A capabilities approach to housing and support

I’m speaking at the National Housing Federation conference this year (link below). Here’s my blog ahead of the event which you can also find here: http://www.housing.org.uk/media/blog/a-person-centred-service-means-focusing-on-capacity-not-need/ 


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The challenge laid down by the Care Act, which reframes social care from responding to a list of medical conditions to creating ‘wellbeing’, is for every public service intervention to be effective at meeting need, but framed around the person’s idea of a good life and their capacity to build it with those closest to them.

13 April 2015

Arthur is an older man with a number of co-morbidities and extreme anxiety. He makes numerous inappropriate calls to the ambulance service which waste valuable resources, but struggles to engage with interventions to address this behaviour.

Arthur is a keen and expert angler, with a gift for teaching his skills to others. He is happy to give his time to help others learn how to fish.

Both of those are factually correct descriptions of ‘Arthur’, but they lead us in very different directions. The first sees Arthur exclusively in terms of his needs and problems and presents services with a challenge in terms of how to manage his behaviour. Perhaps Arthur needs more medication or intensive mental health outreach work?

Fortunately, professionals took a capabilities-based or asset-based approach to supporting Arthur. They got to know him well enough to find out what is important to him and what he enjoys. Some agencies would then find a volunteer to take him fishing, but in this case, they found people who wanted to learn to fish from Arthur. Arthur no longer calls out ambulances unnecessarily, but rather than one service dependence being replaced by another (drugs or more intensive support), Arthur has found a role in which he is valued and helps others.

This is the difference between a simplistic view of personalisation, in which the challenge is to tailor services to individual needs, and a genuinely person-centred approach, which stays focused on questions which are meaningful to people: What does a good life look like? How can we achieve it? An approach can only be holistic if it can comprehend an individual’s capabilities and potential as well as their needs. Many younger disabled people lack employment. Many older people with high support needs can feel that they lack a meaningful role. For Arthur, the key to meeting his needs was to set them to one side for a moment, and focus instead on finding that meaningful role.

A number of approaches, such as Local Area Coordination, Village Agents and Community Navigators, are examples of how to build this thinking into the ‘front end’ of the public service system. The Care Act reshapes care assessment to look at people’s goals and capabilities as well as their eligible needs. Even where people have higher support needs, interventions can be shaped around their capacity.

For instance, around 8,000 Shared Lives carers are trained, approved and supported by a CQC-registered local scheme, then matched with an adult who needs support. They then share family and community life. Many adults with learning disabilities or mental health problems live with their chosen Shared Lives carer as part of the Shared Lives carer’s household, either for a short period to put down roots before getting their own place in the local area, or as a long term arrangement. Others, such as people with dementia, become regular visitor at their Shared Lives carer’s house, for day support or short breaks. The approach combines regulated personal care from a paid and trained Shared Lives carer, with the sense of belonging and purpose which comes from being a valued member of the household. Shared Lives carers typically say, “She/he is just part of the family” and the household aims to feel like ordinary life, rather than a service.

There are now over 12,000 receiving support from a Shared Lives arrangement, but it remains little known. The challenge laid down by the Care Act, which reframes social care from responding to a list of medical conditions to creating ‘wellbeing’, is for every public service intervention to be effective at meeting need, but framed around the person’s idea of a good life and their capacity to build it with those closest to them.

Alex will be speaking on redesigning services around the abilities and strengths of clients at the National Housing Federation Care and Support conference on 17 June 2015 in Birmingham. Click here to find out more and download the programme.

The Care Bill – first thoughts

The government has published the Care Bill, which was published in draft form as the Care and Support Bill. The draft Bill set out some positive changes to social care, attempting to make the system more future focused and preventative, with more scope for assessments and processes to consider what people can do for themselves, particularly at an early stage, as well as what services can do for them. We think a system of this kind creates the space for approaches which focus on supporting family and community contributions and community development, which fits the ethos of our members, who deliver Shared Lives, Homeshare and micro-enterprises, very closely.

We had a number of conversations with the Bill team and the Joint Committee scrutinising the draft Bill, which made lots of very positive recommendations. The Joint Committee Chair, Paul Burstow, chaired a roundtable at RSA where we discussed strengths-based approaches and he wrote the foreword to a pamphlet, the New Social Care: strengths-based approaches, published by RSA which I edited (www.SharedLivesPlus.org.uk).

So have any of the changes we were arguing for happened?

In summary: yes. Councils will in future have to fund or commission agencies which reduce or delay the risk of people needing care and support (Clause 2). There should be much more useful information provided to anyone at risk of needing a care service (Clause 4). Whilst the Bill does not categorically set out the wide entitlements to up-front planning support, regardless of eligibility tests, for which we argued, the Bill and the accompanying explanatory note are clear that the most recent changes are intended to ensure that the Bill is the bones of an ‘assets’ or strengths-based approach which can be fleshed out in regulations and guidance.

My initial conversations with colleagues in the sector have tended to be about whether the new parts of the Bill which are intended to maximise the resilience of individuals, families and communities, create a risk Continue reading

Have we become a neglectful society?

Norman Lamb, the Care Minister, gave an interesting interview in the Telegraph over the Christmas period, which was given the rather unfortunate headline, “Neglectful Britons blamed for forcing elderly into care homes”. This picked up on the Minister’s view that we have become a “neglectful society” and that we need to rebuild “neighbourly resilience”, without which, he was quoted as saying, pensioners lead dismal, lonely lives.

Mr Lamb was given a hard time for this by Sarah Ditum, writing in the Guardian, who said that “The government has some cheek to say we’re not caring enough” and pointed out that more unpaid family carers are caring for more hours per week than ever; a huge contribution which Ditum argues the coalition is undermining with cuts to public services.

Ditum is right that, as social care services are being ever more tightly rationed, whilst the impact upon the NHS is starting to show, the impact upon family carers is often hidden, yet very real.

However, I don’t read the Minister’s comments as being about unpaid family caring. His suggestion that we have become a “neglectful society” is strikingly reminiscent of John McKnight’s suggestion, that we (in his case, the ‘we’ being US citizens in the 1990s) have become “a careless society”, in his book of the same name. McKnight was one of the founders of ‘Asset Based Community Development’, an idea which Lamb’s predecessor, Paul Burstow, talked about approvingly in the run-up to launching the social care White Paper. ‘Asset-based’ or ‘strength-based’ approaches start with the premise that seeing only people’s needs and vulnerabilities (their ‘deficits’) will lead to services being designed to impose outside ‘expertise’ at the expense of individual, family and community resilience. In other words, poorly designed, if well-intentioned, social services can become part of the problem, ‘colonising’ communities and ordinary human relationships and leaving citizens who have, in McKnight’s words, “grown doubtful of their common capacity to care”.

So McKnight was not arguing that people had stopped caring about each other, but that they had stopped seeing the active support of those around them as their role, instead believing that only the state was qualified to provide support. It’s a powerful – and by virtue of its power, a dangerous –  argument, but one which needs serious consideration.

A small-state fanatic could see it as an excuse to cut services in the naïve belief that people will start supporting each other as soon as the state ‘gets out of the way’. McKnight was instead arguing for services which were more led by people and which worked alongside and supported their relationships, rather than supplanting them. You only have to look at the isolation of thousands of older people or the disempowerment of many people with learning disabilities living in ‘service settings’, to realise that even well-funded traditional services cannot address isolation, in all its many forms.

I met Mr Lamb a number of times in the Autumn, including to discuss asset Continue reading

Improving the social care Bill

I was at a Dept Health briefing on the new Care and Support Bill today, which set out a useful overview of the story the Bill was trying to tell about the new social care system. The Bill starts with an overarching principle, which is that the purpose of social care is to promote well-being, rather than just to respond to crises. The Care Services Minister has noted that rest of the Bill will have to be read in the light of that first clause, which sets a very positive tone for interpretation of everything else. It then sets out some duties on councils which are at the population level – things councils must have in place for everyone who lives in that area. The prevention and information / advice provisions are in this bit (clauses 2 – 7). Then the Bill moves focuses in on an individual’s journey through the care and support system, looking at assessment, care planning and personal budgets.

As I’ve said in an earlier blog, I think there are a lot of places in the White Paper and the Bill where there are deliberate attempts to create ‘assets’ thinking about people’s skills, potential and responsibilities, where previously social care law was all about assessment of needs, vulnerability and (limited) entitlements. But the Bill in particular could go farther in enabling and not getting in the way of an asset-based system. It’s great that the Bill team are up for exploring how to do this and keen to meet with groups of people who use and provide care and support to discuss how.

One of ways in which I think the Bill could be improved will be to look at the distinction outlined above: between population-level / whole-area duties, and individual entitlements. Continue reading

Making the right connections

My blog on taking an assets-based approach to healthcare reform, particularly where public health and other behaviour changes are required, is on PublicService.co.uk here: http://bit.ly/LJRVab

Simply improving the way we commission existing health services will not achieve what society really requires, says Alex Fox, chief executive of Shared Lives Plus. He argues for a more meaningful reform of social care to challenge the primacy of hospital-based treatment….. http://bit.ly/LJRVab

What’s all this talk of ‘assets’ about?

One of the recommendations which received the warmest welcome from the government, during the discussions which fed into the social care White Paper which we are expecting in the coming weeks, was the idea that we have to move from a ‘deficit’ to an ‘asset’ based view of people. It’s unfortunate that those are horribly jargonistic terms which need some explanation, and which are open to misinterpretation.

‘Deficit-based’ refers to the fact that, at the moment, you may have to prove how bad things are (and often, how little money you have), before you can get a response from the social care system. There’s a reason for this: if services aren’t ‘rationed’, more people might want them and there’s not enough money in the system to pay for them. The problem is that forcing people to prove how little they can do is demeaning and can actually add to the problems a person was facing in the first place.

An ‘asset-based’ approach says that we should always look for people’s strengths, resources and potential to solve their own problems. This has to be right: my kids’ school is open to everyone their age and the teachers are focused entirely on helping the children to grow and become more independent and responsible. It’s a happy place. I feel slightly less positive about my GP surgery – it’s there for everyone, but I only go there with a problem I can’t fix and I’m in the hands of experts who know stuff I don’t understand myself. Social care is often a place of last resort. It is becoming more asset-based, in that Continue reading