We live in a society which auctions the care of disabled and older people. Not to the highest, but to the lowest bidder.
This has been going for years. Sector leaders have long condemned the concept of ‘reverse auctions’ for care packages, in which a homecare or other support contract is won by the lowest bidding care provider, but care contracts can still be put out to tender using a scoring system which puts lowest price as the most important factor and the Care Provider Alliance expressed concern about this issue again this year. In other areas, when an individual is assessed as needing support, a pen portrait of their needs is circulated to care providers approved to be on the local area’s ‘dynamic purchasing system’ and those providers bid for that care package. Again, lowest price is at least one factor in their bids and providers have reported feeling that the real extent of someone’s support needs have not been made fully clear, meaning that the care package offered will not meet their needs. In some areas, only one ‘affordable’ option is presented to the individual who may not realise they are not obliged to take it. These auctions are presentable as offering ‘choice and control’ to the individual, despite the obvious limitations on that choice. Any provider which achieves a certain ‘quality score’ can enter the framework and be on the list, but it is easy inadvertently to set conditions on quality which effectively eliminate innovative and start-up services which may not have a track record of providing conventional care. (This is why the duty on councils to develop diverse provider market places in the Care Act is so important: its implementation needs much more attention.)
This was not what was envisaged by disabled people and their families who developed personalisation, which was the idea that people would plan the most effective care and support when they were in control of an individual planning process which started with what a good life looked like, not with a list of low-cost services. Planning creatively in this way enables people to make best use of their own capacity and of the family and community resources available to them. That also usually results in the most independence and lowest overall cost to the state, whereas narrow price-focused processes bring missed opportunities for independence, or lead to family care breaking down. But instead of people planning a life, and then choosing the support they need to live it, care providers in some places now compete for the individual, and an algorithm makes the choice. (Approaches like TLAP’s Making It Real are designed to push back against this kind of pretend personalisation.)
The Shared Lives model is resistant to that kind of automation, partly because it is based on matching the individual with a specific Shared Lives carer: both parties meet and make a choice to share their lives with each other before any support package starts. That resistance can be a double-edged sword though: if Shared Lives looks too complicated or ‘messy’ to include on an area’s shiny new system, it may just be omitted from the choices offered to people. In one area, commissioners have apparently described Shared Lives as a ‘luxury’ model, despite the overall package being demonstrably lower cost than traditional equivalents, sometimes by tens of thousands of pounds.
These problems are not just a symptom of the lack of money available to pay for care providers. They are also symptomatic of cuts to the teams which plan and buy care on behalf of us all. Experienced commissioners who understand how social care works are more likely to be able to recognise the value of truly personalised support and to think through the consequences of cut-price care, which can rapidly lead to a crisis and expensive medical care.
Most of us do not have to contemplate what it would be like to have a price put on our happiness, safety or dignity. There has never been greater pressure upon price in our public services. We can’t rely upon algorithms to deliver good lives: we need to develop care navigation and brokerage teams who can help people make good choices, and which can help to build community approaches like Shared Lives. People who need support will be more likely to achieve real value for money within local marketplaces, where people and local providers can connect with each other, rather than left adrift in virtual ‘emarketplaces’ or to the free market. And we should simply outlaw processes which put lowest price first.
thanks for the lesson, which I shared here: https://socialhealthpracticeottawa.wordpress.com/2017/11/14/when-a-progressive-model-of-community-based-care-looses-its-values-in-the-name-of-value/
Thanks Bill. Worth saying that I still believe personalisation is the only way forward when done properly – it just isn’t able to fix a lack of resources.
So true. When we needed Dom care for my dad when he came out of hospital we were told categorically that we HAD to use a provider on the council list, even though we were funding 100%. None of the 4 offered were rated Good and were offering totally unsuitable hours – i.e. 10am to get up and 5pm to go to bed!
Thank you for this thought-provoking article Alex.
I would just like to point out that all public services have been adopting more business-style approaches and applying them to public services for quite a few years now. Part of the idea in creating a ‘marketplace’ for social care is based on an assumption that competition between providers will push down costs. It is therefore not surprising that cash-strapped local authorities may prioritise cost, but most contracts I have seen also include a focus on delivering high quality services. However, we cannot get away from the fact that this is part of a society-wide (or should that be government) assumption that the markets are the cheapest and best way to deliver services. Whether we may agree with this or not.
Thanks for commenting David. I guess government would argue that the market approach is designed to do three things: push down costs, raise quality, increase innovation. In reality, when budgets are cut very significantly, the first consideration becomes increasingly dominant, while the value of the other two is always in my view limited by the lack of service user/family/citizen power in defining what ‘quality’ and ‘good’ look like.
Council’s are criminals for the way they deal with social care clients. I came into the system thinking they were there for the best interest of the disabled client, but they don’t give a fig. Social workers have become expert at hiding and not evidencing their wrong doings, and that includes worker at the Share Lives I deal with. My next step may be out of the industry completely.