Category Archives: Social Care

Almost a million adults have currently given up paid work to care for friends and relatives. Most of these unpaid carers are women and in large part they are exiting the labour market because social care provision is inadequate. Meanwhile, life for the women who are paid to provide social care has become much harder. As social care provision has been eroded, they have faced a regressive, sexist, and systematic subordination of their interests as women, and because they are women.

The inadequacy of equal pay law

In 1997, most care workers were employed by local authorities and received an employer-funded pension, pay when sick, and the security of 37 hours a week of regular work. However, female care workers were underpaid in relation to men in comparable work. State employers promised that within a decade they would eliminate sexist wages and provide the care workforce with equal pay. This simply didn’t happen. Instead, sexism in wage-setting was effectively put on steroids through privatisation: the care workforce of today is employed in jobs which carry less than half the financial value of the jobs that care workers occupied 20 years ago. A systematic degradation has also been made possible by the utter inadequacy of equal pay law. Evidently, the Equal Pay Act 1970, and provisions in the Equality Act 2010 which replaced it, are not fit for purpose.

Equal pay law was supposed to ensure that the blight of sexism in pay-setting was eradicated. Not so for care workers. Where women do not work in close proximity to men, equal pay law offers very little and prevents women from comparing their wages to those of men who do not work for the same employer. It is a widespread misunderstanding that equal pay law protects the wages of women: it does not. Rather, the right to equal pay prevents male wages from being undercut. Inadequacies in equal pay law perpetuate the historic subordination of women in low-waged work, prevent care workers from achieving economic independence, and exemplify the economic invisibility of skills and abilities which are thought to arise ‘naturally’ in women.

The inadequacy of minimum wage law

The financial crisis of 2007/2008 heralded UK labour market changes in which care work became the largest source of low-waged work for women. The real value of the national minimum wage fell each year until 2014. For more than a decade, politicians and policy-makers were aware of minimum wage law being flouted in the social care industry. Nothing was done despite voluminous evidence that huge numbers of care workers were paid unlawfully low wages.

In various forms, non-compliance with national minimum wage law has continued even though the state is the main customer as well as the regulatory overseer of the social care industry. When the social care minimum wage scandal of 2017 highlighted that thousands of care workers were paid nothing more than pocket-money to ensure the overnight well-being of vulnerable adults, employers were outraged that they should have to pay care workers what was legally owed. The government’s initial response was to suspend the full enforcement of minimum wage law in the social care sector; months later, it implemented an industry-specific exception scheme in which care workers will not receive all the wages to which they are entitled until March 2019 and employers will avoid penalty fines.

The inadequacy of statutory pay protection

Yet a lack of political interest in enforcement has not been the only minimum wage issue to blight care workers’ earnings. Care workers are failed by the current right to a minimum wage where their work is not recognised as ‘work’ for the purposes of statutory pay protection. Regulations exempt the work of co-habiting family members paid as care workers via direct payments from minimum wage protection. Regulations also exempt the work of care workers who live-in and are treated ‘like family’ by their employers from minimum wage protection. In case law, the work of carers who are contractually required to remain on-site during lengthy shifts is not automatically recognised as ‘work’. Judges have devised special tests to apply when care workers bring minimum wage claims. Unlike the situation facing other workgroups, it is not enough for care workers to simply be present because their contract requires it: they must additionally show they are busy, needed, working alone or carrying special responsibility for others.

The engrained culture of non-payment

The National Minimum Wage Act 1998 and its accompanying regulations were supposed to communicate the universal value of paid work but do not require employers to pay for all the hours they require a worker to work. The scheme merely calculates a minimum wage total to be met or exceeded when pay is averaged across all hours worked. Although the right to a minimum wage was supposed to prevent exploitation, it has become standard industry practice for care workers to work for free during increasingly large parts of each working day. For example, in 2014, homecare employers calculated that workers were unpaid for an average of 19% of their working time due to non-payment of travel time between clients. On top of this, they were routinely unpaid for time spent training, waiting for ambulances or other healthcare professionals, time spent waiting for co-workers to help them lift heavy clients, time spent in supervision meetings with management – and the list goes on. An engrained culture of non-payment in the care industry has been made possible by the inadequacy of UK minimum wage law.

Why all this matters

Hands-on care work is the UK’s most highly female-segregated occupation. Traditionally, women are expected to provide care for free within families and they continue to provide the vast majority of unpaid work at home. A sex-based ideology about women’s subservience to the needs of others still circulates in the contemporary labour market, and minimum wage law does not do enough to assert the value of care work.

There are two million workers in adult social care, the vast majority of them women. If we continue to tolerate care workers being employed to work without pay, the future of care work will be based on sexist expectations that care work should be done for free. Unless we stand up and demand that carers’ skills attract decent economic reward, the future of social care will be based on the idea that caring skills are ‘natural’ for women and don’t have to be paid for. Until the wages of care workers are free from sexist devaluation, and until the work of care workers is fully recognised, the labour of all women is devalued.

First published on the British Politics and Policy blog

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Deborah Harrington’s interesting posting on “The Myths and Legends of Hypothecated National Insurance” (March 29 2018) in particularly relevant in the light of media speculation about hypothecated taxes or National Insurance contributions to pay for health or social care.

In Wales there is a further variation on this general theme with Professor Gerry Holtham (Dept. of Regional Economics at Cardiff Metropolitan University ) proposing the establishment a social care levy for Wales. (See link below)

The levy, based on weekly payments between £1.75 and £7, would differ from a tax in that the receipts would not go into a general government budget but rather into a separate social care fund with its own independent trustees. “A portion of ..(the fund) receipts would go to local authorities to expand social care provision straight away. The greater part of the receipts would be held back for future needs and meanwhile invested to grow over time and enable even greater social provision to be made in the future as the population ages.”

And following the National Assembly for Wales having secured its own tax raising powers at the beginning of October 2017 the Welsh Government Finance Secretary, Mark Drakeford, signaled that a levy to support social care was one of the new tax ideas he was considering.

Solving Social Care. And more besides

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There is an unwritten – but golden – rule in political speech-making (as in story telling): pledges should come in neat numbered clusters, often in threes or fives, any fewer and it seems you have nothing to say, too many more and no one will remember them. So, the Health and Social Care Secretary Jeremy Hunt was taking a chance when on 20 March he made his first speech on social care to the British Association of Social Workers, setting out seven key principles to guide the forthcoming social care Green Paper. But the risk is not only that the commitments will prove less than memorable, but that they will fail to be sufficient to address the long-standing challenge of reforming long-term care.

The seven principles cover familiar ground and press the right buttons to connect with important values, but there is nothing here that suggests radical thinking or unexpected developments, or indeed that anything much has moved on since these issues were last on the table. The seven principles are the following:

  1. Quality.
  2. Whole-person integrated care.
  3. Control.
  4. Respect and nurture the workforce.
  5. Supporting families and carers.
  6. Sustainable funding.
  7. Security for all.

Another danger with a numbered list is that it implies a hierarchy – rightly or wrongly – and many of those listening to the speech will have been mentally rearranging their preferred order.  Be that as it may, the list is largely uncontentious; no one is going to argue against these principles, and they may well be the ‘right’ ones. Some others could have been added, perhaps principles reflecting universalism; building inter-generational solidarity and social inclusion, but this isn’t a bad starting point. The fact that a very similar list could have been proffered at any time in the last decade points to the reality that the problem with social care reform is not with the underpinning principles or objectives, but with how to create an affordable and acceptable funding model that enables these ambitions to be delivered.

Quality

It is self-evident that services need to be of good quality and that too often they are not, and that the way services are inspected should play an important part in driving up standards and rooting out poor performance, both in provision and in commissioning. But that improvement agenda will come with a price tag.

Whole-person integrated care

The focus on whole-person integrated care develops a familiar refrain; the fault line running between health and social care creates fragmentation and confusion. It makes it virtually impossible for the lay person to understand or navigate, particularly when they have complex needs and co-morbidities that require a coordinated approach. Joining up services has long formed the core mantra of successive Health Secretaries, and the ambitions for the delivery of the Five Year Forward View for the NHS revolve around the goal of  achieving integration through the vehicles of Sustainability and Transformation Partnerships and Integrated Care Systems.

Jeremy Hunt has announced yet more pilots around joint health and care assessment and plans as another step towards integration, adding to the multiple developments around the Better Care Fund and the Vanguards promoting new models of care. But such innovations have not been met with uncritical acclaim; there are flaws in models that chase funding, and analysis by the King’s Fund among others points to the limits of transformation in a ‘downward spiral’ when additional funding is being used primarily to reduce hospital deficits. The National Audit Office has similarly suggested that the ambitions of Sustainability and Transformation Partnerships are overly optimistic.

Announcing new pilot initiatives to address integration by changing systems and processes is insufficient, particularly without addressing the big question of funding, and indeed the impact of separately funded health and care systems on individual users.

Control

Control, the third principle, is about personalisation and people having scope to direct their own care and support, and access to the information and support they need to do so.  Again, these are familiar words that have been part of the lexicon of care for more than a decade, and still the reality for people is often very different. How we get to the destination remains unclear; merely repeating the familiar and warm words is not enough.

Respect and nurture the workforce

Respecting and nurturing the social care workforce is overdue; these are the underpaid and undervalued care workers who are too often the focus not of praise but of criticism. The announcement that there will be a joint NHS and Social Care 10 Year Workforce Strategy is welcome, and an opportunity to address critical issues of recruitment and retention, career pathways and promotion opportunities that will attract and support people into working in social care as a valued career choice.

But the strategy will need to address the reality that many people in social care are not going to want to move into nursing, or to follow a career path. The need to embrace the skills requirements and opportunities for people who will continue to provide vital day-to-day personal care for people in their own homes and in the residential sector must be part of the strategy, as must be the question of regulation and accountability for groups that are still outside the framework of professional regulation.

Support for families and carers made a welcome appearance as a principle identified by the Health and Social Care Secretary. Indeed, many will have wondered what had become of the National Carers Strategy that was consulted on almost two years ago, and then disappeared from view. Hunt confirmed that “ahead of the Green Paper we will publish an action plan” on how to support carers. What that might look like is not known but Jeremy Hunt confusingly spoke in the same breath about volunteers, and about tackling loneliness, which might suggest that clarity around an action plan for carers is still a little way off.

Sustainable funding and security for all

The last two principles – sustainable funding and security for all – finally get to the big issues that remain unresolved, but fail to indicate anything about how they might be addressed. The Green Paper is still primarily about funding long-term care for older people, and the decision to separate this from a wider consideration of care needs for younger disabled people was widely criticised when it was announced following the 2017 election. Some sign that this approach may be shifting was evident in Hunt’s acknowledgement that the answer will not “be necessarily the same for different age cohorts” and that “there may be changes that are equitable and achievable for younger people that would not be either of those for the generation approaching retirement.” Getting a sense of inter-generational solidarity and buy-in to a revised social contract will be critical to reform, and any approach that salami-slices the population risks instead becoming highly divisive.

Hunt underlined the principle of “shared responsibility” in achieving security for all, with a “partnership between the state and individuals.” But importantly, he accepted that the current system “is far from fair”, particularly in the lottery of health which means fully funded care for illnesses such as cancer, and largely unfunded support for people who develop dementia and degenerative conditions. The Green Paper will present ideas about risk-pooling and potential costs, and will need to do so in a way that avoids earlier criticisms of a death tax.

Breaking the silence on long-term care is an important step, but the debate has barely moved since it was last visited. The Care Act remains on the statute books, but the implementation of the capped cost model of funding has been cancelled, and we are back to a position many would think we were in following the Dilnot Commission’s report in 2011. The confusion which surrounded social care during the 2017 General Election campaign caused a rapid unravelling of the policy; whether the seven principles for the Green Paper will provide a sufficient foundation for development and for genuine fresh thinking remains to be seen. On the basis of what Jeremy Hunt has outlined so far there is perhaps some reassurance and hope that a principled way forward will be found, but certainly there are no grounds here for excitement or unbounded optimism.

First published on the British Politics and Policy blog

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Over the past decade there have been growing calls for reform of social care funding. Following numerous Commissions, Inquiries, and election promises, yet another Green Paper is promised for summer 2018. There are strong arguments in favour of a social insurance approach, and much to be learned from Germany’s experience about building a financially and politically sustainable funding model.

Mandatory long-term care insurance (LTCI) was introduced in Germany in 1994. Launched at a time of welfare state retrenchment, it was configured to deliver financial sustainability. After a decade of stable funding that built institutional and popular legitimacy, there have been modest increases in contribution rates and the value of benefits has increased. A series of reforms since 2008 has also extended the scheme to provide coverage for people with cognitive impairments such as dementia.

English social care funding today resembles the fragmented, residual, local government-based, means-tested situation in Germany before the introduction of LTCI. While acknowledging the different institutional frameworks of the two welfare states, there are nevertheless important lessons that England can learn about sustainable funding and achieving consensus on reform.

Universal social rights and cost-containment

A major driver of reform in Germany was the reliance on stigmatising means-tested social assistance by older people who had ‘spent down’ their assets. There was also disquiet amongst regional (Länder) governments about the pressures on their budgets, while policymakers wanted to insulate health insurance funds from long-term care costs, discourage unnecessary institutional provision, encourage new providers and support family care.

Major welfare state reforms in Germany require broad political support. This need to achieve consensus delivered an LTCI scheme featuring universal social rights within a strong cost-containment framework. The Federal government has substantial regulatory and cost-controlling powers with the overall budget, contribution rates, ceilings, benefit levels and eligibility criteria all fixed by Federal law.

Pay-as-you-go LTCI funds are managed by (legally distinct) health insurance schemes. The individual contribution rate is currently 2.5% of wages payable up to a contribution ceiling with childless adults paying a little more. For those in work, employers pay half the premium while the retired pay full contributions, thus helping to address inter-generational equity concerns. LTCI membership is compulsory and non-employed people are covered by employed householder insurance contributions.

Benefits can be claimed by people of all ages. Eligibility thresholds were developed to fit the funds available, but there is no means testing and no account is taken of individual circumstances. Until 2008, eligibility depended on the level of physical ‘care dependency’ but has now been extended to include care needs arising from cognitive impairments. Although all are eligible for LTCI, most beneficiaries are over 65.

There are two ways in which benefits are distributed: cash payments to the person needing care who then pays a family member, volunteer or paid carer; and in-kind professional services. Cash payments are more popular and significantly cheaper than services. Levels of benefit are based on dependency and range from £283 a month (the lowest cash benefit) to £1,784 a month (the highest in-kind payment). Most beneficiaries receive home-based care. Benefits don’t cover all costs, with shortfalls being made up by private funds or social assistance.

LTCI’s original design aimed to demonstrate that a defined contribution approach could work in social insurance. It was agreed through broad political consensus and delivered a decade of stable funding, albeit at the cost of consistently falling real-terms benefits (down by over 20% between 1994 and 2008). A series of recent reforms have expanded and strengthened LTCI, improving access, benefit levels, and care quality. The original eligibility criteria were criticised for their bias towards physical disability, so LTCI was extended to cover people with dementia and other cognitive impairments while core benefits were also enhanced.

What lessons can England learn?

German LTCI embodies a societal acknowledgement that long-term care needs are neither individual nor negligible residual risks. Long-term care is a social risk requiring social protection. This is not a partisan position; the need for reform, the introduction of LTCI and subsequent scheme expansion were all agreed by both main political parties.

The Federal government manages contribution levels, eligibility criteria, and benefits payable ensuring tight cost containment. Benefits were increased for the first time in 2008 and are now reviewed every three years. After 25 years of operation, despite population ageing, an extension of the scope of LTCI, and increases in benefit levels, contributions have only increased by 0.8% of salaries.

The society-level pooling of risk, the creation of a single fund and the key Federal government role have eased financial burdens on regional governments. Central government provides the legal framework, policy direction, and much of the funding for policy implementation, thereby giving political and public assurance of the long-term sustainability of LTCI.

LTCI is a universal scheme with employees, employers, and retired people all contributing. Eligibility rests on care needs alone and the previous dependence on stigmatised means-tested social assistance has been significantly reduced. Universality enhances the popularity of LTCI – disabled children, working age adults, and affluent older people are all potential beneficiaries. Over time, LTCI has become increasingly equitable.

LTCI was designed to support family care; recent reforms have increased social protection measures for family carers. The hypothecation of LTCI funding also makes an explicit link between contributions made and benefits receivable that English care does not. All of these arrangements help to enhance the popularity of LTCI.

Conclusions

While LTCI is congruent with the German social insurance model, it was still a radical departure from past policy. LTCI added the first new social insurance pillar in decades; moved the focus of public care funding from regional to Federal level; and expanded public welfare effort at a time of welfare state retrenchment. The need to achieve political consensus and the welfare austerity agenda of the 1990s shaped the predominantly public, defined contribution design of the programme. Using the established health insurance funds and associated infrastructure allowed rapid implementation and avoided the need for major institutional reforms.

LTCI benefits depend on current need rather than past income and LTCI shares the lower contribution ceiling of German health insurance. This reduces the redistributive impact of the scheme and means the main beneficiaries are those who don’t qualify for means-tested benefits. The probability of ‘catastrophic’ care costs for people with average and above average incomes is reduced significantly by risk pooling under LTCI, thus making it popular amongst this group.

At inception, the design of LTCI (fixed contribution rate, low contribution ceiling, and fixed price benefits) delivered multiple policymaker goals. These include medium-term contribution rate stability, universal benefits, support for family care, a lower funding burden on regional government and less reliance on stigmatising social assistance. After a decade of institutional existence, established policy networks and commentators became increasingly articulate about the short-comings of LTCI. The stability of the scheme provided a platform on which a second decade of funding growth, eligibility expansion and structural improvement has been built.

By Caroline Glendinning and Mathew Wills 

First published on the British Politics and Policy blog

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The outsourcing of public services to private companies is a model in disarray. The impetus for challenge has been the collapse of the outsourcing giant Carillion but concerns have also been raised across a number of other public services including probation, the prison service, forensic science service, and the NHS. Much less interest has been paid to the longer-standing privatisation of adult social care, where the debate tends to be focused on levels of funding and the respective obligations of the state and citizen to contribute to individual care costs. This relative absence of policy interest in examining the ownership structure of adult social care may be due to three related factors – market penetration, market fragmentation and market fragility.

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 situation with adult social care, where the process has been in train for over 30 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%.

Market Fragmentation: There is no compact adult social care 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 5500 different providers. 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 – the privatisation of care alongside 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 adult social care 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. Either through financial collapse or strategic withdrawal the market model is at tipping point.

There is a growing view that the problems associated with the outsourcing of adult social care need to be addressed, but if no ‘big bang’ change is feasible, what are the alternative options? Better and fairer funding is a prerequisite but the local state (as the biggest commissioner of services) and national government (as policy-maker) can also act in other ways that could create better care quality and reshape the provider mix. Four dimensions can be identified: commission local and small; commission holistically; commission individually; and commission ethically.

Commission Local and Small

The trend, especially in the residential sector, is for small operators to be replaced by large provider chains with more than fifty care homes which in turn house up to a hundred residents each. A focus on smaller and more local commissioning is needed to counteract this trend. Small organisations hold vast expertise about the issues affecting people locally and can serve very specific communities of interest. Moreover, much of what they do focuses on bringing people together which ties in closely with the policy focus on loneliness, ideas around Asset-Based Community Development, and on supporting communities to rebuild their own social infrastructure by harnessing community businesses.

Complementary to this is the concept of Local Wealth Building, 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 here 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. Central government also has a role to play here, for example by minimising corporation tax rates for small local businesses.

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. However, market-shaping is a much broader strategic task spanning several council departments and other partners – social care, transport, housing, economic development, health, 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 local governance.

Commission Individually

Policies on access to social care support have created two groups of ‘individual 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 ‘customers’ 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 – 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 Competition and Markets Authority  raises the prospect of enforcing consumer law, but others will take the view that it is simply not possible to replicate a market with informed ‘consumers’ in the social care sector. However one option that can work for some people is that of personal budgets and more recently personal health budgets, though here too there are issues to be resolved around matters like making choices and decisions; receiving information and advice; budget management, monitoring and review; and risk management and contingency planning.

Commission ethically

Ethical commissioning could include 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, and encourage staff to participate in collective bargaining.

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.

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.

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.

The privatisation of adult social care in the UK has an unusual policy trajectory compared with other sectors. Devoid of any real debate or stated purpose, a 30-year process of outsourcing has grown 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 serious 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 can, over time, reshape ownership structures, increase provider stability, focus on ethics rather than cost, and enhance the quality of care.

First published on the British Politics and Policy blog

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An update on the work relating to the joining-up of health and social care in Cheshire West and Chester and a view on the next steps. This is a fast moving agenda and often people get just one part of the story.

Jigsaw of services

A fragmented system 

First of all its worth recapping on the fact that health and social care have very similar challenges but remain fragmented. Health fall under the purview of the NHS covering things like GP services, community health services and hospitals. It is ultimately accountable to the Secretary of State and free at the point of delivery. In Cheshire West and Chester, health care is commissioned by two clinical commissioning groups. One for the Vale Royal area covering Northwich, Winsford and surrounding areas and another for West Cheshire covering Ellesmere Port, Chester and surrounding area. Ideally we would like one commissioning geography so we have a common approach across the Borough.

Social care covers support that maintains people’s independence covering issues such as mental health, physical disability, learning disabilities and support to older people. It provides or arranges services following an assessment and is means tested. Its accountability is to local elected Members.

Both health and social care are currently experiencing massive challenges in demand as people get older and conditions become more complex. Funding is not keeping up with this demand.

Something needs to change both in terms of investment and the way services work. I want to emphasise however that its been made clear to us by the Cabinet that the shared public service ethos of the NHS and social care need to be preserved. The answer can’t be to encourage the market to fill the space. Actually the direction we have been given is that collaboration rather than competition is the answer.

One of the major issues is that services can often be reactive and only kick in once somebody is unwell or in crisis. Some of this is because the range of services across health and social care are fragmented and don’t  join up to prevent people from needing intensive support.

Often GP services are not connected up with hospital services. Community services are not joined up with social care. We have separate processes, separate budgets and separate ways of working. This leads to missed opportunities to intervene early to support somebody to lead a healthier and more independent life.  This is not the best use of public resources but also isn’t fair on our residents who can see that the left hand isn’t talking to the right hand.

Local challenges

At the local level we have a number of challenges where we feel the further  joining up of health and social care would make a huge difference.  Obviously it’s great that people are living longer but often this means we will have people living with multiple conditions that require a joined up approach over health and social care.

We have issues with health inequalities and poor lifestyles particularly in our more challenging areas.

  • Our demand at A&E is at very high levels.
  • We have too many delays of residents from hospital to other settings, reducing capacity in our hospitals.
  • Our GPs are under pressure to support the most complex patients.
  • Wider staff are under pressure to deliver the best possible care.

Financially, in the West Cheshire area, it’s been estimated that unless the way we work changes, we face a financial gap, mostly in the NHS, of around £65 million by 2021. We’re fearful this could lead to some form of top down intervention in the NHS where we lose the ability to set our own destiny. This is already happening, to some extent, in the Vale Royal area.

What this means for vulnerable residents

Not joined up services

But these are all organisational challenges. Ultimately the biggest challenge faced is that our residents are not receiving the care and support they need. They can’t understand why things can be so fragmented particularly if they have complex needs.

What integrated care looks like? 

So what would more integrated look like and how could it help? Well this video provides some background. Its been produced by a national health charity known as the Kings Fund and I think is sums it up very well.

Emerging national policy 

This challenge has been recognised by national politicians and the needs for more integrated care was a key feature of the latest Labour Party manifesto.

Some guiding principles 

Labour will focus resources on services to provide care closer to home and deliver a truly 21st century health system. We will work towards a new model of community care that takes into account not only primary care but also social care and mental health…..

The National Care Service will be built alongside the NHS, with a shared requirement for single commissioning, partnership arrangements, pooled budgets and joint working arrangements. We will build capacity to move quickly towards a joined-up service that will signpost users to all the appropriate services at the gateway through which they arrive.

Our response

  • We will focus on change that benefits our residents rather than just structures
  • We will make this local and bottom up. This is not being driven by the STP and we will  take action to avoid this being ‘done to’ us through a top down reorganisation
  • We will ensure full public engagement throughout this process
  • We will not participate in any competitive procurement process or participate in any process that reduces the public service ethos and leads to fragmentation
  • We will make the case for additional funding to NHS England and central Government
  • We will push for one health and social geography that reflects the local authority boundary
  • We will fully engage and protect our staff through this process
  • We will only proceed if there is a sound business case and political support
  • We will ensure that the governance incorporates the local democratic mandate and fully link into the Health and Wellbeing Board

 Its hopefully helpful to set out what we’ve already done around integration and what the next steps may look like.

  • Back in 2013, nine integrated care teams were set up including GPs, community services staff like District Nurses, social workers and support staff. Their job is support people with complex conditions, particularly those at risk of needing hospital care and residential care.
  • We have also worked with NHS colleagues on a single care record to bring together vital health and social care information into one place. This enables to take a joint approach to planning care and avoiding people having to tell their stories many times.
  • We have recently joined up our reablement teams with a similar team in the Countess of Chester. This was designed to ensure people can be supported to get back home as soon as possible.
  • We have pooled around £100m of health and social care funding through something called the better care fund which enables us to make joint decisions on resources to support the public rather than just thinking about the separate resources for each organisation.
  • Our A and E in the Countess has enhanced its services and created a new facility in the hospital to support urgent treatment and avoid admissions where they are not necessary.

We think the next step however is to bring all this good practice together into a much more robust integration programme. This will ensure that the actions we take are better coordinated and implemented with real rigour.

The step after that, some years down the round, may be to develop something called an Integrated Care Partnership. This is where you take integration to its full extent and you would have one budget, one management team, one set of outcomes, one local governance approach, one public sector approach and one clearly defined way of working. In other countries this has been called an accountable care organisation but we don’t use that term as it’s often confused with the American model where the profit motive and the market drive health and care. Clearly that’s not the model we want to follow.

What this means for our residents

Already the joining up of care is benefiting local people. This case study outlines where an integrated approach has delivered a better service that has avoided wasted time for staff and most importantly our residents.

Mary, 85, has memory loss, is deemed “frail elderly” and has an allocated social worker named Ann. Ann receives information regarding a potential safeguarding concern relating to financial abuse by Mary’s family members.

At times, Mary can be reluctant to engage in support from social care, making co-ordinating support for Mary difficult. With integrated care, by carrying out joint visits with health staff, professionals are able to build a trusting working relationship with Mary. By working jointly with the community matron, Ann is able to complete a detailed assessment of Mary’s needs, including looking into the safeguarding concern, using information provided by health colleagues that would not have been available without an integrated approach.

On one occasion, Mary develops a Urinary Tract Infection and becomes extremely confused very quickly. Mary is deemed to be unsafe to remain at home and, working jointly with community matron colleagues, Ann is able to quickly access respite care for Mary to prevent a hospital admission. Mary is now back at home and tells staff she feels well supported.

Full integration programme

We think our immediate next step is to make the case for comprehensive integration programme that will make a real difference on the ground. This would precede any more radical change such an Integrated Care Partnership.

It would involve bringing the health commissioning team in the CCGs together with the local authority commissioning team so we take a common approach. This would perhaps be quicker to do for the West CCG area initially as the commissioning team in vale royal also links into East Cheshire council.

We will develop new care pathways for our residents, working  with clinicians and social workers, so there is real clarity on care can be joined up around individuals. We also want to improve the way our integrated teams operate. Having been in place for around 4 years we want to ensure they have the tools and resources to support people in the community.

A key priority for us to take further joint action to avoid residents being delayed in hospital and not getting home in a timely way. This involves joint ways of working between health and social care, more information sharing, better planning  and more capacity in the community to support local needs.

Our single care record could be enhanced further so that further information can be shared to inform joint working.

Our information, advice and guidance we will look to join this up with the NHS so that our residents know where to go for support. We’ll also be looking to join up our data and intelligence to better target our resources at people with complex needs.

What next? 

Following the implementation of this programme, one possible destination could be an integrated care partnership. This would take integration to its full extent. It would involve health and social care coming together into one unified arrangement.

Integrated care partnership

This would involve joint governance through the health and wellbeing board and a integrated care partnership board. It would be supported by one commissioning team, one management structure and one pooled budget that could be up to half a billion pounds.  The budget and responsibility to pull the system together would sit with one existing organisation. This would very likely be an NHS provider due to legislation and the fact they would be contributing the majority of the resource.

The service delivery would remain in the public sector and involve all local NHS services and some adult social care services. Until the concept has been proven and we have the same geography with health we cant put all services in this arrangement initially. We would also start with any staff being transferred  through secondment rather than TUPE

Where else is this happening?

This model has just been put in place in Salford, a Labour controlled Borough.

Salford Together logo

The area had delivered a very similar integration programme since 2014 and felt that the next step was to take integrated care to its full extent.

In July 2016, local leaders established a new joint commissioning board, comprising city councillors and GPs from the CCG’s governing body, to oversee a larger pooled budget of £236 million for all adult health and care services (excluding specialised services).

Under the new arrangements, the city council and CCG  direct Salford Royal Hospital Trust to deliver or manage a range of adult health and care services. In mid-2016, the council transferred its 450 social care staff to Salford Royal to undertake assessments and contract for the provision of adult social care support. This means that Salford Royal will deliver a large proportion of the services, including acute care, community health care and some social care services in-house.

Potential timescales 

So what does this journey look like in terms of timescales? If Members are supportive we will resource up for a full integration programme as soon as possible. This would be supported by a team with the best talent from across health and the local authority. Its initial focus would be for West Cheshire but we would also look to put in place arrangements with Vale Royal.

Also we will lobby heavily for a single health geography that aligns to the local authority’s boundaries

We can start further work thinking about the feasibility of an integrated care partnership but this will not be the priority. The key focus will be on changing services on the ground. Any business case for a more radical arrangement would need to follow and be a Member decision.

In 2018 we will start to see further changes on the ground, with the majority of the projects delivered by 2019. Only after that point would any integrated partnership go live by which stage we hope to have moved to a single health geography.

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Every winter, the crisis of care deepens. Here we are, in the eye of the storm, with the contradictions glaring out from the abyss. 10+ hour waits at A&E, causing countless unreported harms in delayed treatment. It’s upsetting to think soon, someone is likely to die in the corridor, just as last year (The Guardian, 2017)

The infamous Corridor is usually where patients are taken by Ambulance when they are unable or unsafe to walk (e.g. the bedbound, the nursing home resident) or when their condition requires continual assessment & management (e.g. amber-flag sepsis, breathing difficulties on oxygen etc.), but are not life-threatening (heart attacks, strokes, etc.). When the Ambulance Triage bay is full, patients queue on beds on Corridors, waiting to be moved into the bays and triaged. With hospital staff unable to safely care for the numbers on the Corridor, ambulance staff remain with the patients until able to handover. Ambulances parked at A&E cannot respond to life-threatening calls. Not only this, I have seen colleagues waiting 2 hours beyond the end of their already long 12 hour shift (and remember, we usually do 4 in a row, and many are now on 6+), unable to go home due to A&E delays. This has a massive impact on morale and fatigue, and subsequently, the care that clinician is able to give.

The question may be asked: If the corridors are full of patients brought in by Ambulance, why are Ambulances overloading A&E? This is the question I wish to address in this article.

On top of the everyday demand of people who are genuinely ill and require A&E admission, it is possible to point to categories of Ambulance/A&E patients that don’t require admission and therefore, are contributing to the crisis on the corridors. No, I’m not talking about drink or drugs.

The first one is the policy of Residential and Nursing Homes (I’ll refer to them collectively as ‘care homes’) to outsource medical care to the state, despite residents paying in the region of 4 figures per month for care. Rather than invest in falls prevention and staff trained in health assessment (such as Advanced Nurse Practitioners, Paramedics or Emergency/Urgent Care Practitioners), many homes state that carers must call 999 (some are generous and allow for 111 – which usually results in an ambulance in any case) for any medical condition – emergency or not. I have personally been to numerous 999 calls (and 111 referrals) for simple coughs, colds, chronic pains, or low energy falls or slips out of bed with no injury. Often, by the time we arrive, the resident is soundly asleep, and receive a surprise awakening at an uncivilised hour to have Ambulance crews poke and prod for a short time, hopefully without shipping them off to A&E.

In this way, care homes absolve themselves of any financial responsibility towards the medical side of a patients care (except in nursing, where medications and some care is given, but no health assessment, diagnosis or management which requires further training).

As a Paramedic, it is my opinion that the NHS is indirectly subsidising privatised social care, with the proceeds going into care home profits, with no incentive to reduce the bill to the state, and no incentive to invest in prevention.

Why would a capitalist invest £100k/year+ in a team of Paramedics to provide care within the home in order to prevent drawing on the state’s resources, or invest in falls prevention, with no financial incentive to do so? I stand wholly for the re-nationalisation of care homes into the NHS system. However, while we blindly hang on to a mixed system, it is important for the NHS to look at charging care homes for state resource use, thereby incentivising investment in preventative care. This will, of course, introduce its own corruptions and contradictions – an incentive to not call 999 may put genuine patients at risk, for example. This illustrates that incentives are merely a plaster, and nationalisation is the only cure.

Research has been undertaken to understand the medical picture in care homes (Smith et al., 2015), and they correctly point out that care home patients have more complex needs than the average elderly population, requiring more admissions than average. However, they miss the underlying profit motive for over-engagement with emergency services, and the reasons for high conveyance rate by Ambulances to A&E.

The Mirror (2018) recently reported that ambulance conveyances had risen 62% from Care Homes since 2010. This will be partly a function of the aforementioned increased engagement with emergency services. However, to understand why there is a high conveyance rate from Care Homes by Paramedics, many of which are for ultimately non-emergency conditions, one must understand that Paramedics are formally trained only in emergency conditions – those that go to the ‘Resuscitation’ area of A&E. We pick up the non-emergency conditions as we go along, but that doesn’t make for confidence in discharging on scene. Combine that with a culture of fear imposed by management in the Ambulance Service, especially the fear that a wrong decision could see you sacked, and you end up with conservative medicine, and a large number of nursing and residential home residents in the Corridor at A&E with non-emergency conditions.

A similar process plays out as a result of a computer triage system employed by 999 and 111 with inherent vulnerabilities that cause a large number of ambulances to be sent to the same non-emergency conditions in the community (More in depth analyses of this issue can be read here and here). Without training and confidence to discharge without further care, and when alternative pathways are closed or oversubscribed, they end up in the Corridor at A&E.

When the Ambulance Service is being flooded, the first place one must look is how we manage the floodgates. A computer has not made an adequate gatekeeper, and clinicians must return to the role in order to correctly manage demand.

Many alternative pathways being closed is another major factor in large numbers of conveyances, leaving paramedics isolated and without choices for safety netting. Paramedics, despite the lack of training and the fear, try incredibly hard to refer to other services if possible. A ‘Safety Net’ allows ambulance clinicians to feel more comfortable discharging on scene. Long established services have been closed due to CCG budget cuts. Also, many new trial alternative pathways are introduced during office hours, when most remaining services (such as patient’s own GP) are already open. Unsurprisingly, these are undersubscribed, and are often closed soon after. The problem doesn’t disappear during office hours – it is incredibly difficult to get a same-day GP appointment – but it is especially prominent out-of-hours. It is during the night and on the weekend when ambulance clinicians are left isolated, and it is easy to see why many take the safe option of conveying to A&E.

The Corridor is a result of a perfect storm: Emergency Ambulance Clinicians being sent to non-emergency calls without the correct level of equipment, training or support, left without a suitable alternative pathway, in the face of media attacks and fear of repercussions from management, are practicing conservatively and filling up A&E Corridors.

To stop the Corridor Catastrophe, the Socialist Health Association should stand for:

  • Renationalisation of Care Homes & the rolling out of Health Assessment staff and falls prevention schemes. In the interim, a charge to the Care Home should be placed on Emergency Service contact. Both should result in lower 999 engagement, and more preventative medicine investment, lowering the number of conveyances to A&E.
  • The reintroduction of ambulance clinicians with medical support as gatekeepers to the 999/111 system, abolishing the use of computer triage. A well trained Ambulance Clinician on the phone with adequate support will be able to assess and manage calls more efficiently than a clinician in an Ambulance. Correctly directing non-emergency demand away from emergency-trained clinicians will lead to less conveyances in the name of conservative medicine, and free up ambulances to deal with true emergencies.
  • The establishing of a separate urgent care service which can draw on the great work done by Ambulance Clinicians in the urgent care field, and the advantages of mobile assessment, and can progress in delivering the right care with improved training, equipment and GP support, without impacting the safe delivery of emergency care. This service can bridge the gap between emergency and primary care, taking the pressure off A&E.
  • The adequate funding of alternative, community pathways to take the pressure off A&E.
  • The introduction of a ‘Just Culture’ within the Ambulance Service to enable Ambulance Clinicians to feel able to give the correct care for the patient, not the correct care to keep their job safe.

James Angove is a pseudonym. The author is a socialist and a paramedic in the UK, whose identity must be hidden due to the treatment of health care professionals and other whistleblowers who talk about issues within the health service.

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What is larger than the UK’s entire economy, soaring in price, wildly profitable, the leading cause of personal bankruptcy, bankrupting the United States and a massive economic bubble that nobody has heard of yet? Healthcare in America… a modern-day gold rush is on as young Americans clamour for healthcare careers in the same way that young adults were jockeying for technology careers at the peak of the Dot-com bubble in 1999.

The US approach to health and social care provision continues to exert defining influence on the possible futures of UK provision and at least some can see the dangers inherent in this. How can we understand developments in the US and how does this arm us to understand – and intervene in – developments in the UK?

The US spends more on health than any other country in the world, nearly a fifth of its GDP in 2015 compared with 9.1 percent in the UK, 11.2 in Germany, 5.5 percent in China and 4.7 in India (all figures for 2014). In 2015, US health care spending reached $3.2 trillion, or $9,990 per person. Primarily, increased spending was driven by rising costs for private health insurance, hospital care, physician and clinical services. Alongside this, rising general poverty meant more people drew on Medicaid and Medicare, state health benefits for poor US citizens. The price of drugs continues its inexorable rise, rapidly soaking up state benefits which have failed to keep pace with rising health costs.

This rising cost context of health care has seen share prices in health-related industries soar. In 2017 three vast health conglomerates were in the top 10 of the US Fortune 500 – each of them richer than former market giants such as General Motors and AT&T. Health market leader McKesson is a pharmaceutical distributor and health technology developer. Another, United Health, a health insurance provider, has over 100 million customers globally.  Health industry mergers in the US have been accelerating over the last 15 years, peaking in 2015 and 2016 in a process of what Marxist would call the centralisation of (health) capital. In 2015, the record year for M&A in the sector, total deal values were in excess of $100 billion, over a third of the total UK GDP for that year.  Mergers and Acquisitions in health industries is a worldwide phenomenon with, in the UK, M&A in the sector actively promoted.

The global expansionist ambitions of the US health industry helps drive this trend, and capital is currently being sucked into global health industries as never before by the promise of what is known as the “Rising Billions”   Over the next five years, between three and five billion new consumers world-wide will become connected to the internet. The ‘Rising Billions’ are consumers of goods and services, but are also patients in need of medical care and medical commodities, so called ‘health customers’. Alongside the health commodities these health customers might consume, eHealth systems are areas of profitability for the health industry giants. eHealth includes things like, for example, systems of communication between health providers and practitioners and remote health monitoring, potentially useful areas of innovation. Problems arise, however, when this technology is used to enhance profit rather than service provision. For example, virtual consultations between doctors and other professionals and patients, another growth area, bring the possibility of doctor ‘call centres’ advising patients from anywhere in the world steps closer radically changing doctor-patient relationships and health professionals roles and status.

This technologically-driven approach to health and social care is already evident in the UK. For example, Jay Strickland, director of Southwark Council’s Adult Social Care department quoted in the Financial Times  extols the virtues of using motion detectors to replace care workers in older people’s homes: ‘We could pop in at lunchtime to see someone…[But at] five past one, she could be on the floor. So there’s no real value to this.’ Once a motion detector system of monitoring patients has been embraced, then there’s no need for monitoring staff to be in the same borough or city, or even country. Again, a call centre approach is implied here, perhaps with a smaller care staff on standby locally to attend in a crisis in this neoliberal ‘Just in Time’ approach to health care delivery.

A key driver behind the avalanche of UK legislation over the last five years is the aim to construct a legislative framework in which new, privatised, joint institutions of health and social care can be developed. Twenty three so-called ‘vanguard sites’ have been tasked with exploring new, population-based market-oriented for profit models for local health services. Multispecialty Community Provider (MCP) and Primary and Acute Care System (PACS) vanguards are aiming to integrate NHS services and social care. The MCP care model is described as a ‘new type of integrated provider’ which aims to combine the delivery of primary care and community-based health and social care services. Importantly, this will include providing ‘some services currently based in hospitals, such as some outpatient clinics or care for frail older people, as well as diagnostics and day surgery’.   In other words MCPs are vehicles for shifting some NHS provision into the Independent Sector for private capital to run at a profit.  PACS are non-hospital based private health and social care provision, seemingly expanded versions of MCPs. The Kings Fund says of PACS:

Under this new care model outlined in the NHS five year forward view, a single entity or group of providers take responsibility for delivering the range of primary, community, mental health and hospital services for their local population, to improve co-ordination of services and move care out of hospital.

While some vanguards continue to use informal partnerships, commissioners and providers in many areas are putting in place more formal governance arrangements – in some cases describing the new arrangements as integrated care organisations (ICOs) or accountable care organisations (ACOs) or systems. In April 2017 this direction of travel was taken to its logical conclusion when health leaders in Manchester’s NHS and social care commissioners offered a tender of £6 billion over ten years for one organisation to provide all ‘out of hospital’ health and social care provision. Their tender document sets out plans for ‘local care organisations’ to provide all non-acute services – including social care – across the city. The LCO will hold a single 10 year contract to provide services for a population of around 600,000 people. Meanwhile, neighbouring Stockport’s vanguard project, which is somewhere between a MCP and a PACS, is being developed without a competitive process. The standard MCP model set out by NHS England incorporates primary, community, mental health and social care services, but leaders in Stockport are looking to expand this to establish a privately-run health conglomerate also providing hospital services including the emergency department, acute medicine and frail elderly care. Clearly, the care models can be moulded to the needs of the local authority, so long as they are focussed on releasing more of the state health sector to private profit.

This commitment to a qualitatively greater amount of funding in one tranche to the Independent Sector comes very swiftly on the heels of the first experiment in this direction, when Circle Health took on the running of Hinchingbrooke Hospital in Cambridgeshire. The contract to run the hospital was supposed to last from 2012 for 10 years and was worth £1bn. Circle announced its intention to quit after less than three years saying the contract was “unsustainable”. In September 2015 the Care Quality Commission found that patients were being neglected at the hospital, that hygiene was inadequate, and that staffing problems were affecting care.  Clearly, practical lessons will have been learnt from this total failure. However, the key one won’t have been – that the failure is a consequence of attempting to run health and social care to previous standards of delivery for profit. As the disasterous privatisation of the social care sector in the UK over the past twenty years has clearly shown, this is not possible. The problems at Hinchinbrooke and the problems of the social care sector were not caused by ‘inefficiencies’ or ‘poor execution of service’ but by the US-inspired health provision for profit model itself.

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Their quest to ‘inspect’ quality into care homes is futile.  Turning them into a proper regulator makes much more sense.
The CQC should have total powers over the sector.  Clear accountability and someone to nail if it goes wrong.
I can think of a dozen new powers:
  1. Develop and publish an annual, independent, strategic assessment of the sector, with recommendations for government on the realistic cost of care and funding levels.
  2. Provide national model-contracts for care home providers, so the public know what to expect and where they stand.
  3. New powers to decline any home registration that does not have a CQC recommended safe staffing and skill-mix.
  4. End the difference between care homes and nursing homes.
  5. Develop accredited training for the care-home sector workforce.
  6. Publish clearer ‘Which’ style reports on care homes, making it easier for families to chose through an improved, user friendly website and help line.
  7. Publish ‘advisories’ on the viability of care home operators and prepare contingency plans for failure.
  8. Create a centre of excellence making it easy to find and share best practice.
  9. Provide an easy to navigate complaints and dispute resolution service.
  10. Create an identifiable, accessible local presence, that includes elected members, to improve public confidence in the CQC and democratic accountability.
  11. New powers to prevent differential charging between the LA and private sector clients.
  12. Powers to require care-home providers to post a performance bond to guard against the cost of failure.
Focussing these functions, in one place, makes one organisation accountable for the care home market, its conduct and it gives the CQC something useful to do…
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The Grenfell Tower fire has shaken many aspects of the prevailing British political culture. Most strikingly for me, in the aftermath of the fire, Tottenham MP David Lammy gave an interview in which he argued that ‘people want the social back’. This is a potent image, but what might it mean? And what might be the implications for social policy? Lammy was pointing to the wilful erosion, if not eradication, of the social fabric of life in British cities — in particular, to the ways in which supportive social relationships were previously interwoven with, and sustained by, public services and the welfare state. How might we go about bringing the ‘social back’?

David Lammy

The sentiment that Lammy articulated was clearly not just a nostalgia for ‘community’, not least since it was precisely the community — embodied in a range of social networks, churches and other voluntary organisations — that formed the front line of support for the fire’s survivors. This happened, noticeably, in the absence of the local state, as Kensington and Chelsea Borough Council faded from view. Nor was it a call for the Cameron fantasy of the ‘Big Society’, since this was precisely one of the big ideas, along with austerity, that enabled the erosion of public services and welfare provision through the meretricious claim that the ‘big state’ had crowded out the community spirit and voluntary ethic.

And yet, neither should it be seen as a simple returning to the pre-1979 ‘golden age’ British welfare state. Lammy certainly saw the importance of public infrastructure and support for building dense social connections, talking about Tottenham in the 1970s and 1980s where ‘there was a proper civic society, we had a civic glue. A lot of that has gone’. And yet, despite the nostalgia, the ‘golden age’ of welfare statism was not quite so golden, especially in its Labourist form in the UK. The ‘universal’ welfare state was constantly contested over the limits and conditions of universality, around race/ethnicity, gender, disability and more. Its disciplinary character and its conditionality were also the focus of challenges. Tottenham in the 1970s was not immune to such divisions or to their contestation.

Rather, I want to suggest that we understand David Lammy’s statement as a call for a future ‘social’; an expanded and expansive ‘social’ built around social solidarities constructed in the face of diversity. Such solidarities need an infrastructure of local and national state services that provide support, promote a sense of social security and belonging, and enable individual and collective development. Above all, they demand forms of state that treat citizens, in whatever form they appear, with respect. As the local council’s policies and practices, underpinned by national political directions, made clear, the erosion of the social has involved denial, disdain and disenfranchisement on the part of public authorities.

Most of this is familiar to those who study social policy. Collectively, we have traced — for a very long time — the decline of the social, eroded through neoliberalism’s many anti-social projects, from the Thatcherite claim that ‘there is no such thing as society. There are only individual men and women and there are families’, through decades of contracting out and selling off the public realm, to the more recent eviscerations from policies and practices driven by austerity talk. Connecting them is an underlying claim that ‘we can no longer afford’ these things. The Grenfell Tower fire has demonstrated just how the costs of not affording these things have been distributed — and why a public infrastructure for the social urgently needs to be reconstructed.

In the shadow of the Tower, we can now look back and see the loss of the social. What we have lost is marked in the abandonment of public housing and the denigration of its tenants, not only, if most obviously, in Kensington and Chelsea. We can feel it in the strained and straitened public services from schools to hospitals, wracked by endless programmes of reform but shorn of basic funding. It can be traced in the demonization of the poor and those dependent on welfare. We can see it in the wholesale degradation of the public realm, the wanton promotion of private interests, and the cynical fostering of social divisions.

But the shadow of the Tower also marks a combination of horror, revelation and possibility. The horror at the event itself has been combined with horror and revulsion at the conditions, practices and attitudes that the fire and its aftermath revealed. But it is also a moment of possibility: the possibility of anger, challenge, and contestation. Such reactions bring into view the potential for reconstruction; not just of the housing and lives of those shattered by the fire, but of the social itself. David Lammy is surely right and many of us now ‘want the social back’. The urgent challenge for social policy is to think about how to contribute to a project to build a future in which a new social can be realised.

First published by the Social Policy Association

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Long-term care is a policy chestnut which seems to resurface every couple of years, under UK governments of all colours. Each time there is extensive analysis and review undertaken; much handwringing about how costly any approach will be; and various options are considered and rejected. Green Papers, White Papers and even legislation may follow, before the process grinds to a halt once more, and the issue is parked in the ‘too difficult’ red box until such time as it becomes expedient to have another go. So here we are again.

The launch of the Conservative Party manifesto during the general election campaign in May 2017 saw Theresa May signalling a volte-face on long-term care and shelving the implementation of the capped cost model, only recently enshrined in the 2014 Care Act, and yet to be adopted. The chaos which followed, with attempts at offering ‘clarification’ on the policy, underlined the lack of any coherent policy or any evident grip of the issues. The bear pit which the manifesto had unwittingly dug for the Party was apparent in the critical reaction to the so-called ‘dementia tax’, and the failure to resolve the matter was probably at least in part responsible for the Conservatives’ fall from grace and the loss of a majority at the election in June.

long-term care

Since the summer, what should be done about long-term care has been the elephant in the Cabinet room. Like many other issues, it has been overshadowed by the ongoing uncertainty, confusion, and turmoil of Brexit, to which everything else continues to play second fiddle. Nonetheless, the Queen’s Speech had acknowledged that the government would “bring forward proposals for consultation” on the future of social care. Since the speech there has been little or nothing to indicate when or if such a consultation would occur; there was considerable speculation that a paper might appear in the autumn, but nothing emerged.

Finally, on 16 November a written statement to Parliament from First Secretary Damian Green  announced that the government will “publish a green paper on care and support for older people by summer 2018. The paper will set out plans for how government proposes to improve care and support for older people and tackle the challenge of an ageing population.”

This is not a social care green paper. As other commentators have also pointed out, the focus is solely on older people. Care for younger disabled adults, including people with a learning disability will not be part of the green paper but will be addressed by a parallel programme of work across government. Failing to address the entire population needing care and support – or who may do so in the future – is short-sighted; many younger adults with disabilities or long-term conditions will become older people with those conditions – how will the transition between those age groups be managed? There is already considerable disquiet about age inappropriate facilities for younger disabled adults; people with degenerative conditions who find there are no residential facilities for their needs and that they are placed instead in care homes for older people lacking specialist facilities for their needs.

There are risks too that a segmented approach to long-term care policy will deepen divisions between generations and encourage the already entrenched and negative view of older people solely as a burden on the rest of society. There is an opportunity for a new social contract to be developed that unites generations and spreads risk across populations, but it won’t be addressed by an approach that salami slices needs in this way.

A further glaring omission from the green paper announcement is any mention of family carers. A new national carer’s strategy had been in development in 2016, and involved extensive on-line consultation. The website for the strategy states blandly ‘we are analysing your feedback’, but was last updated on 2 June 2016, so that seems unlikely. It was widely anticipated that the delayed strategy would instead be incorporated within the green paper, but there is no sign of it, and the failure to address the needs of family carers who continue to provide the majority of care and support is deeply troubling.

The green paper is not imminent; Damian Green’s statement indicated it would be published “by summer 2018”, so there are several more months of inaction, uncertainty and worry for people concerned about whether and how they will pay for care.

The failure to square the circle on social care and develop a solution that is equitable, affordable, transparent and sustainable, is of long-standing. The repeated dodging of the issue dates back at least two decades, and indeed the fault line between health and care established in 1948 is, in many ways, at the root of the difficulty of distinguishing between universal and means-tested health and care services.

It is increasingly evident that short-term patching of the system cannot work. The much-cited ‘additional £2bn’ allocated to social care over three years barely touches the sides and fails to address the underlying deficiencies. At the same time an attempt to develop a non-partisan cross-party solution is in play with 90 MPs signatories to a letter to the Prime Minister on 18 November urging a new approach. The need for the Budget to address short-term pressures on the system is part of the demand, but more fundamental is the “proposal to establish a cross-party process in the form of an NHS and Care Convention in order to deliver a sustainable, long term settlement”.

Without such a fundamental approach it is hard to see how the challenge of funding social care will be resolved. The history of the past two decades – from the Royal Commission on Long Term Care established in 1997, through multiple Green Papers, White Papers, Commissions, reviews and legislation – points to the complexity of the task and the failure of successive governments.

The Local Government Association has acknowledged that “difficult, brave and even controversial decision-making will be required to secure the long-term future of care and support” for adults of all ages, and for carers who support them. But there is no alternative; politicians have circumnavigated this issue time and again; failure to find a lasting solution which has genuine cross-party commitment will lead inevitably to a replay of broken commitments, flawed legislation, and short-term political opportunism. This is unfinished business crying out for resolution, not another version of Groundhog Day.

This was first published on the  British Politics and Policy blog

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The UK has had a policy of competitive tendering for public services since the 1980s; this is despite the fact that there has been no research evidence of its success. At the heart of this policy are a set of policy rules, set by central government, which force local government into using a competitive tendering process to ‘purchase’ public services. These rules are often called EU Procurement Rules, although the UK has twisted these rules to make them harsher and more damaging. For instance, most countries exclude services like social care from competitive tendering – but not the UK (nor, so far, Finland). This is another example of how the UK often falsely blames the EU for its own rules. It is likely that competitive tendering has played some part in alienating the British people from the European Union.

A personal perspective

Competitive tendering began in the 1980s, but it became central to all social care (support for people with disabilities, including the elderly) after the 1992 NHS & Community Care Act. From this point onward local government was forced to become a ‘purchaser’ of services, while the private and non-profit sectors became ‘providers’.

These changes happened at the beginning of my career and much of my early thinking and practice was focused on trying to make sense of these changes. More experienced colleagues were more pessimistic than me, they believed that these changes would be wholly negative. However I felt that these changes, whilst dangerous, did present some opportunities for positive change.

In 1996 I wrote my first book Unlocking the Imagination where I argued that the model of commissioning proposed by government was wrong; however I tried to persuade local leaders to adapt that model to design a better system to promote inclusion and empowerment for local people. But it turned out that I was naïve and that my colleagues were right. The UK’s system of competitive tendering has been very harmful and there have been no serious efforts to reshape it into one that promotes better values. The dominant neoliberal ideology, which has reduced everything to financial transactions and contractual control, has won the day.

The only successful challenge to competitive tendering has come from those people who have managed to exit the system, by demanding control over their own funding. First the 1996 Direct Payment Act allowed people to ask for their own budget, instead of a service. In 2003 I led a project called In Control to individualise all social care services using personal budgets. These initiatives have had some success, but they have come into conflict with the established system:

  • We said, give people and families control, because they know best
  • The system said, no we need even more control, because we know best

Today, in England, less than 25% of the funding has been individualised, most funding remains locked inside the competitive tendering regime.

The impact of competitive tendering

The impact of competitive tendering has been wholly negative and it has caused a number of serious problems, each of which has got progressively worse over time:

1. Lowering costs by cutting frontline salaries – When competing for funding the easiest way to win a contract is to reduce the salaries of frontline staff. However, and at the same time, salaries for senior managers have rapidly increased, so the level of income inequality inside organisations is now extreme. For example, the CEO of an NGO (Non-Governmental Organisation, often called a ‘charity’ in UK law) may be earning €210,000 pa whilst frontline staff may be on €16,000 (a ratio of 13:1). Social care has also seen rapid growth in precarious work: zero-hour or short-term contracts. Things have got so bad that many NGOs can no longer afford to meet minimum legal standards for pay and have been lobbying government to be exempted from these standards. It seems shameful that some NGOs are campaigning to keep standards lower rather than fighting for better rights for disabled people.

2. Increased compliance and reduced advocacy – In the past NGOs acted as advocates for people and for important causes; however today their independence has been eroded. They are very reliant on government funding and they can lose funding very quickly. Today NGOs provide little meaningful advocacy and this has contributed to the deep cuts in social care – 700,000 people have lost support since 2009 – a cut of over 40%. This was one of the major reasons why the United Nations recently condemned the UK Government for using its austerity programme to target cuts on disabled people in breach of the UN Convention.

3. Toxic culture of mistrust and regulation – The financial, bureaucratic and transactional focus of tendering damages the quality of relationships within and between organisations. Anything too warm and human now seems suspicious and contrary to the principles of tendering; only bureaucratic processes can be trusted. This has created a culture of mistrust which has infected almost every aspect of social care. It is assumed that government only wants to save money, service providers only want to make profit and that staff are all potential abusers. Every problem is solved by adding more rules, regulations and penalties. John O’Brien has called this new world Cog World, and its spirit is entirely hostile to the purpose and nature of social care and independent living – it is like expecting a robot to dance.

4. The death of creativity – Before the era of competitive tendering most innovative work was carried out in the NGO sector and it was common for NGOs to cooperate with each other and with government. Today’s NGOs now compete with each other for work and fear cooperation. The tendering process has also killed creativity. Government officers who issue contracts for funding will never be a source of creativity; it is only people, families and practitioners who can develop creative solutions to problems. This is the true source of efficiency and positive social change. Competitive tendering creates organisational chaos, yet it is fundamentally conservative. Commissioners are constantly purchasing last year’s solutions. Contracts that are ripped up every three years will never foster real creativity, which demands time, commitment and the capacity to take risks. Competitive tendering is like gardening with hand grenades.

The myth of the social care market


Although there is no evidence to support the use of competitive tendering the idea that this is a reasonable process is sustained by a series of myths and linguistic tricks. We apply important sounding language from another world and then imagine a reality that does not exist. In the process we become blind to the critical damage that is being done. For instance, Government often refers to a social care ‘market’ but this is an illusion. In the current system:

  • Government decides what people and families need
  • Providers do the work on behalf of the government
  • People and families must accept what has been decided for them

Even if you like markets it is clear that the social care system is not really any kind of market. The current system is more like the Christmas myth:

  • Santa Claus decides what all the children deserve
  • The elves make all the presents for him
  • The children wake to find out what he has delivered

Unfortunately Santa Claus does not exist and it is not a good idea to ask someone you don’t know to make important decisions about your life on your behalf. It is also not a good idea to enslave a race of elves to carry out your wishes. People with disabilities need rights, not gifts; and professionals need to work in partnership with people with disabilities and their families, not for the Government.

The new language of social care also makes us forget that creativity is essential to human services – at every level. Notice the language we have been forced to use:

  • Procurement
  • Tendering
  • Purchasing
  • Commissioning
  • Service Provider
  • Service Delivery
  • Consumer
  • Service User
  • Regulation
  • Quality Control

This is the language of industry. Strangely, at the same time as traditional industry has declined, its language has been imported into the world of social care. We had hoped that, as the institutions began to close, people with disabilities could take their place as full citizens. Instead we’ve converted human relationships into manufactured commodities that can be sold and purchased in bulk.

The way out of the madness

After 25 years this system of competitive tendering is now approaching collapse:

  • The social care system is in deep crisis with funding slashed and service providers operating on the fringes of legality.
  • Local government cannot afford to contract with more than a handful of services because of the cuts to their own core staff, and some authorities find they must go back to providing services themselves.
  • Service providers are merging with each in order to cut costs and to reduce the level of competition for contracts.

But the biggest cost of this system is the opportunity cost: for 30 years we have missed the opportunity to do the right thing, to focus on creating inclusive and welcoming communities and on developing ourselves as active citizens. Instead of seeing people with disabilities as leaders in the transformation of our communities we have wasted our time by wrapping some people in over-regulated and under-funded services while leaving others isolated and unsupported.

The alternative is clear enough:

  1. Self-directed support – Treat people as citizens and ensure they have a clear entitlement to support, one which is implicit in the UN Convention on the Rights of Persons with Disabilities
  2. Community sourcing – Encourage inclusive communities by respecting and supporting community groups and citizens to bring about the necessary social change.
  3. Local support – Ensure that local communities have the structures, expertise and information to enables them to develop local solutions.

Finland is showing us the way. It is time to throw competitive tendering in the bin. It is time to reclaim our citizenship and design a social care system that treats us as full human beings, not as lots to be sold off to corporations at the lowest possible cost.

Read the article: Not for Sale and show your support via Citizen Network Finland.

First published by the Centre for Welfare Reform.

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