Soon, all councils in England are going to have some new duties, thanks to the Care Bill which will become the law setting out what every area has to do when offering social care. I want to look at a couple of those duties in blogs over the coming weeks, starting with the duty to develop a diverse ‘market’ of care providers, so that people who can now take control of the money allocated to them to meet their social care needs have a real choice of different things to buy (otherwise, what’s the point in having a Direct Payment or personal budget?).
I can think of four kinds of ‘provider diversity’:
- A range of approaches (eg you can choose Shared Lives not just care homes or home care)
- A choice of providers (different organisations out there, even if they are doing some of the same things)
- A range of scales of provider, from the security and infrastructure of going to a household name like Bupa, to the personal relationship of getting support from a tiny micro-enterprise which may have been set up specifically with you in mind
- A choice of ownership model.
I’ve blogged before about the ways in which we at Shared Lives Plus and our sister organisation, Community Catalysts, are helping to bring Shared Lives and Homeshare into prominence as distinctly different social care approaches people have not previously been offered. Likewise, when it comes to diversity of scale, we’ve supported Community Catalysts in its extensive work to grow the micro-enterprise sector: Community Catalysts has supported 40 or so councils to develop micro-enterprise friendly areas; we have worked together with DH support to produce guides like last year’s guide to Commissioning for Provider Diversity. That work’s been successful in the areas which have bought into it, but we know that in most areas, the smallest micro-enterprises are very vulnerable to being inadvertently squashed out of existence, whilst at the other end of the spectrum, there are plenty of acquisitions and the average size of the larger providers is increasing, which suggests that the number of different organisations is decreasing, not growing as the Bill envisages.
So there are challenges in delivering each of those four kinds of provider diversity, but perhaps it’s the last of the four where there is almost no real activity or progress.
As long as we see ownership as being a public/private choice, we will be thinking about the role of people who use services as being consumers of offers owned by others. Those owners may well be passionate about doing things well, but whether they are the shareholders of a PLC or the Trustees of a major charity, they will also be passionate about growing their particular organisation, taking a bigger ‘market share’ and being better than their competitors. Inherent in those goals is a drive towards growth. Growth is hard to achieve whilst also becoming closer, rather than more distant, from people who deliver and use services on the ground. Growth tends to involve competition, increased market share, acquisition and merger. How many boards which are driving towards growth, invest as much of their energy in a balancing drive towards closeness, personalisation, community building and empowerment of front line workers and people who use services?
Provider diversity is often seen as a commissioning duty. I’d argue that it’s a shared responsibility between commissioners, providers and people who use services. Commissioners need to build local marketplaces which are open to new and small providers. They need to ensure that public money can be spent a different scales, ensuring large scale contracts, where they are unavoidable, use approaches such as Framework Agreements and Alliance Contracting, but recognising that those approaches don’t guarantee diversity, so there is a need to use personal budgets to help money to be spent on an individual scale, and to help personal budget holders to come together, whilst also devolving money to neighbourhood groups, which are ways to spend money on the small and micro scale. Personal budget and Direct Payment holders have already developed a new sector, in the form of personal assistants. They have also in some places helped new kinds of provision to develop by coming together to buy support collectively from new kinds of organisation, or through sharing ownership in new enterprises, such as the estate-owned co-operative which is taking on some forms of service provision in Marsh Farm.
Finally, providers of all sectors have a responsibility not just to push for growth come what may and to look honestly at the downsides as well as the upsides of growth when it is achieved. There are ways for large providers to do this: social franchising can be one way of working big whilst feeling small. Moving towards more democratic ownership models is another. And Macintyre, a large provider charity, is bringing its expertise in public service contract delivery to help new local social enterprises to start up and thrive through being a partner in the Shared Lives Incubator.
We are sometimes asked if we shouldn’t take our expertise in Shared Lives and start running Shared Lives schemes, particularly where a local scheme is failing. I can feel the temptation in that thought, but I’ve always felt that to compete with our members in this way would be an ethically fraught to say the least, and perhaps ultimately self-defeating if our goal really is a more diverse market of locally-rooted Shared Lives schemes.
Growth is rarely questioned as a fundamental principle of success in running organisations. Discussion of getting smaller is generally considered taboo: until of course the failure to stay relevant and close to communities (arguably latent in every growth success story) brings an organisation crashing back down to a more human scale again. But in a world where it’s increasingly common to hear stories of local and user-led organisations being competed out of existence by national charities with turnovers of tens of millions, it might be time for the boards of values-led providers to start asking, How are we going to get smaller?
In a future blog: it’s time to stop talking about prevention.