Reverse auctions

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.

Advertisements

Stroke survivor Brian gets ready to move on

This story from Shared Lives South West shows how Shared Lives is providing great health care as well as social care. The story can be found here. It’s a great contrast with the story about room renting which hit the headlines last week – see my previous blog. We are working with NHS England and 7 local NHS CCGs to develop new health care options. Here is an extract from the full story with thanks to Shared Lives South West, who continue to inspire us all:

If you rewind a year, Brian Lee’s future looked bleak. While out walking in local woods he had a stroke and ended up in intensive care and endured a four-month hospital stay.
His health deteriorated further while in hospital as he also suffered two minor heart attacks and Brian was extremely weak.

The medical trauma left him with complete memory loss and his mobility was severely compromised- making it difficult for him to walk even short distances.

Fast forward to now and his life couldn’t be more different.  Thanks to the support and care he’s received from the Shared Lives team and ultimately his Shared Lives carers Jeanette and Alan Eames as well as his own determination, Brian is well on the road to recovery.

He’s recently managed to plan and go on holiday to Thailand and is preparing to move out to his own flat and live independently.

“I was so stubborn and determined. I had to prove to myself that I can still do things,” said Brian.

“Jeanette and Alan have helped me through it all. I was decrepit feeble creature when I arrived at their home in March.

“I couldn’t walk down the drive, now I can nip up to town. I never dreamt of being so independent again when I came out hospital.

Since moving in with the Eames’ family, near Okehampton, they have been there to support him every step of the way-  from helping him with appointments to liaising with his friends to help him move forward and sorting his medication and preparing him for his trip to Thailand, where he visited with no support. It was paramount his carers got him ready for the trip and made sure he was able to manage all his medication.

The Shared Lives team were also on hand to make the match with the Eames family. They charity’s Funding and Benefits team also maximised his benefits.

“They prepared me and made me ready for life outside,” said Brian.

“I think what was most important to me was to realise limitations early on, then I think you have to scale back on your expectations, then you can move forward positively.
“The main help was with my medication, that was a key thing. With Jeanette’s help there were visits to the doctors to make sure my balance of medication was right, as when I came out of hospital it was all wrong.

“I was on knock-out drops, I wasn’t living life as it should be. By 11am I wanted to go back to sleep again. I spent most of my time just sleeping. It was too much and there was a real temptation not to take them.

“Jeanette got it sorted out for me.”

“I also made sure he was taking the right medication at the right times to start. Now he has pots and has hang of doing it all himself,” said Jeanette.

Banking also became difficult as he struggled to remember numbers.

“If you ask me about a phone number or bank details and I wouldn’t have a clue,” he said.

With advise from Jeanette, they decided to change passwords to key dates that he could remember.

“That way I could do somethings myself with support,” said Brian.

The full story is here.

More than just a room

There has been a great deal of interest in the media in a small start up company called Care Rooms, which has been developing an idea in which people would rent out their spare room to the NHS, for use by older people who are well enough to leave hospital but not well enough to return home. The hosts would be paid £50 a night and would microwave three meals a day and ‘provide conversation’. If personal care was needed, this would be provided separately by services visiting the host’s house. Shared Lives has been mentioned in some of the media coverage, which has mainly focused upon the risks of the proposal.

One of the problems with Shared Lives and Homeshare being so little known, is that people frequently ‘invent’ them, often without having thought them through that carefully. Recently we saw a think piece from a firm of public service experts describing its groundbreaking idea for younger people to live with older people: Homeshare is a decades-old international movement across 16 countries used by thousands of people.

What struck me about the reporting of Care Rooms was how little of it was from the perspective of the (mainly) older people who would be its recipients. Why would people who are well enough to leave hospital want to be a lodger in a stranger’s spare room eating microwaved meals, rather than going home? In Shared Lives, which is already being developed as home from hospital care with support from Dept Health and NHS England, the benefits to an isolated older person are that their Shared Lives carer will provide personal care (because Shared Lives is a regulated care service with the training, back up and safeguarding processes needed to do so) but perhaps more importantly, the Shared Lives ethos is that the participants get to know each other before deciding that they will get on: it’s a social arrangement in which the older person is welcomed into the household. Even when it is used for relatively short periods of post-hospital care such as stroke rehabilitation,  people can form connections which outlast the ‘formal’ care provision. That sense of belonging and community appears to lead to people recovering faster and further because health and wellbeing are closely linked. Care inspectors CQC say that incidents of neglect, poor care or harm are rare in Shared Lives households, compared to their frequency in care homes and home care services: this is partly because Shared Lives carers go through an approval process lasting several months, but also because people choose to be together and enjoy each other’s company.

That kind of ‘care’: care as an emotion rather than just an activity, cannot be bought. It does though require thoughtful selection, matching and choice-making to happen. It’s taken the Shared Lives sector 40 years and the work of tens of thousands of participants to put that in place.

Mystery and Bureaucracy

A twitter exchange between Rob Mitchell and Prof Chris Hatton put me in mind of the famous quote from L’Arche founder, Vanier: “Some people say that communities start in mystery and end in bureaucracy”.

Chris, a skilled combiner of academic rigour and humanity, said, ‘Bureaucracy is a vampire. It feeds on people’. Lots of people reading this blog will relate to that, perhaps because they will have felt their own lives drained by working within, or even living within, a public service bureaucracy. What is bureaucracy though?

We all come across bureaucracies. They feel inhuman: some are machine-like; some fanged as Chris says; some have tentacles which we feel reaching around us into our lives.

But a bureaucracy is always a group of people, choosing to behave in a certain way. People will dispute that word “choosing”. The nature of bureaucracies is that, whilst someone at some point wrote their rules, and other people added to them, they feel like they have come to life, operating beyond the control even of those who profess to lead to them.

But whilst Vanier’s quote is often read to mean that every community – a group of people who share some beliefs and ways of behaving – already has some bureaucracy in it, it also suggests that every bureaucracy is also a community.  He could equally have said that every community starts in mystery, and ends in mystery: the mystery of how a group of humans created something which feels so utterly unlike themselves.  The bigger the bureaucracy, the deeper its mystery: the gap between the values of the people within it and the way we feel instructed to behave. This is why I think the challenge facing public service leaders is no longer how to scale up (the business growth model of marketised public services) but how to scale down.

But even in a vast bureaucratic community, no rule is unchangeable, or incapable of more than one interpretation. The choice to be human can feel difficult, or downright dangerous, when we work within a bureaucracy, but nevertheless we make choices. Ultimately, then, the nature of a bureaucracy, lies in the choices the people within it make every day.

The need for a Slow Policy movement

(I was not aware when writing this blog of this 2005 paper by Peter Bate which has a similar theme and which draws on In Praise of Slow by Carl Honore, also new to me. Some ideas percolate, well, slowly.)

There is a slow food movement, which began in Italy, based on the belief that fast food lacks real nourishment and flavour and that its intensive production methods and short cuts are unsustainable for the environment within which it is grown and produced. Slow food is produced with time, care and the understanding of local culture, farming and ecology which can only be developed over years, or even generations. It tends to value small-scale production for its sustainability and for being rooted in community and place.

At present, government and the NHS express the importance of a policy change through the urgency of the deadlines they set themselves and their partners and the amount of money they can ‘find’ in an emergency to fund the change. NHS Sustainability and Transformation Plans (STPs), in which every area was required to set out how its health system would transform itself to survive the current resource crisis and become sustainable, were clearly important, and therefore urgent. So, most were drafted by small groups of very senior people, who regretted they had not the time nor resources to engage widely, particularly with charities, grassroots groups and people with lived experience who are the most complex and time-consuming to find and talk to. It is no surprise that STPs, despite many containing necessary and pragmatic ideas, have been widely reported by the media as ‘secret NHS cuts plans’.

This cycle of crisis, frenzied activity and shallow changes is endlessly repeated. The urgency turns out to be illusory every time: whilst a report will be rushed out in months, underlying causes of problems will remain unaddressed for years. STPs are morphing into the next set of initials whilst the NHS and social care continue to go bust.

We need a slow policy movement in our public services: a new norm for how to create change. No more flurries of reports and plans from the same group of highly paid people, who remain embedded in group-think. No more heroic leaders on a mission to fix things.

Instead, the slow policy approach would be to cultivate different people and networks which are more deeply-rooted in the lives and service cultures of those affected: people with lived experience, their families and front line workers, who all need training, preparation and a slower pace in order to contribute meaningfully. A change programme would examine the problem or challenge from the point of view of people use services, families, front line workers and people who do not or cannot currently access the service. The conversations with them will start with “What does a good life look like?” not “How can we improve, cut or close replace our service?” The questions will include, “What are you willing to contribute to achieving the goal we all agree is important?” (which is a different question to “Will you pay for our service?”, or “Will you volunteer for us?”)

In place of short term pilots generating tentative findings, new models should be implemented on a small scale but with a plan to scale them up incrementally if they appear to be working, until they replace the current system. As my colleagues in Local Area Coordination say, ‘move slowly, to move fast’. With people who use services genuinely involved in their design and delivery, we would finally have the confidence to remove resources from models which do not work, rather than continuing to resource the status quo, regardless of how much more effective new models proved.

High Performance Failure

Every public service organisation has the potential to forget its purpose – working for the people who use its services – and instead being run for the benefit of those who work for or lead it. This happens in poor services through incompetence or laziness, but it also happens in high performing services, which get seduced by their own reflection.

The recent scandal of St Olave’s school, found to be unlawfully expelling sixth formers whose first year results looked like they might bring down the school’s A level results and threaten its league table position, is an example of this phenomenon. This was a state school, spending public money, which was lauded as one of the best, but which was in fact becoming in some ways one of the worst: wilfully failing and damaging young people at a crucial time in their education. This now appears to have been the practice of a number of ‘top-performing’ schools, who presumably shared the view that their league table success, and accolades for their leaders, outweighed the importance of harming those pupils seen as inconvenient. Arguably, this ‘wheat from chaff’ view of children is just a reflection of a wider crisis of values within the education system, with its lingering fondness for selective schools.

The school system has some features of which make this ‘high-performance failure’ more likely. The head teacher and the education system places huge value on the ‘heroic leader’, with ‘super heads’ wielding unchecked power. 2016 Harvard Business Review research looking at hundreds of heads showed that the most lauded head teachers, who made dramatic short term gains in academic performance, often through excluding more pupils, left no lasting legacy of success, but probably a trail of destruction as they removed ‘problem’ pupils and staff who disagreed).

Governing boards can lack real power, with parental voice limited or non-existent. Despite talk of empowering pupils, the focus of most school policies is on their compliance to rules set by others. An extreme example of this was circulating the internet today: the behaviour policy of an academy school, which, whilst clearly starting with the laudable aim to raise young people’s level of ambition (speaking clearly and confidently in full sentences, for instance) had strayed into an Orwellian nightmare: shy pupils could expect to be punished for speaking too quietly (city hypothetical future job interviews, this would make them appear ‘not that bright’) or even failing to smile enough, which was ‘ungrateful’ and ‘negative’. Despite glib slogans about how successful this would make children (“We’re Charter. We’re smarter”), it’s hard to see what leadership or creativity skills could be learned from being subject to such a monoculture.

This is partly a product of the gap between simplistic notions of success and quality in the education system, and what makes a diverse group of children not just as academically successful as they can be, but also as happy, kind and resilient – which are outcomes either unmeasured or which take second place to results. We also see this gap in adults’ services which are ‘high-quality’ but fail to help people achieve wellbeing or build resilience. Continue reading

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.