Can we escape the invisible asylum?

Since their origins in the Poor Laws, our ideas about helping people have been tangled up with feelings about excluding or punishing them. To become the subject of state support was once to cross a physical threshold: the gates of the workhouse, lunatic asylum or long-stay ‘hospital’ for disabled people. Many of those thresholds have disappeared into folk-memory, but the idea of separating people into those who are citizens of their communities, and those who are wards of the state, remains threaded through our health, care and support services, in ways which have become so familiar they are invisible.

The rules and assumptions of the invisible asylum can be felt in ‘community’ services which feel nothing like community. They start with assessments and means tests which challenge people to prove their level of need, often at the cost of believing in their independence. They are felt in approaches that treat families who have managed on their own for years, as though they are capable only of being ‘difficult’ for the very services which ignored them before they reached crisis point.

This is not to decry the value of our underfunded and undervalued public services. But for our welfare state to survive, we need to be able to see it clearly: the miracles our services can achieve in the operating theatre and their small, devastating failures to see the person underneath the patient’s gown. There was a time when most of us could ignore those failures, hoping that we wouldn’t find ourselves in need of state support, or would need it only for a brief period which we prefer not to think about. But now we live longer lives, with longer periods of ill health, frailty or social isolation. Whether those years – and in many cases decades – in which we need state support will amount to a good life is not solely in the gift of GPs, surgeons or social workers. It depends for most of us on the relationships we have with everyone we rely on: our family and friends, alongside people paid to help us.

So we need models of community support which focus as much on ‘community’ as ‘support’. Working for nearly eight years with the remarkable people involved in Shared Lives and Homeshare has brought into perspective for me the inability of many services to escape the asylums of their origins. I have also witnessed supportive relationships which do not sacrifice the social for the care, which recognise interdependence is as important as independence, and that caring is an emotion before it is an activity.

In my forthcoming book, A new health and care system: escaping the invisible asylum (Policy Press, February 2018) I outline a possible health and care system which would take the ethos and practices of asset-based and community-orientated support models and build a system and a sustainable economics around them. A system which would demand, measure and pay for the goals – wellbeing, resilience, confident households – we all agree we want, but seem to accept we cannot have. The people who currently shape services have proved themselves incapable of designing approaches to achieve those more human goals. They can only be co-designed with the people who make long term use of services, their families and workers. They would offer us more but would only work if we were prepared to have more asked of us in return.

Those services would be organised at a more personal scale, perhaps eventually eschewing the traditional idea of an organisation entirely, so the book focuses as much on what needs scaling down to human size, as on scaling up the innovations of which we need more. It starts with those failures we should see as inexcusable, yet ignore or dismiss, but it is rooted in the belief that we can and do care for each other, and that the only future for our public services is to create spaces in which people with support needs, families and front line workers can have the relationships we would all wish to have.

You can order A new health and care system: escaping the invisible asylum from the Policy Press. The launch at Nesta on 28 Feb, which has done so much to support our work, is here. The Northern launch event with Greater Manchester’s Chief Officer Jon Rouse is at MetroPolis on 20th March.

The Green Paper

My think piece on the Green Paper is in the Guardian today:  Human stories will convince the public that social care is worth investing in

“More caring, social kinds of social care already exist. Some, such as Homeshare and Local Area Coordination, Community Circles and Wellbeing teams need scaling. Others, including Spice’s Time Credits and Community Catalysts’ micro-scale approaches, reach thousands or, like Shared Lives, are national. When people hear about these approaches, with their human stories of small achievements that mean the world, they connect with them. They see the value of ordinary life chances for disabled people or a good last 1000 days for older people. A green paper based on those stories could finally persuade the public that social care is worth investing in.”

The Asset Based Area 2017

This new Think Local, Act Personal resource started as a blog post here. Thanks to the TLAP team and its Building Community Capacity network, along with inspiration from local areas such as Wigan (see the Wigan Deal link below), it has now become a how-to guide giving ten pointers towards becoming an Asset-Based Area. Here is my blog for the Dept Health social care blog on the paper:

A GP noticed that one of his older patient’s appointments were increasing, and felt that this was not for medical reasons, but due to her isolation which had worsened following a bus service closure. He linked the lady to her Local Area Coordinator (LAC).

The coordinator helped her to build more links and activities in the community to reduce her isolation and to approach a community organisation which ran a community bus service. Her increased support networks meant she felt less reliant on her GP.

They were also felt to be key to her quick return home from hospital after a heart attack.

The LAC helped link the community organisation to colleagues who gave support for a successful bid for a new community bus service.

At a time when primary care services are feeling under huge pressure, it can be hard to argue for new approaches and creative thinking. But this story shows that, with the right help and a positive mindset, someone possibly viewed as a ‘problem’ can not only find ways to help themselves, but their new connections can also lead to benefits for the whole community.

LAC is an example of an asset-based approach, which, like all similar approaches, starts with questions like, “What does a good life look like to you?” and “What can we do together to pursue it?” Coordinators have the time and remit to get to know people: not just what they need, but also the goals and capabilities they and those around them can bring.

Sometimes this means that someone accessing a service will need less formal support.  However, asset-based thinking shouldn’t be limited to ‘informal’ or voluntary organisations. Nor should it be seen as only relevant to preventative services. It needs to be embedded across the whole system, including in approaches to supporting people with significant health, care or other needs.

Shared Lives carers, having been through rigorous approval processes to join local CQC-regulated schemes, are matched with adults needing support, such as people with learning disabilities, mental ill health or dementia.

This is not a referral process: matching means both parties getting to know each other and making a positive choice to share their lives. The adult either moves in with their Shared Lives carer or visits them regularly for short breaks or day support.

James has significant learning disabilities and mental ill health. He has spent significant periods in institutional care and still needs some hospital stays, but his life with his Shared Lives carer Phil revolves not around the times when he is most unwell, but around the day-to-day things he and Phil both enjoy doing such as fishing and going to the greyhound races.

The Asset-Based Area was coproduced with input from many people and organisations working in asset-based ways, from the Think Local Act Personal national network for practitioners and commissioners who share an interested in Building Community Capacity.

We wrote it because we cannot successfully or affordably add in asset based approaches around the margins, whilst ‘core business’ remains unchanged. We need whole areas to take up the challenge of becoming asset-based, resetting their relationships with local citizens, as Wigan council and a few others attempted. It is time for steady, incremental, whole-place change: it’s all or nothing.

Every community needs catalysts

My colleague Sian Lockwood OBE is Chief Executive of our sister organisation, Community Catalysts CIC, which has developed a highly effective model for helping local areas to find, grow and sustain community enterprises, some of them micro-scale, as a way of creating completely new care and support choices for local people. The model involves recruiting and training a local enterprise Catalyst who is embedded in the area to find, nurture and network local social entrepreneurs, helping them to set up enterprises and to navigate any bureaucracies they run into along the way. This can often be the missing link between personal budgets and real choice. Sian writes:


“We currently have a programme in Somerset with a focus on stimulating and supporting locally-led home and domiciliary care services in the most rural parts of the county. Domiciliary care services involving personal care are highly regulated and there are real challenges in enabling very small community enterprises to negotiate these regulatory and legislative barriers.  Our Somerset Catalyst has found no shortage of local people keen to provide home and domiciliary care services for other local people. They drew on his personalised and patient coaching to create an enterprise that is legally compliant and  sustainable. In 9 months he has uncovered and supported nearly 70 of these little ventures – each one different, formed by the passion and personality of the entrepreneur and local circumstances. Pearl, for example, runs a florist’s shop in one of the larger villages. Our Catalyst says that ‘she always has the kettle on’ and has become the person to go to if you need some local knowledge and advice. She found that many of the older people visiting her shop were asking for advice about people who might do cleaning, shopping etc and she started to look for local people who might do those jobs. Our Catalyst was able to help her out with putting some simple systems and processes in place that made that self-employment brokerage service safe and sustainable.

Pearl now has 27 local people on her books who between them are supporting nearly 50 older neighbours.”

Heart and head: The case for community micro-enterprise

This guest blog comes from Sian Lockwood OBE, CEO of our sister organisation, Community Catalysts:

Community Catalysts people are passionate about and ambitious for community micro-enterprises that invest in the health and well-being of their locality. We have been working since 2007 to support their development and growth and have seen over and over again the impact that they have on people’s lives – and on whole communities.

Alongside our development work we are the network organisation for community micro-enterprise and ventures and have links to over 750 community entrepreneurs, each with a unique combination of skills, knowledge and experience, driven by different interests and passions and shaped to the needs of people in their community. Each with a different story.

Stories are an important way to convey the impact that community enterprise can have on people’s lives. They appeal to people’s hearts and open their minds and imagination to what is possible. But in the financially constrained world in which we operate winning hearts is not enough. Local authorities considering investment to support the development and growth of community enterprise need a hard-headed evidence based business case.

We are delighted then with the two reports published recently – one by Birmingham University and the other by TLAP – which go some way to developing the ‘head’ case for community micro-enterprises with a focus on health and well being.

The Birmingham University report Does Smaller mean Better? Evaluating Micro-Enterprises in Adult Social Care is on a research project looking at the value and contribution of community micro-enterprise in contrast with larger more traditional care providers. It provides evidence that confirms conclusions drawn from our own work with community micro-enterprise over the last 8 years:

  • Community micro-providers offer more personalised support than larger providers, particularly in home-based care
  • People using community micro-enterprises were more likely to get help to do the things they valued and enjoyed, compared with people using larger services
  • Community micro-providers are better than larger providers at some kinds of innovation. They were more flexible than larger providers in the way care in the home was delivered (eg staying to have a meal with someone rather than simply preparing food and leaving)
  • Community micro-enterprises offered support in potentially marginalised communities, with some set up and run by people from those groups e.g. disabled people
  • Micro-providers offer better value for money than larger providers

Continue reading

Micro-enterprise: care and support on a scale that’s “just right”?

This is a guest blog from researcher Catherine Needham of the University of Birmingham, who is launching the first research to look at whether size of provider organisation makes a difference to outcomes and cost-effectiveness. The summary is very readable and should be of interest to all care commissioners. Dr Needham writes:

It has long been evident that large-scale care provision on a time-and-task model has not been delivering care and support which is personalised and leads to valued outcomes. This week, a team from the University of Birmingham, of which I was a part, launched findings which solidify the evidence base about the benefits of micro-enterprise over larger providers.

Twenty-seven care organisations in England were included in the study, covering a range of sizes and functions, including day activities and support in the home. Interviews were done by academic researchers working alongside people with experience of local care services on a co-research model. Among the 143 people interviewed were owners, managers, members of staff, carers, and those receiving care services, including older and disabled people.

Findings show that micro-enterprises offer more personalised support than larger care services, and contribute to better outcomes (measured using ASCOT, the Adult Social Care Outcomes Toolkit). These benefits stem from micro-enterprises having greater continuity of staff, greater staff autonomy and greater accessibility of managers compared to larger organisations. The research also found that micro-enterprises offer good value for money: their hourly rates were on average lower than the larger comparator organisations, helped by low overheads.

The micro-enterprises in our sample talked about what had helped them to get started, and what barriers they faced in staying in business. Many had benefitted from local micro coordinators, part-funded by Community Catalysts, which helped them understand care sector regulation and funding.

To keep going the micro-enterprises had to market their services to potential users as they didn’t have a formal contract with the local authority in the way a large care companies did. Most people supported by micro-providers had a direct payment or were self-funding, and had found out about the provider through word-of-mouth or local advertising. The relatively low take-up of direct payments by older people highlights the need to provide alternative routes into micro-enterprise. Social workers, GPs and other care professionals need to be informed about micro-enterprises operating close-by so that they can match up people with support in their local communities.

Like most academic studies, the research answered many questions but generated others. In particular I was struck Continue reading

Commissioning and control – where is the citizen?

A guest blog from Simon Taylor (, who supports our micro-enterprise members:

Another fascinating but frustrating blog just crossed my radar. It is from the Chief Executive of the British Association of Social Workers, Bridget Robb about how social workers feel frustrated with the commissioning of homecare and alienated from their own authorities’ commissioning systems.

It is a thought-provoking piece exploring how front line professionals can be excluded from decision-making and commissioning processes. She argues that many social workers are unhappy about the quality of much of the domiciliary care that they arrange, but “feel that they have little power and control over the services. Social workers need to be able to work with a small number of locally based suppliers of home care in small localities in order to build up relationships with the suppliers”.

The last line would hearten many micro-enterprise care providers who would relish such engagement. However, it is disheartening when even professionals do not feel as if they have any control, choice or power.

Alongside this, in my inbox, was news of a new Government attempt to drive up quality in local authority adult services. It is a new website launched to compare authorities’ adult social care performance via the Adult Social Care Outcome indicators. It hopes to help local people hold their council to account by making this, already available information, more accessible.

This seems laudable, but does raise the question of how local people will be able to use the information they can gather to hold their council to account, if BASW feels that even social workers can have no impact upon the support services they are able to purchase? Continue reading

Finding out more about micro-enterprise workers

A guest blog from Simon Taylor (, who supports our micro-enterprise members:

A reduction in the local authority workforce has not seen all these people disappear from the care and support workforce. Some join established agencies or providers but many have looked at their skills, considered their frustrations with former work and seen new opportunities to start their own micro-enterprise services.

Skills for Care’s report from last year’s “State of the Adult Social Care Sector and Workforce in England”, highlights some shifts in the workforce. The report shows the reduction of the local authority workforce (-9.3%) with a converse increase in Direct Payment employers (+15.8%) and the independent sector (+3.1%).

The report didn’t include statistics on micro-enterprise providers, but we know that some of the growth in micro-enterprises is through former local authority workers starting their own enterprises. Other enterprises are started by people entering social care for the first time, including some disabled and older people themselves starting their own micro-enterprises. These micro-entrepreneurs cover many areas, from residential support, services delivered in the home, help to access the community and many others which defy characterisation. Over 150 enterprises are now Shared Lives Plus members, benefitting from support, advice, insurance and a voice, whilst our sister organisation, Community Catalysts, supports areas to become micro-friendly and helps enterprises in the start-up phase.  

We are working closely with our very supportive colleagues at Skills for Care to look at how to include self-employed providers in national workforce information gathering. Getting more information about the people working in micro-enterprises will help us to ensure that their work is considered by policy makers and workforce planners.

Hence this very short survey:

If you know of any self-employed providers, please ask them to take part and ensure their voice is heard too. If you want to talk to us more about our micro enterprise services or our work informing policy do get in touch.

How to commission for a diverse range of providers

A guest blog from Simon Taylor (, who supports our micro-enterprise members:

When the Care Bill becomes law, commissioners will have a duty to promote a range of services that meet local people’s needs. This won’t be easy with tightening budgets and the drive to commission services ‘efficiently’, which many areas have seen in terms of having fewer contracts to manage. In addition, councils will have duties to support the development of preventative services and to help individuals to use Direct Payments and personal budgets to purchase support which is of their choosing.

Shared Lives Plus, supported by the Department of Health and endorsed by sector partnership Think Local Act Personal, has produced “Commissioning for Provider Diversity – A Guide”, which will help councils commission in a way which gets better value for money through having a wide range of local services, not just a few large contracts.

The report draws on the voices of the smallest of providers who deliver services at the ‘micro’ scale and on the work of our sister organisation, Community Catalysts, which supports local authorities to create the conditions in which micro as well as larger providers can thrive. The report explains the principles and then sets out the practical steps for commissioners to take, including identifying the met and unmet needs of personal budget holders and enabling citizens to have a say at every stage.

From our membership, we hear stories such as Continue reading

Saving money or seeking outcomes?

A guest blog from Simon Taylor (, who supports our micro-enterprise members:

Delegating decisions in care and support

Last week Think Local Act Personal launched its report on making the best use of the available resources when developing adult social care. It highlights options which could save councils money when other traditional costs saving methods are exhausted. This debate underlines the delicate balance councils must manage. Many unfortunately use remote senior managers or panels to maintain control over the money. All too few delegate decisions to front line workers to try and avoid costly red tape. The report identifies how councils can evidence the benefits of options like delegation to encourage them to use such approaches.

My initial reaction was astonishment that some local authorities struggle to release control to the professionals in their employment and are unable to understand the cost implications of their approaches.  The excellent report and toolkit developed by Think Local Act Personal working with the Towards Excellence in Adult Social Care Programme is a start for councils to consider and implement change.  

However, we need not only to hand power to front line workers, but also to people who use services so that they can be at the heart of decision making.

We need also to look beyond cost reductions. Delegation Continue reading