Rebuilding communities and rebuilding social care are deeply linked challenges

This article appeared on the Social Care Institute for Excellence website on 25 May here. (I’m a SCIE Trustee.)

The focus of the first weeks of the crisis was on sustaining hospitals. It was a difficult, complex but clear challenge and it was met. As it became clearer that the virus had swiftly found social care’s most vulnerable services and was sweeping through people living in care homes in particular, politicians and planners have tried to bring into focus the much more fractured picture of social care services, which range from large nursing homes, through community support services and homecare, to individuals organising their own teams of Personal Assistants. We found out what we were good at: building huge hospitals in a matter of days is an incredible achievement. And what we are not good at: identifying where deeply entrenched inequalities in our communities will meet inequalities in our public services and create human tragedies.

There was a widely-shared photograph of the head doctor at the London Nightingale Hospital waiting for his first patient at a lighted door in a vast metal shutter. It’s a heroic image. Of course, the Nightingales, fortunately, remained almost unused as the daunting acute care challenge was largely met. There are few images of the thousands of people who died unnoticed in care homes, much less those isolated at home who were visited by untested and poorly equipped social care workers. It is hard to take a picture of the vast number of small, spontaneous acts of kindness that have happened within Mutual Aid and other grassroots community groups, and we may never know their contribution to keeping people alive and hopeful.

There is already talk of big, structural change post COVID-19. It will be tempting to do what we were good at during the peak of the crisis, but what we need in the next phase and beyond is unlikely to revolve around easily-defined service delivery challenges which can be achieved by a small group of heroes.

Support people need in the place where they live

As much as we will need our hospitals and medical facilities to recover and thrive, we will need a wider support system that enables people to live safely and well at home. That is where the safety and wellbeing of older and disabled people has always been found, and the current crisis has just brought home how important it is for people to be able to get the support they need – formal and informal – in the place where they live. For many people facing an extended period of isolation and the risks that will bring to their mental health, the role of friends, neighbours and – socially distanced – family will feel increasingly important.

The virus has brutally exposed many of the weaknesses in our social care system. But it has also highlighted an abundance of caring within our communities. We have a stronger desire to help each other than we realised: three quarters of a million people volunteered to help the NHS and social care before the programme had to be paused while the system tried to catch up. We have more creativity than we knew: people and organisations finding a million ways to offer their help, knowledge or skills to others, often for free. What we’ve found does not, of course, begin to balance out the devastating impact of the things our services lack, let alone the people we have lost.

Both formal and informal needed

And those good things are no more evenly distributed than the deaths and the shortages, exacerbating already deep-rooted inequalities. But given how difficult the coming months (and years) will be, we must make everything we can of what we’ve found, and what people have offered to give.

Social care is rooted in an attempt to bring together the formal and the informal: the social as well as the care. We know that people will not live safely and well where one or both are absent, or cannot work together: the large impersonal institution where there is support but community is kept at arm’s length; the isolated home where an individual endures hours without human contact.

So, we need a renewed drive towards living at home, or where that is not possible, a place which feels small and personal enough to feel like home. We can no longer tolerate people of any age living long-term in big, impersonal institutions. We must see the connections which people are making with each other, in all of their humanity, diversity and messiness, as being as crucial to the next phase as the smoothly-running hospital was to the first. And if we are to see people stepping forward to connect with people who use or live in support services, they will need to be able to feel a shared sense of ownership of those services: community as a mode of ownership, not just community as a ‘setting’. Put bluntly, few people want to volunteer for a large profit-making business owned somewhere offshore. If we want people to continue to step up, connect and be generous, they must be offered a greater sense of ownership and real relationships in return.

Look to the community

Neighbourhood level care organisations have already shown they can reach tens of thousands, like the famous Dutch Buurtzorg dementia support service with its self-managing community teams, or Shared Lives which reaches 14,000 disabled and older people through a family-based support model which behaves like a franchise in every way except for the fact that no one owns it, nor profits from it. We have seen these community-rooted organisations proving adaptable in the face of COVID-19, using online technology to create and sustain connections which are traditionally carried out face-to-face. The Shared Lives sector is seeking investment in an unprecedented modernisation of its recruitment and matching processes to ensure they can carry on during lockdown, and that the home-based support model can be a much bigger part of a pandemic-proof and sustainable future.

The crisis is still peaking and the bleakest news from the social care sector is yet to come out, as we start to understand the scale of what has happened, but not yet been counted. Many smaller provider organisations are already staring at bankruptcy. But we cannot wait until the crisis has passed to start building the future. We must start now.

Invaluable

We have been campaigning with our members to persuade the Treasury to adjust their Self-employed income support scheme (SEISS) scheme, which replaces lost profits for self-employed people losing work during COVID-19, for Shared Lives carers, who can apply to the scheme, but typically aren’t eligible for any replacement income, because the Shared Lives tax break usually shows their profits as zero. This has left Shared Lives carers feeling unvalued and contemplating leaving the sector, just at a moment when we desperately need to sustain and expand home-based alternatives to hospital and care homes.

So we are utterly disappointed that the SEISS has not been adjusted by the Treasury to address this, despite our very positive engagement with the Dept of Health and Social Care, and the support expressed for the Shared Lives sector by the Minister of Care Helen Whateley and cross-party MPs, including the Shadow Health team and Labour party leader Sir Keir Starmer. We have been contacted by MPs of all parties as a result of the campaigning which Shared Lives carers have been doing on this issue locally.

In parallel to our national lobbying, we have been working with councils to encourage them to use their social care continuity funding to help Shared Lives carers who have lost income, and also the even larger numbers who are providing more support than ever to someone who lives with them, and cannot at present access day support services. We have many examples of councils doing this and we are talking with the Dept Health and Social Care, and the Local Government Association about how to help more areas to follow suit.

Money can be a touchy subject for Shared Lives carers. There are still areas where people have been caring without a pay rise for years: pre-COVID we were working on this with members, asking councils to sign up to a pledge to give Shared Lives carers the same pay increases as other social care workers. I’m struck by the attitude of one or two areas who seem to feel that because Shared Lives carers give so much of their lives, and don’t expect to be paid for every hour spent with someone, that they shouldn’t really care about money. Some of our members said recently that they feel treated with suspicion if they raise the subject.

The truth is that we all need to live. The fact that our members are often staggeringly generous shouldn’t be a reason to take them for granted, as one area did when they wrote a Shared Lives carer in her 70s to say that with day services closed, the person she cares for would be home with her all day now, and they expected her to provide this extra full time job of care on a ‘voluntary’ unpaid basis.

Shared Lives works so well because it allows people to separate the money that they are paid for the formal part of their role, from their relationship with an individual who many describe as ‘just one of the family’. Nobody goes into Shared Lives for the money. Let’s make sure during this crisis that money is not the reason that anyone has to leave the caring role they love.

Lost and found

Here is an extract from my new blog for the Royal Society of Arts here

In the social care sector, we are currently all too aware of what we don’t have.

We still lack adequate protective clothing for workers doing the most important jobs.

We still lack people in key roles – like the social care workers who until a few weeks ago were ‘unskilled’, but are now the heroes we applaud from our doorsteps each week.

We still lack virus tests, which means we lack the knowledge we need to keep people safe. Individually, many of us lack money because people are losing paid work. We lack social contact, freedom, green spaces, hugs. (and pasta.)

The things we lack are causing hardship and hopelessness. We are also finding some things we didn’t realise we had.

We have new friendships, and support where we weren’t expecting it, as thousands of grassroots mutual aid groups have sprung up.

We have a stronger desire to help each other than we realised: three quarters of a million people volunteered to help the NHS and social care before the programme had to be paused while the system tried to catch up.

We have more creativity than we knew: people and organisations finding a million ways to offer their help, knowledge or skills to others, often for free.

What we’ve found does not, of course, begin to balance out the devastating impact of the things we lack, let alone the people we have lost.

And those good things are no more evenly distributed than the deaths and the shortages, exacerbating already deep-rooted inequalities. But given how difficult the coming weeks (and years) will be, we must make everything we can of what we’ve found, and what people have offered to give.

This moment of people stepping forward and reaching out to each other will pass very quickly. Without action, it could be replaced by something much bleaker in the hard years to come.

The story of the next few weeks will, I believe, be of the NHS doing better than feared.

But the challenges within social care will be brutally exposed. Particularly where three problems are found together: lack of money, lack of central planning or strategy, and buildings which house too many people in close contact.

We will rebuild our social care services after this. But surely we cannot want to reconstruct the broken systems which contributed to us being here?

I believe that building better systems should be based on three closely linked principles:

  • A renewed drive towards living at home, or a place which feels like home
  • Formal support combined with community connection
  • Care organisations controlled and run at the neighbourhood level

For more on how these will work together, read the full blog: https://www.thersa.org/discover/publications-and-articles/rsa-blogs/2020/04/social-care-reform

Social value?

The Social Value Act (SVA) allows public bodies in England to score the creation of social value when they are putting public services out to tender. Bidding companies can score extra points for the way in which they will deliver the contract, where they can show they will have a positive impact on the environment or local communities. Employing local people from low-income communities can be scored, as can volunteering, or carbon reduction.

I’ve championed the Social Value Act for several years now, arguing in the Joint VCSE Review that its powers should be used by default, rather than as an exception. What’s not to like: the taxpayer gets extra value for money, and social purpose organisations are more likely to win public service contracts?

So I was concerned when I read in the excellent report on disability services commissioning from the Voluntary Organisations Disability Group (VODG) of one charity’s experiences of the SVA being used in such a rigid way it felt almost impossible for a small organisation to demonstrate the kinds of added value being asked for. I’ve subsequently talked with the charity and seen the part of the tender specification, which accounts for 20% of the tender score – an unusually high proportion. It’s a frustrating study in what results when you see a useful , creative concept through the lens of a bureaucratic world view. The form has been written with large private sector contractors in mind, and over 8 pages itemises a host of specific kinds of social value. Some makes sense: the number of employees, apprenticeships and work placements for people from specific local communities features. But there is also a long list of prescribed kinds of employee volunteering which bidders can commit to, with a strong preference for visiting schools and giving careers talks for some reason. Each kind of social value has a multiplier applied to it, which means that each ‘unit’ of social value may be worth £1, or nearly £30,000 for some of the employment related units. It looks like it’s been derived from the NHS Sustainable Development Unit’s helpfully-intended calculator.

You can see the rationale: if social value is to be scored, there has to be some rigour to it. How do you compare carbon reduction with creating volunteering opportunities? But the problems are also obvious: what would be the point of committing to any of the kinds of social value which attract 1:1 scores, if some attract 1:30,000 scores? And for an organisation with a small staff team and low margins, the ability to commit to large amounts of employee volunteering will be much more limited than for a large corporate. The charity I talked to creates huge social value: their whole approach creates community connections, draws on volunteers and social action as its core operating function, and no public money is siphoned away from the community to offshore tax havens. But it could easily be out-competed on social value in this format by a large corporate which is clever about the way it cites its employee volunteering programme in all of its tenders.

One of the problems here is that social value is being placed in a gap where commissioning for outcomes should be: if organisations were judged on the wellbeing outcomes they created, a good social purpose organisation would already have a built-in advantage. The commissioner in this instance sees social value as something created in addition to the main purpose of the contract, which doesn’t allow them to value organisations which build social value and community impact into the way they deliver their core work. Ironically, I can find little evidence of not-for-profits being involved in designing the tools and calculators developed to enact a change in the law which was intended by parliament to work in support of those organisations.

The other problem is the balance between the need for transparency and fairness in public service contracting, which is subject to legal challenge, and the desire to value something which is valuable precisely because of its subjective, locally-decided nature. If other areas emulate the approach I saw, social value will be killed off as a concept just as it is gaining momentum.  So it feels urgent that the sector, government and NHS promote good approaches such as Liverpool CCGs social value objectives (picture below)  and Greater Manchester’s framework which, crucially, includes the intention to develop the voluntary sector:

  • Promote employment and economic sustainability – tackle unemployment and facilitate the development of residents’ skills
  • Raise the living standards of local residents – working towards living wage, maximise employee access to entitlements such as childcare and encourage suppliers to source labour from within Greater Manchester
  • Promote participation and citizen engagement – encourage resident participation and promote active citizenship
  • Build the capacity and sustainability of the voluntary and community sector– practical support for local voluntary and community groups
  • Promote equity and fairness – target effort towards those in the greatest need or facing the greatest disadvantage and tackle deprivation across the borough
  • Promote environmental sustainability – reduce wastage, limit energy consumption and procure materials from sustainable sources
Liverpool CCG
Liverpool CCG

How would we know?

If an area becomes ‘asset-based’ in everything it does, how would you know? You would expect to see everyone – public services and charities; citizens and people with power – thinking, speaking and behaving differently. This is the second of three blogs written with the Chair of Think Local, Act Personal, Clenton Farquharson MBE, and available in full here. Last time, we revisited the Asset-Based Area (ABA) model which tried to distil down how an area can become asset-based in everything it does from strategy down to the grassroots, into ten actions, starting with mapping your local assets, and including sharing power with people who are usually excluded, and building a diverse range of community approaches which are now gathered in an online catalogue. Three years after the original thinking, we are developing the ABA model in more detail through the Social Care Innovation network.

In this blog, we want to think about how we would know that an area had become asset-based. What would we measure and how?

Greater Manchester has adopted use of system activity measures collected every quarter, combined with a range of personal outcome measures collected locally across the city region. These include measures already well-established across public services, such as health outcomes, measures of demand and cost, and wellbeing outcomes: recognising that wellbeing – living a good life in a good home and a welcoming community – is intertwined with more clinical outcomes.

Key Human Indicators

Many areas and organisations have Key Performance Indicators (KPIs). Perhaps every area needs Key Human Indicators. Are people achieving wellbeing? That usually means that people who need support are able to experience the right balance of independence and connection for them, which will change at different times in their lives. For workers and systems, KHIs will include warmth, kindness (as set out in Julia Unwin’s brilliant report) and dignity. Networks can be more important than bureaucratic service structures. In Shared Lives, friendships are seen as key indicators of wellbeing, so Shared Lives Plus’ national outcomes measuring tool asks participants how many friends they have and whether Shared Lives support is helping them make and sustain those connections, or getting in the way.

Read the rest of this blog on the Social Care Institute for Excellence website, in the Social Care Innovation Network’s minisite.

The idea of the Asset-Based Area

The Social Care Innovation Network is helping 15 local areas and a similar number of innovative organisations take innovative approaches to social care and support. We aim to provide answers to the challenge of scaling up primarily small, community-focused examples of innovation. It’s led by The Social Care Institute for Excellence; Think Local, Action Personal, and Shared Lives Plus. We are keen to encourage as many people as possible to contribute, share and benefit.

I’ve co-written three blogs with Clenton Farquharson who chairs TLAP (among other things) on the thinking behind the Innovation Network and the workstrand that Clenton and I are leading on, which is on The Asset-Based Area. This is our first blog (the full article is here):

The idea of the Asset-Based Area (ABA) started life as a blog and was co-produced 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. So many areas are doing some community building or transformational stuff, but so few are trying to turn their community initiatives into core business. There is not enough ambition, partly because it’s hard to get past the apparent paradox that the good stuff often feels small and personal, whilst the challenges faced by public services feel huge.

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 have attempted, with local priorities defined and put into a community plan which is built on local knowledge. So we tried to distil down how an area can become asset-based in everything it does from strategy down to the grassroots, into ten actions, starting with mapping your local assets, and including sharing power with people who are usually excluded, and building a diverse range of community approaches which are now gathered in an online catalogue.

Three years after the original thinking, we are developing the ABA model in more detail through the Social Care Innovation network, and revisiting this as a work in progress as we do. We’ve grouped the ten actions into three:

  • Co-production, partnership and power sharing: building & valuing community capacity and community organisations, tackling inequalities
  • A strategic approach: a clear story translated into shared outcomes, asset-based commissioning, grant-giving, and provider market development
  • Diversifying workforces & building local enterprise: investing in volunteers & social entrepreneurs, valuing lived experience, growing mutuals & co-ops

We are also taking this opportunity to look at where the model needs improving – and as ever we want this to be a joint effort so your views are very welcome.

One key area that the model does not say enough about is self-directed support. (Read the rest here).

 

Hero, villain, angel, machine

The other week I broke a bicep tendon, which I wouldn’t recommend. I posted this twitter thread with some reflections about using the NHS.

I had quite a few responses, so I’m reposting it as a blog here:

As an NHS Assembly member I thought I should road-test the NHS. So last weekend I snapped my bicep tendon while rock climbing training. Ouch. Here are some reflections.

Firstly, this was a self-inflicted sports injury, but can only be fixed by surgery. That the risks we choose to take (exercise, lack of it, etc) are covered, free-at-point-of-use seems miraculous at times like this.

A&E on a Sunday at Leeds LGI hospital. A wait of course, but in under 4 hours, I was assessed, x-rayed, seen by a specialist, booked me in for next week, by busy, effective, kind people.

I was phoned on the Sun and Mon to book and confirm a Tuesday appointment. The surgeon and his team there were friendly & clear. Options & risks explained. Surgery booked for Sun.

One of the great things about our NHS is the sense of equality. The surgical ward’s patients were a cross-section of Leeds. An unconscious homeless man brought in by 2 police. An older lady keen to chat. A young man having to wait ‘too long’ left in a huff (or maybe in fear?)

An unconscious homeless man was brought in by two police officers. An older lady fretted about getting home. A young man left in a huff when told how long his surgery would be.

Being trolley-ed half-dressed to theatre, scalpels & general anaesthetic feels like being wheeled away from the land of the living. Porters have a degree in cheerfulness which helps a lot.

I met the surgeon just before being anaesthetised. Ideally, I’d have had some significant last minute risk info earlier. He did what seems to be a great job of the op.

Waking up. I burble at the endlessly patient nurse & spill my water. Back to the ward. More kindness + a chemically-enhanced sense of wellbeing. I love the NHS!

This album on my phone seems to have lasted a month.

All morning on the ward TV politicians shouted about Brexit, immigration & NHS crisis. While the multi-cultural, multi-national team were busy, effective, cheerful & kind to us all.

I hear a passionate discussion about an issue to do with unnecessary waiting, and what the team planned to do to fix it. A strong sense of us patients as people with lives outside of this ward.

I think about someone I know in a mental health crisis & my experience of those services: overwhelmed with demand. Long-term care lost behind waiting lists & ‘life-or-death’ criteria.

With my ‘self-inflicted’ injury fixed, I thought about my colleague Meg who talks about being treated for self-harm injuries with less compassion: results of a mental illness seen as ‘self-inflicted’

Is the balance right between the impressive resources here & those available to people with life-long conditions? This team is under pressure, but imagine social care resourced like this…

Later I read this harrowing BBC report into Mark Stuart’s death: autistic & fatally lost in a hospital’s care system. His parents said, “It was like he didn’t matter”.

The NHS is a miracle which has not yet reached all those who need long-term care. It is easy to simplify the NHS to hero, villain, angel, or machine, based on our latest experience.

The NHS needs us not to worship it, or despair at its faults, but to see it clearly, value it and question it. The staff here were at their best when they listened, explained, empathised.

In some places, that culture of kindness and professionalism will break if we take the NHS for granted. We need to invest in it. & we need to listen to those who don’t yet experience it.

The bill for all this was of course, nothing: just paying my taxes. I dread to think how much my care has cost the NHS, or how much private paying health care systems would charge.

Finally, huge thanks to everyone at the Leeds General Infirmary – you are doing an amazing job in tough circumstances and I couldn’t be more grateful.

Accelerating Ideas – shaping local systems

In two blogs, I and my colleague Anna McEwen will reflect on what we achieved, struggled with, and learned around two of the main objectives of our recently completed Accelerating Ideas UK development project, supported by Nesta and funded by the National Lottery Community Fund.

  • establishing a new strategic advice arm and supporting commissioners to start and expand Shared Lives and Homeshare services
  • establishing our work in all four UK nations, building on our success and government support in England and Wales

We wanted to develop a strategic advice business for two main reasons: to help local leaders to work with their  provider organisations to improve and grow Shared Lives, Homeshare and other personalised models, and to bring us a sustainable source of income so that we rely less on grant funding.

This work started to in earnest in 2017-18 and accelerated rapidly: nearly 70 contracts to date, including work with Australia’s changing disability support service and in British Columbia. A typical example is the Shared Lives service review for Bridgend Council which included an evaluation and analysis of Shared Lives in Bridgend, and a comprehensive business case and options appraisal looking at externalised and in-house delivery, working with other localities, and growing the scheme. A key aspect of our work is the work of the team of people with lived experience and their Shared Lives carers, who carry out peer-to-peer research, alongside colleagues who look at practice, use of resources and compliance, to produce a rounded picture of what a local service does, its outcomes, but also how it feels to the people who actually use and deliver it.

One of our largest projects has been with Greater Manchester Health and Social Care Partnership (GMHSCP) to develop and implement an ambitious five year plan for an additional 600 people using Shared Lives, across Greater Manchester. Jo Chilton, Programme Director, Adult Social Care Transformation Programme said, “Greater Manchester has high ambitions for scaling up Shared Lives but we want to ensure that people currently involved in Shared Lives and those who may wish to be supported in Shared Lives in future, help assess how ready we are to do more, and what would need to happen to make our ambition a reality. Our partnership with Shared Lives Plus is vital to getting this right from the start.” This included a detailed evaluation of five of the ten Shared Lives schemes using a combination of scheme health checks and data analysis. The city region is investing and working towards the UK’s most ambitious goal to date, of  15% of people who have a learning disability and use social care to be using Shared Lives.

Our main challenge has not been winning work, it has been expanding our delivery capacity to keep pace with demand. We use a small number of associates for specialist tasks, but a lot of the delivery has been in-house, and the expansion of our capacity off the back of demand for support, rather than through grant-funded expansion, is one of a number of culture changes for our team: we have needed to be willing to take some different kinds of risk to expand. We tailor our work to the local places we are working in, rather than around a bid submitted to a grant maker.  In changing our model, we were focused on remaining true to our values and serving our members, who are 6,000 Shared Lives carers and 170 local organisations. The key to this has been to develop an offer which is shaped by our values and coproduction approach, and marketing this and our unique place as the only national Shared Lives and Homeshare organisation, not as extra cost or time, but as the best reason to work with us: after all, what would be the purpose in expanding the most personalised support approaches, if you didn’t pursue that expansion in a personalised way?

Some of the impacts of this are more expected than others. We have long understood the need to get local areas to invest in development work, if they are to value it, so we hoped to see the buy-in we have achieved through contracted work, but one risk we identified was that it might make our campaigning work harder, around issues like Shared Lives carer pay, for instance. In fact, embedding the practice of coproduction with Shared Lives carers, and developing closer relationships with local leaders, has in some areas made it easier to raise issues around valuing supporting – and paying – Shared Lives carers, rather than harder.

It’s not all been plain sailing, of course. All the advisors who helped us develop this business talked about the risks of under-valuing and under-pricing our work, over-promising, and under-estimating the time needed for work. We thought we’d understood that advice, but we did all of those things and had to learn the hard way. This has increased pressure on our team at times. We’ve coped with those challenges though and this new way of working has not only given us a more sustainable future as a charity, it’s brought a level of learning and insight which we could not have achieved in any other way.

Could self-management work in care homes?

This blog is co-authored by Helen Sanderson, founder of Wellbeing Teams and Alex Fox, CEO of Shared Lives Plus.

Social care’s inspectors, CQC, consistently find that smaller care homes are, on average, better than big care homes. John Kennedy’s JRF research into older people living in care homes found, unsurprisingly, that relationships are key: people want where they live to feel like a real home.

The number of small care homes is reducing, however, because the economics of running a small care home are increasingly difficult. Care home businesses are consolidating as the pressure increases. This shouldn’t inevitably mean that each individual service gets larger, but care homes for older people with 100 beds are commonplace. This may create economies of scale for those businesses, but it may equally create dis-economies of scale, as the markers of great value in care can become harder to achieve in services which reach institutional scale: feeling connected and human both inside the service and with the wider community. Where those businesses are hierarchical, it can also be harder to foster the trust in workers, personal sense of responsibility and autonomy that create transformational support relationships in social care. Some of the largest businesses have financing and ownership models which feel a long way from the idea of ‘community’ or ‘social’ care, and appear to have been used partly as vehicles for risky property speculation. We have seen some huge care provider bankruptcies affecting thousands of older people and there may be more on the way.

So, given that half a million people live in care homes is there a way to create the high value and quality of small care homes, with the economies of scale on things like training and registration which larger businesses can enjoy, but without the added costs of large management infrastructures and profit-hungry big business models?

One approach is the household model, where a care home is divided into small, self-contained households with a focus on creating a family like atmosphere. Dementia Care Matters supports care homes to use this approach and become Butterfly Care Homes. One Butterfly Care Home in Nottinghamshire reports a 43% reduced incidence of falls and 1.7% reduction in staff sickness.

Belong villages have a similar household model. Each Belong household is grouped into an ‘extended family’ sized community for around 12 people, with bedrooms that lead into an open-plan shared communal space, and a kitchen.

In both Butterfly Care Homes and Belong Villages team members often have greater autonomy than traditional care homes. Could self-management take this further?

One of the most promising and widely-talked about ways of organising care and support teams is the Buurtzorg community care model from the Netherlands: recruiting people who are able to work as part of small self-managing teams, supported by coaches rather than a traditional line management structure, with use of tech and data to track activity, payments and outcomes. This model can create better-paid, more fulfilling and autonomous roles, in which people have the time to build consistent relationships, and get better outcomes, at lower overall cost where people can move to independence, because of the better outcomes and vastly reduced need for management infrastructure.

A new briefing paper from the RSA boldly suggests that self-management could save social care. The paper describes five case studies from the UK. One of these case studies is Cornerstone in Scotland, who have drawn inspiration from it to completely reimagine what a large support business looks like around a self-managing rather than hierarchical management structure. The Wellbeing Teams model, which provides integrated, holistic community care on Buurtzorg-like principles, has already been awarded ‘outstanding’ by inspectors, CQC, as has a Buurtzorg UK team. Building-based care services have been slower to experiment with the self-managing model, perhaps because people who are attracted to a devolved, relationship-based way of working have tended to have more affinity for community-based care, but the model’s benefits are arguably most needed in the part of our sector which is most at risk of institutionalisation.

A fully scalable self-managing approach to care homes would perhaps look something like this:

  • Small, ‘home-sized’ care homes or using a household model, with teams recruited who had the skills and aptitude to self-manage, sharing responsibility rather than leaning on a traditional management structure.
  • Those small, largely autonomous businesses networked within a franchise-like structure, with a centrally-developed IT and finance system to track activity, outcomes and payments.
  • Coaches supporting each team and communities of practice for teams to share their challenges, innovations and learning.

Self-management wouldn’t be a panacea for the care home industry: self-managing teams in care homes would also need to adopt the most personalised and empowering cultures and approaches. The best care homes have strong links with their local communities. Few people want to volunteer for a large, faceless company, but where a care home feels genuinely like part of the community, there is huge scope for added value through volunteering, forming Community Circles and the invaluable benefits to health and wellbeing of feeling part of a community, not removed from it. This would fit particularly well with a mutual model of ownership, in which residents, families and perhaps even the wider community had a stake, as well as workers.

Often when we talk about reforming and personalising social care, we focus on models which are the most community-embedded, or, like Shared Lives, seen as the most innovative. But we need to gains of personalisation to reach the whole of social care: they can’t be reserved for the lucky few. There may be models of self-management in the care homes industry which we haven’t included here, so we would be grateful to hear of any examples we have missed. And if you are in the industry and just hearing about or starting to consider this radical transformation, we would love to hear from you. We will be happy to add links to this blog, but most of all we would love to start a new conversation.

Inequality creates ineffectiveness

Youth Justice Officer and author Andi Brierley (@andibrierley) may regret posting such an interesting comment on my blog entry about coproduction – because of course I asked him to turn it into a guest blog. I’m glad I did anyway: this is such a powerful personal piece on why we need many more people with lived experience working in – and leading – our public services. It follows Rachel and Tim’s guest blog yesterday about more meaningful relationships in social work, both of these pointing to the fascinating conversations which are taking place across the adult and children’s services divide about the relationships we have – and those we need – between people offering and seeking support. Andi writes:

I was born to a mother living in a children’s home aged just 16. I spent time in care as a result of mum’s capacity issues leaving me and my siblings abused and neglected. I was excluded from school aged 15, addicted to heroin aged 16 and then exploited into selling drugs by older men. When I was eventually caught, I was sent to a Young Offenders Institution for 18 months. This sentence did little to address my life challenges and upon release, I served a further 3 sentences for offences that all related to drug and alcohol related offences.

I eventually started volunteering for the Youth Justice service in 2007, only two years after release from my last prison sentence. Having been granted an opportunity, I grabbed it with both hands and have worked in youth justice ever since, qualifying in 2013. I have also written a book ‘Your Honour Can I Tell You My Story’ about my experiences, in which I draw on my unique combination of 11 years as a service user and 13 as a youth justice worker, to argue that our institutional responses to disadvantaged communities, children and families do not – and cannot – work.

Let’s take the Criminal Justice System. The regulatory body of Probation and Youth Justice, Her Majesty’s Inspectorate of Probation (HMIP) is set up to regulate ‘risk management’ processes. Do these processes keep us safe?

According to a 2016 Ministry of Justice report, 25% of the adult prison population had experienced care and 42% had been excluded from school: they were known to services from a very early stage in their lives, and many excluded from school and criminalised in their care setting (see this 2018 DfE report). So risk management at that early stage was ineffective, and then, post-incarceration, the reoffending rate for children within 12 months of release is a high as 70%.

The most severe risk management tool is incarceration, which politicians want us to believe ‘rehabilitates’ offenders. However, rehabilitation implies that these individuals were once living a ‘normal life’, which the statistics above show was not the case, and the reoffending rate is currently 46% for all prisoners within 12 months of release. For prisoners serving short sentences, this rises to 60%.  I can’t find research on this, but from my lived experience, I think these will disproportionately be care-experienced prisoners: care experienced and traumatised individuals are more likely to be dysfunctional than organised armed robbers. The National Audit Office estimated in 2010 that this reoffending costs us as a tax payers, anywhere between 9.5 to 13 Billion.

So it seems hard to argue that the current Criminal Justice System is effective when dealing with children that have experienced childhood adversity. Research conducted by the US health maintenance organisation Kaiser Permanente and others found children that suffer abuse and neglect in the absence of an attachment to a positive adult show profound neurological damage. They found that that the more exposure to adversity, the more likely the individual is to experience teenage pregnancy, criminality, drug addiction, health problems and even early death. I can relate to this both personally, but also professionally. I am currently working with children that do not and cannot understand the impact of their environment on their own behaviour, yet we continually view them as a risk instead of doing more to change their environments. The criminal age of responsibility being 10 years old doesn’t take into account neurological impairments.

I believe that the root cause of this is the core belief of the criminal justice system that the children are making choices and therefore they can assist in helping them make better choices. This view is rooted in many professionals’ belief that they themselves would not commit crime, even faced with the environmental factors the children are facing. Let’s explore this even further. To become a professional in the care or criminal justice sector, you often require a degree, particularly if you want to rise to senior management level. Yes, there will be professionals that have faced adversity and even some that come from disadvantaged communities. However, they are extremely unlikely to have experienced the level of childhood adversity or transgenerational trauma the children in the criminal justice system have, particularly those that end up in custody. Currently, only 6% of Care Leavers obtain a degree between the ages of 18-21. The number of incarcerated children obtaining a degree will be considerably lower. This indicates criminal justice services, with some exceptions, are being shaped by a group which does not include people who know first-hand what it is like to be exposed to the environmental factors the children within it face.

HMIP recently inspected the service I work with and spent a week reading what we as professionals write on the recording system. They didn’t speak to the young people in reaching judgements about our practice. Now I see why, when I was a service user, I didn’t know the system was ‘managing’ my risk in this way. I was secondary: the institutional process was primary because that was what the regulators focussed on. But our failure to listen to or value service users goes a long way to explaining the ineffectiveness of the system in helping offenders desist from offending.

I am by no means the person with the answer, but I do have a unique perspective. I know for certain that professionals that haven’t experienced childhoods like ours should not take the view that they wouldn’t have been significantly challenged by such experiences. The Criminal Justice System needs to be built upon the findings of the Adverse Childhood Experiences research which can’t show the reason for a particular offence, which is a decision on an individual day, but does show clearly how a childhood like mine affects the individual’s life course and goes some way to explaining the root causes of the behaviour.

The system would become more effective if it was flexible enough to incorporate the views of people within the communities that the individuals come from. Lived experience is a skillset, so we must reduce barriers to work within the system itself, such as criminal record checks. Einstein said that the definition of insanity is continuing to do the same thing over and over,  expecting a different outcome. Co-production needs to be more than a buzz word. To create a more balanced, personalised and appropriate response to crime, which will keep us safe and cost less money, I have learned that we must fight the social inequalities and marginalisation faced by the vast majority of children who offend.