setting up local community initiatives in ways that the government believes in rather
than what they might actually want (which would be more serviecs).

What about social work then?

Not a lot here about social work; ghastly thing nobody wants that. Except that if you
met many of the people who’ve received some palliative care social work they would
tell you what they appreciated. A lot of them would tell you that someone who took
the trouble to sit down with them and work through what outcomes would be best for
them. You also need someone who is prepared to turn out and flexibilise the response
to people’s needs when it needs to change, as in palliative care it often does.

What you do not need is a commissioner who sees it as their job to carry out an
assessment according to the local authority’s tick box and then stick to it like grim
death until the next review.

That’s my new bit of jargon: flexibilise care.

And to do it, you need social workers with a bit of independence of mind and practice,
to travel through the care system alongside people. People and their families
flexibilise by nature, because they lead complicated and constantly changing lives.
Just setting up a commissioning system to incentivise people who want to do things in
a different way isn’t going to do that.

So the Vision doesn’t respect people and their choices. That’s probably because it is
having to create a system that covertly recognises that all its community paraphernalia
is to cope with an underresourced system. There’s every sign that it’s going to
continue to be underresourced.

On the web: the Social Care Vision (again):

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docu
ments/digitalasset/dh_121971.pdf

The Skills for Care State of the Social Care Workforce reports (May 2010):

http://www.skillsforcare.org.uk/research/research_reports/state_of_the_adult_social_c
are_workforce_reports.aspx