Let’s get started

The government’s care inspectors, the Care Quality Commission, have just published their three year report on social care, having now inspected all care services in England under their new regime. They found that whilst three quarters of care services are good or outstanding, a fifth of all services need to improve and that rises to a third of nursing homes, which care for people who have the most complex needs. There has been a lot of focus on the role that funding cuts play in this, which is undoubtedly significant: commissioners in some areas are trying to pay so little to their care providers that it is hard to see how those providers could even meet their legal duties such as minimum wage. There needs to be more money put back into the system to avoid catastrophe and the government needs to stop diverting any new social care money into a focus on saving acute hospitals, as has just happened with the Better Care Fund.

But there are other lessons to learn. In this report as in all recent ones, CQC has found that smaller services are more likely to be good than bigger ones. People want to live in somewhere that feels like home, but huge care homes are still being built and registered for older people, and ‘units’ of ten or more beds are still be developed for younger disabled adults.

Staff turnover in social care is over a quarter a year and rising. The model of recruit quickly and cheaply hides huge re-recruitment costs and must contribute to the failings that the inspectors find.

Shared Lives is an approach in which Shared Lives carers are recruited slowly: a three to six month approval process. Shared Lives feels small and homely because it only takes place in the Shared Lives carer’s family home, and the surrounding community. So it perhaps shouldn’t be surprising that CQC once again find that Shared Lives outperforms all other forms of care. Shared Lives carers are trained and paid, and the scheme which recruits, matches and supports them also costs money, but this model is not more expensive: it is consistently significantly lower cost.

Shared Lives is not perfect everywhere. It is coming under increasing pressure from commissioners desperate for even greater savings, who don’t understand that the time and care taken in setting up and supporting Shared Lives is crucial to its safety and success, and also the reason it costs less overall. Some Shared Lives carers are being put at risk of burn out as they are expected to care 24/7, again with risks to people’s wellbeing and ultimately much higher costs. But the lessons from this model are clear: invest time and money in the conditions for success, not managing failure. Focus first and foremost on a good life if you want good services. Ensure rules and regulations are there, but in the background when they’re needed, not the whole focus of everyone’s time and energy. Think small and personal, not big and cheap. 

The government is about to consult on social care. This cannot just be a discussion about what social care costs and how to pay for it. It has to be a discussion with what that money is spent on, starting with the ambition to offer Shared Lives to everyone who want it. Almost every area now has a local Shared Lives organisation to build on. Let’s get started.

What could be

Finally, social care is being recognised by our political leaders as vital to our nation’s health and wellbeing. All parties now recognise that ordinary people can be called upon to pay vast amounts towards their care, in contrast to our free-at-the-point-of-need NHS. There is public recognition of what social care is, for the first time. But now we need to visualise what it could be.

Our annual State of Shared Lives Sector reports give a glimpse of a possible future. They have consistently shown that Shared Lives is growing in England, and now we have evidence of new growth in all four home nations. They have also highlighted the difference Shared Lives makes to people’s lives. Many people who might otherwise have lived on their own or in a care home are finding a settled home with their chosen Shared Lives household. Meanwhile, a new group of older people and others who live with their families, but need regular overnight or daytime breaks, get those breaks from visiting their chosen Shared Lives carer, often matched with them because they both enjoy the same activities, rather than struggling with the stress and disruption which more institutionalised breaks services can bring. People live well and sometimes achieve the impossible.

This year our annual report for England (as reported in Community Care) paints both an encouraging and concerning picture. In previous years, Shared Lives has grown strongly, despite the cuts which are shrinking all other forms of social care. The net growth has been about 1000 additional people per year. This year, the number of people using Shared Lives in England has grown by around 580, to just under 12,000 people, around half of whom are living with their Shared Lives carer, and the other half are split between short breaks and daytime support. Look at the numbers of people using Shared Lives by region, however, and it is clear that there is a widening gap between those regions which are accelerating and those which have in previous years been stalled, and are now starting to slip back. So the regions which are growing, have added over 1,100 additional people. Half of this growth comes from the North West, with London and the South West splitting most of the rest. There are signs of growth in the North East, which has been one of the smallest regions and where we are working with directors’ association ADASS and the region’s Shared Lives schemes and partners to create a regional hub. The South East and Yorkshire have seen significant reductions, however, after having previously been regions which were using and developing Shared Lives strongly. The East and West Midlands remain essentially unchanged and the East of England, which has been the smallest region for some time, is now falling. Meanwhile, the model is growing in Scotland, Wales and Northern Ireland and we have embarked upon ambitious new programmes in each nation, with strong support from the Wales Government in particular.

With so much news about cuts and the crisis in the NHS, it is easy to believe that the future of public services will just be less of what we have now. But we believe Continue reading

What helps and hinders change?

We recently published a very brief guide to six linked innovations, to show how they can work together to create whole-area change. Here is my Guardian blog. Thanks to Community Catalysts, Local Area Coordination, Community Circles and Helen Sanderson Associates who were the partners with Shared Lives Plus.

The five organisations involved also pulled together this list of what enables and what gets in the way. We’d be interested in your thoughts on these. I’ve mentioned below a couple of areas doing inspiring work on this agenda  – but I’d be interested to hear about others I’ve missed.

Enablers

  • Applying asset based thinking to the whole area: the new ‘core business’ rather than series of ‘pilots’ eg Wigan, Thurrock, Bracknell Forest
  • Strong coproduction infrastructure including ULOs, self-advocacy groups, peer support groups for people with specific conditions
  • Effective roll out of Direct Payments and personal budgets including ISFs, with widely available information, advice and brokerage services which are also accessible to self-funders; minimum red tape approach to spending individual allocations; people supported to pool their individual resources.
  • Multi agency strategic planning with a focus on wellbeing as the primary goal, expressed through cross cutting aims eg reducing loneliness, increasing social connections and resilience, reducing mate and hate crime
  • A culture of shared responsibility, and a shared goal to reduce dependence and customer service culture eg Wigan New Deal
  • Strong VCSE infrastructure which is inclusive of all kinds and sizes of not-for-profits including small community enterprises
  • Funding including social investment for double funding and innovation. Access to local or national innovation funds.
  • Consistent use throughout area of effective measuring tools including ASCOT, POET; use of evidence and data to facilitate conversations with citizens about change.

Barriers

  • Cuts to public service budgets and different approaches to managing those cuts
  • High levels of inequality and lack of inclusion and social integration
  • Strategic goals defined centrally/ top down and overly focused on the financial stability of the acute end of the system, or divided by condition group, rather than focused on outcomes and cross-cutting goals
  • Difficult local politics preventing risk taking and decommissioning what doesn’t work.
  • Lack of commissioning capacity and skills; tendency to commission largest organisations to reduce transaction or unit costs regardless of cost-effectiveness of models.
  • People prevented from making real choices by limited or filtered information about range of support and services; or by unnecessary rules around the use of public funding and personal budgets. Provider lists which exclude new entrants and start-ups.
  • VCSE sector under-developed or dominated by small number of large organisations; VCSE infrastructure organisations unstable or unsuited to current environment.

 

 

 

Person Shaped Support

 

Lesley Dixon is Chief Executive of PSS (Person Shaped Support) which has a long history of social care innovation and is one of the leading independent providers of Shared Lives services. PSS has just published a report on the outcomes and costs of its Shared Lives support, which includes powerful personal stories alongside data which should interest many people working in the sector. Lesley writes:

Social Impact Reporting is a big priority for us. At the end of each year, we make it our business to take a detailed look at what works, what difference our services make, what is cost-effective and ultimately whether we are doing any good for the people we work with.

We recently published our first Social Impact Report for Shared Lives and TRIO,  which looks at the fantastic achievements made by our Shared Lives schemes across the UK; in Merseyside, Wirral, Manchester, Wales and the Midlands. The report includes information on the people we work with, the pathway they follow when they come to the service,  the outcomes we support people to achieve (including case studies) and what our service-users think about the service. It outlines some cost-benefit analysis information, looking at the value of our Shared Lives projects when compared with other, costlier forms of care in the areas we work in, and also looks at some of the innovative work being done with our TRIO project in Wales, the hospital-to-home work we are trialling in some of the schemes, and our work with Shared Lives Plus on the My Shared Life tool.

Perhaps our biggest finding from this report is around the savings our scheme can make to the public sector. We found that Shared Lives is 51% cheaper than residential care and 35% cheaper than supported living. This means that on average, a Shared Lives Placement at PSS would represent an annual saving of £23,491 per person, compared to if they were to be placed in residential care, or an annual saving of £11,922 if they were placed in Supported Living.

Whilst there are some really good findings and inspiring case studies in the report, we know there is more we can do to keep getting better.  We plan to use the My Shared Life tool from Shared Lives Plus to help us manage impact on an ongoing basis, as opposed to a reflective report at the end of each year.  This will help us ‘course correct’ where we know that some of the things we are doing could be more effective or where they aren’t working.  We also really want to embed some measures which can help us demonstrate that what we are doing is high quality (such as some of the NICE Quality Standard measures), as well as some other tools which can help us establish baselines and demonstrate an emotional impact – such as people no longer feeling socially isolated or lonely.

 

What would good look like?

When we talk about the shift towards a ‘people-powered’ NHS, we often talk in terms of culture and vision, but avoid suggesting actions which would transfer power to people, whether that power is in the form of money or other system levers. Chapter Two of NHS England’s Five Year Forward View set out how healthcare would become more community-based and people-powered. Whereas other changes involved setting up new kinds of organisation or using money in different ways, Chapter Two was a vision for doing things differently, with less clarity at that time about what new kinds of systems, services and relationships between people and the NHS would make that vision real.

During the last two or three years, we have learned more about what helps and what gets in the way of making the vision real. Shared Lives is one of a small number of new community-based support models which NHS England is directly backing to make the shift. Many of the Sustainability and Transformation Plans (STPs) which every area produced for its local health and care system talked about the need for a more community-based model but I haven’t read one which sets out a process for the transfer of money, knowledge, power or responsibility to local people and their representative organisations.

When that transfer doesn’t happen, nothing really changes. A highly regarded social prescribing programme, which demonstrated that it was enabling people to access new kinds of community support and improved their wellbeing, has just been ended by a CCG which decided it couldn’t afford it in tough times. It worked, but never became regarded as core business. The outcomes it achieved clearly weren’t those valued most by commissioners and the organisations involved did not achieve the status of equal partners with their statutory equivalents.

We need to put what we have learned into the NHS’s plans, and later in the year, the social care Green Paper. I think there are three kinds of change which would be present in an area which was doing people-power well:

  1. At least some of the money spent on health and care provision would be paying for people-shaped outcomes such as ‘wellbeing’, as it is defined in the Care Act.
  2. An element of the area’s infrastructure and commissioning budget would be paying for infrastructure that reaches, engages and convenes people, supporting them to take decisions at both individual and area level.
  3. Some of the oversight, performance and regulatory levers would be in the hands of people, via experts by experience and also their local groups. Current consultative structures would be replaced by well-resourced, trained and accountable forums and groups with teeth.

What would push or pull local health systems towards those three new ways of doing things?

The NHS is already putting some of its money and resources in people’s hands through an ambitious Personal Health Budget target. But this needs to be matched by ensuring every area has a brokerage service to help those people (particularly those least able to choose) to make individual choices and to connect with others who want similar things, to pool budgets and start to commission (design and improve services) rather than just to buy them. The Social Value Act enables commissioners who buy public services to demand that their suppliers give them added ‘social value’, such as using volunteers. The Act’s powers are used in a quarter of councils, but by very few NHS commissioners. This has to change.

It’s not just cash that needs to be put into people’s hands. In a people-powered area, family carers would be able to access medical expertise, training, equipment and emergency back up to sustain their caring roles. Social prescribing programmes can put money and resources into the hands of local community groups and social enterprises which help people to live well. Initiatives like Local Area Coordination and Health Champions create connections between people who use health services and their services and communities.

Some of this won’t happen unless the NHS moves some of the money it spends on infrastructure into people’s hands. Health commissioning is expensive, but currently most of it is ineffective in building community-based care, so some of its resources should be spent instead on people and organisations which can help citizens themselves co-design new models of care. Most local areas have organisations which organise and speak on behalf of the voluntary sector, such as the local Council for Voluntary Services and which represent people’s voices in health and care such as HealthWatch and Learning Disability Partnership Boards. Some have organisations which effectively build a local marketplace of lots of different kinds of charities and social enterprises. A handful build the smallest enterprises. In many areas these different kinds of organisations are fragile and disconnected, with unstable funding. User-led organisations and organisations representing overlooked communities are losing funding. None of these organisations have teeth. A people-powered area would bring those organisations together into a wellbeing hub which would ensure that citizens and their local organisations could help to design and monitor health and care services. It would inform and build a local marketplace of service providers and it could help local peer support groups and be a link between such grassroots initiatives and clinicians and other experts within the system. Commissioners should have to make themselves regularly accountable to the people they serve and a hub would be a way to resource and bring together user-led and self-advocacy organisations to make this happen.

This isn’t just about putting resources into people’s hands and offering them new rights. Rights are only meaningful if those people who engage share responsibility and ownership of the new system. So some of the system accountability must be put in people’s hands. As well as the hub model above, we need a new set of measures of what the NHS and care organisations achieve, which measure wellbeing, not just narrow clinical outcomes like mortality. Some health and care system performance measures could be wholly or partly scored by people who use health and care services and their local groups such as self-advocacy groups for people with learning disabilities and carers’ organisations. Local systems would need to develop, resource and challenge those groups to perform that function, which would help to address the longstanding problem of voice organisations existing on sufferance and scraps of money. They would also need to recruit experts by experience to use in commissioning, monitoring and inspection.

This turned into quite a techy blog. That’s deliberate: if we mean the vision for health and care which is rooted in communities and delivered with and by people themselves, we have to be able to describe the different systems and ways of spending money which would make that vision happen.

Sceptical Trust

This blog first appeared in New Local Government  Network:

I know someone who’s renowned for his scepticism. The only problem is, he’s now so sceptical that he doesn’t feel able to trust anything. People who post videos on YouTube seem to have as much, or little, credibility as professional journalists. After all, journalists can succumb to group think. And who’s paying them, anyway?

The results of blanket scepticism look surprisingly similar to the results of blanket credulity. But in a corruptible world, where fake news looks ever more real and we are weary of being let down, how can we trust each other? Why should we?

I work with people who are temperamentally inclined to trust other people. They open up their own homes and lives to people who they have not known for very long. And sometimes it doesn’t work and they cope with this, but I hear constantly that living this way makes them happy. They are realistic about the people they live with, but often able to see and value them in ways that others cannot. Those who are considered vulnerable – the very young and the old – could be most at risk from this openness, but they are also those who appear to benefit most.

For instance, Homeshare organisations help older people to take an unusual risk: to let someone they have only recently met into their homes. There are police checks, references, interviews, but the core of the model is about helping two people establish trust. Recently I was also talking to two young women whose parents were Shared Lives carers. They had valued the experience so much that both were now involved in Shared Lives as adults, contributing untold amounts to those around them and their communities. If Shared Lives or Homeshare arrangements don’t work out, the local organisation steps in to help, but there is always an element of risk.

The risks of trusting no one, however, are stark. When we start to avoid the risk of trusting others, it can give us a short term sense of safety, but everything we value is corroded. Loneliness not only crushes happiness; it is in the same bracket of health risk as smoking. It is now endemic amongst older people, and even the best health or care service can’t fix it.

I also spend quite a bit of my time with a group of people who generally come quite low down on people’s trust list: politicians. My experience of them is that, whilst I often disagree with them on lots of things and sometimes feel we have very different life experiences and world views, they are generally people who believe they are helping other people. They work ridiculous hours and a lot of what they do is not at all glamorous, but is absolutely necessary in a democracy. They are as flawed as the rest of us, but based on having met quite a few, I am inclined to approach them with an attitude of sceptical trust, because without it we have no democracy worth the name. And of course, because I hope they will approach me and others who work for charities with something like the same attitude.

This seems a strange time to be suggesting that we all trust each other – whether we are Shared Lives carers or politicians – more. As 2017 picks up where 2016 left off, I am not completely confident that I will be able to practice what I preach on this, all of the time. But if you’re willing to try to approach me with something like sceptical trust, most of the time, I will do the same for you.

It is, I think, from small acts of trust that functioning communities, organisations and even nations are built.

The Budget

The budget includes the promise of £2bn of new money to fund social care over three years. This is a welcome response to the current crisis in social care which is seeing care homes, home care businesses and other crucial forms of support for adults and older people going bust, or suffering unacceptable levels of failure. The gap between what is currently spent on social care and what is needed is more than £1bn, so this will not on its own bring back support for the 1.2m older people who no longer get support (an increase of around half in recent years).

The money is a grant so, according to Richard Humphries at the King’s Fund, is unlikely to be ongoing and is likely to have ‘strings attached’. I have mixed feelings about this. On the one hand, councils, particularly in the poorest areas where cuts have been greatest (according to the cross party Public Accounts Committee), badly need the freedom to prop up existing services which are collapsing under the opposing pressures of budget cuts, increasing numbers of older and disabled people and increasing costs of providing care (not least the hundreds of millions needed to fund the – very welcome – national living wage in this traditionally low-pay sector). But on the other hand, the Better Care Fund experiment showed that well-intentioned but un-ringfenced money put into a stressed system results in little transformation: the crisis subsides and then reappears. Our forthcoming report on the national picture of Shared Lives development will show widening divergence between places investing heavily in Shared Lives because it offers them a sustainable model which fits with people’s lives, and areas apparently unable to invest in anything new.

Already the HSJ is calling for the new grant to be allocated to initiatives which focus on getting older people out of hospital. A narrow focus on what forms of social care will immediately alleviate the current pressures in the NHS will not ultimately achieve its goals. The models which work are those co-designed by social care providers, including the voluntary and social enterprise sector, and the people and families who make most use of services themselves. They are built around goals like wellbeing, independence and resilience. By putting people’s needs (and capabilities) at the centre, rather than services’ needs, they ultimately lead to benefits for the NHS which would not be achieved if benefiting the NHS was the starting point.

The budget also promises a Green Paper which will consider how to put social care on a sustainable footing. It is impossible to answer that pressing question without giving equal consideration to the question of what the money will be spent on in future. This cannot be ‘a more efficient version of what usually do’. It must be a social care system built around serious ambition for the scale and effectiveness of community-based models which have been considered add-ons for too long. As this SCIE paper outlines, it’s time for the models with most chance of success to become core business.