Time for user-led inspections?

Obviously the quality of NHS care is in the spotlight now that the Francis report into appalling failures at Mid Staffs Hospital has finally been published. But social care is also going through some quality changes. The Care Provider Alliance (which I’m chairing for the year) came together with The Nuffield Trust last week, which has been asked by the government to explore the idea of developing a new approach to quality ratings within social care. We used to have them of course: the inspector, before it became the Care Quality Commission (CQC) and its role diminished to inspection of safety and compliance with essential standards, used to rate services on quality. In Shared Lives, we were very keen on this, because were top of the class with 35% excellent, 95% good or excellent. In truth, star ratings were a blunt instrument, but much mourned when they were abolished by the Dept Health.

Things have changed since then. We have moved on from believing that a visiting inspector can comprehensively judge the quality of a service, towards believing that the key issue is the outcomes being achieved for each individual using a service and that best people to judge the achievement of those outcomes are the individual themselves and their families or advocates. After all, many people are now individually choosing their service using a personal budget and in many cases taking personal responsibility for buying that care via a Direct Payment, so ensuring they are involved in monitoring its quality is the next logical step (see below for more on this).

There was a fairly intense discussion: the CPA brings together the representatives from the vast majority of the independent care provider sector, including care homes, home care and community services, of all sizes. However, I felt there was a fairly broad consensus from CPA members on some key points:

  • There is a need for quality ratings, which are fair, accurate and proportionate
  • There is a need for a strategic overview and leadership from DH to ensure that the Quality Ratings review, NICE Quality Standards, CQC’s activities, PQP & NHS Choices, Healthwatch, the TLAP programme and its quality strand are brought into alignment as part of a strategic vision.  There is currently confusion.
  • The starting point must be the experience of outcomes of people using social care – the kinds of outcomes aimed for will often be the same across different settings, even if the approach to achieving them will differ.
  • We do not believe we can have a single health and social care rating system without adding to confusion and measuring the wrong things for social care in the wrong way.
  • The new system must Continue reading

“It gives me a good feeling inside”

This year’s Shared Lives Plus conference was co-chaired by Paul Croft, who lives in a Shared Lives household and Richard Jones, a Director of Adult Services and one of our trustees. This is what Paul told the conference – he has kindly given me permission to re-print it here:

 “Good morning ladies and gentlemen.  I would just like to say how pleased I am to be here and would like to thank John Dickinson for asking me to Chair this conference.  I think it is a great honour and am delighted to be talking to you now.

I would like to tell you just a little bit about myself and how my life has changed since I joined Shared Lives and moved to Waterloo, just a few miles from here, to live with Geoff my carer with PSS and Bob who Geoff also cares for.

I was at Derwen College in Shropshire at the time and lived there in term time studying catering and office management.  At first I went to Geoff’s in the holidays.  I really enjoyed being at college but we were supervised most of the time and had very little independence. 

When I first went to stay with Geoff my care plan said that I wasn’t allowed to access the community without someone being with me.  I remember wishing I could be like Bob, who was a train driver before his brain injury and would go off regularly visiting places round the country.  At that time I even had to be taken to college at the end of holidays even though I had made the journey many times.

Geoff realised that my life was being restricted because of this and so we started to work on this problem.

I began by posting letters at the end of our street and then going to the shops and bank on my own.  We went out together on longer journeys but when I felt ready we decided that it was time to go on the train on my own.  The station is only 5 minutes from where we live.  I have a very good sense of direction and had no problem going places on the train and also learned to use the bus. Geoff and I have discussed this and both feel this was the real turning point in my life.

When I moved into Geoff’s permanently Continue reading

Personalisation for offenders?

I’ve blogged before about the incredible achievements of a small number of Shared Lives carers who specialise in supporting offenders with learning disabilties or mental health problems. We are working with Manchester Metropolitan University and others to attempt to scale this kind of care and resettlement up nationally. Here’s my column about personalisation in Guardian Society: http://goo.gl/0ASN0.

There is a longer piece about lessons for other sectors from the personalisation of social care published with the RSA: http://goo.gl/fD6NA.

The illusion of choice

Last year’s Open Public Services White Paper set up free schools and the Payment by Results Work Programme, among other changes. It also proposed establishing a framework for choice in health services, adult social care, early years services, schools and further education. Government departments are drawing up Choice Frameworks, to outline what choice should be available, who is responsible for providing the choice, what quality and inspection measures will be in place and what support people will have to make informed choices and complain if things go wrong.

Since choice became one of New Labour’s mantras, there has been a continuing over-optimism across public service reform about the power of choice alone, to the point where you could be forgiven for thinking that choice is a goal in itself, rather than a way of improving better services.

If you ask people if they want choice in services, they say ‘yes’. but  if you are asked if you want A) a choice of services of varying quality, some of which may be at capacity, or B) no choice but a guarantee that all services are good enough, which option would you go for?

People who see choice as a good thing often have a high level of faith in the power of free markets to self-regulate and to improve to meet consumer demand. They are, therefore, often less keen on the idea of intervening in the marketplace to shape what is on offer: after all, the point is that individual choice will play the role previously played by governments, commissioners, inspectors and all the rest of the traditional service sector.

But the introduction of personal budgets and Direct Payments in social care has shown us Continue reading

Countdown to the White paper

Despite stories in the press about delays to the White Paper, as far as we can tell, it remains on track for publishing in ‘the Spring’. ‘Spring’ in civil service speak lasts well into June, of course. We’ve got a fair idea of what’s going to be in it, because the government involved lots of people from the sector in drafting the early ideas and strongly welcomed the ideas we came up with around prevention and the help which people and communities need to tackle problems like isolation, which services cannot fix.

As well as setting the tone for the whole sector for years to come, a good White Paper needs one or two eye-catching initiatives, which capture the imagination as well as the spirit of the policy changes. The impact of complex policy changes can be difficult to grasp by those not immersed in how social care legislation and regulations work, but who nevertheless have strong views on what good care, support and inclusion looks like. Sometimes relatively small-scale changes can exemplify the broader intentions.

So whilst I could take a good guess at the range of policy shifts we’re likely to see in the White Paper and I’m not expecting to be surprised by its ‘narrative’, here’s a rather specific idea which I’ve no reason to think is anywhere in it, but which I think should be considered:

Close as many as humanly possible of the remaining 100+ ‘hospitals’ for people with learning disabilities.

These are the institutions, often ostensibly used for assessment of people considered ‘challenging’, which were made infamous by the BBC Panorama expose of Winterbourne View. The recent CQC inspections of these institutions which followed that exposé  are not finding that all are havens for abuse –far from it. There will be many dedicated and skilled staff working in such places – I used to be a care assistant in a residential home for people considered challenging and I came across no abusive staff and plenty of entirely lovely people working long hours for little money.

But CQC has been finding a significant number of places which are completely unacceptable: buildings which smell of urine; services which lack the proper safeguarding procedure and protection for people’s rights; people with no care plans; worryingly lax use of restraint. The reason such places should not exist is not, however, that they are places where abuse is more likely, although I believe that the risk of abuse increases when people are managed as part of a large group and spend little time outside of an institution. The reason such places should not exist is that, even if they are run brilliantly, a 20 or 30 bed ‘hospital’ in a non-residential area with locked doors and the conflicting support needs of large numbers of ‘challenging’ people, may be able to deliver warmth, food and shelter, but can never deliver the basic quality of life which we take as read: real relationships with people who aren’t paid to be with you. The chance to be a part of a community. ‘Ordinary’ home and family life. You’re much more likely to learn the skills and attitudes you need to take part in ordinary life when you’re living in an ordinary family home. Although the stated purpose of care offered in these ‘hospitals’ is to assess people’s needs, in reality, some people spend months or even years living there because no alternative has been found.

But Shared Lives and other community-based forms of support are in almost every area and have a track record of supporting people considered challenging (see Alan’s story). They are not even more expensive than these institutions – commissioners often make huge savings through helping someone switch to Shared Lives. The heavy lifting of closing long stay institutions has already been done for us. There aren’t many left: let’s make this White Paper an opportunity to close that chapter of history for good.

Bashing and boosting micro-enterprise

We launched a new report today on the top ten ways in which councils are boosting – and bashing – micro-enterprises in their area. Whilst some areas limit ways of spending personal budgets or access to ‘approved provider’ lists to tried and tested large providers, others actively encourage creativity and have thought through the environment needed for successful start-ups. Some councils throw a bit of money at budding micro-entrepreneurs in the hope that some great ideas will stick, whilst others have used the learning from successful micro-enterprise programmes (eg 125 jobs and 40 volunteering opportunities created in three years by Oldham’s Community Catalysts programme) to create a really thoughtful support programme which gives entrepreneurs a fighting chance of success.

The variation in micro-enterprise support is huge. Even areas with expensive brokerage systems are often only able to offer people the option of a Personal Assistant or traditional services. The report suggests that most areas have some way to go to unlock local people’s creativity and to raise aspirations. But the rewards are huge, as Angela Catley of our sister organisation, Community Catalysts, points out in an interesting article about micro-enterprise, which includes a picture of the Green Team in Dudley, which was set up by three support workers to provide people with learning disabilities with an alternative to day services in the shape of meaningful work as part of a gardening team.

Five questions with one answer.

On Friday, a group of senior leaders from council social services departments got together with colleagues from the Department of Health team writing the social care White Paper due later in the Spring. Sue Bott from Disability Rights UK and I did our best to keep order in a passionate debate about how to tackle a question as old as social care: what role should the state play in helping people to help themselves and each other? Peter Hay, this year’s ADASS President and social services Director for Birmingham, opened and closed the discussion and outlined a situation common to lots of areas: demand for services increasing whilst budgets shrink, coupled with recognition that even the best services cannot meet some of the most pressing needs, like isolation or exclusion from community life or employment opportunities.

I felt privileged to listen to the risks which local leaders are taking to turn a dysfunctional system on its head: it’s so very easy to panic and take a short term view when faced with a crisis in funding, but there are places around the country who have refused that easy option. There will soon be an open call for examples of citizen-led approaches to care and support, to which I’d encourage anyone with knowledge of promising local work to respond. But in the meantime, by way of processing some of what I heard and hopefully widening the debate, this blog and one or two following will set out some of the questions we kept returning to.

My first observation is that Continue reading

User-led organisations: endangered species?

I do my best to remain optimistic during these too-frequently grim times. One of the determining factors of what the sector achieves on much diminished resources, will be what we continued to believe was possible. Our public finances perhaps haven’t been this bad since about 1948. But in that year our grandparents looked around at the post-war wreckage and decided that a National Health Service was possible.

Of course, those were the days of when big national infrastructures were created from Whitehall (casual observers may be surprised to hear that the current NHS Bill, with its thousand amendments, is an example of ‘bottom up’ change). Social care has been re-shaped to give more control at the level of the council, the community and the individual.

So User-Led Organisations (ULOs) should be a key part of ‘personalising’ social care. After all, they embody the idea of individuals who use services being in control, and their work is often about people having a voice in local decisions, or being able to shape their own care package. They are also typically small and local, forming a bridge between councils and the people who are most affected by their decisions.

So I couldn’t help my heart sinking when, on the same day, I heard about two areas which were planning sweeping cuts to their ULOs. Had those areas completely misunderstood the basics of personalisation? Apparently not: at least one was an area with leaders who are advocates of personalisation. So what was going on?

It’s always risky to comment on local changes from a distance, but my impression is Continue reading

After the engagement

I spent the Autumn as co-lead on the theme of ‘Prevention’, which was one of six themes identified by the government in their engagement exercise, seeking ideas from the sector to feed into a White Paper on social care which is due to be published in the Spring. I spoke at lots of events and co-authored a letter with the other co-leads which was reported on the front page of The Times. The letter called for no delays in the timetable for care reform, as had been reported in some sectors of the press. Encouragingly, the government have reaffirmed their commitment to reform and Labour called for cross-party talks.

The presentation the co-leads gave to Andrew Lansley MP and Paul Burstow MP is now publicy available. It outlines a future care and support system which would have moved from a crisis service focused mainly on high end services, to a well-being service which gave people opportunities to plan for their future at a much earlier stage and which focused on people’s gifts, skills and assets as much as their needs. The co-leads saw the Dilnot proposals as an important lever for change of this kind, as they would reduce the fear associated with older age and give people more chance to plan.

Whilst expensive services may always be rationed, community-development based approaches such as Local Area Coordination show that access to support to think through non-service solutions need not be. The prevention group heard that there is no prevention and therefore no real savings without focusing on people’s abilities and potential, not just on their needs. It questioned whether there is such a thing as a preventative service, or whether it was more important that every intervention has a focus on reducing the risk of dependency. To do this, you have to think about the whole person, not just concentrate on one set of needs. For instance, aiming for a health intervention with a focus on NHS savings may well simply shunt costs to social care or housing, and vice versa, whereas looking at the whole person within the context of their relationships, family and community has a real chance of achieving outcomes, whilst also making a saving to the public purse as a whole. This made integration at the level of the individual (integrated outcomes frameworks, pooled budgets) and the community (jointly commissioned, home-based health, care and housing contracts) seem more important than structural integration.

You can read my blogs about the future of social care on the government website and elsewhere, such as this one for the Campaign to end loneliness in older age: Is ending loneliness a preventative service?  http://bit.ly/vh7DqX

The government has said it wants the co-leads to stay involved in drafting the White Paper, so although the engagement process has officially closed, I remain, as ever, interested in your views.

A new Trustee for Shared Lives Plus

Richard Jones, Director of Lancashire’s Adult Services and our newest Trustee, says that when he thinks of Shared Lives, he thinks of a young man who used to live in services and now lives with a family and as a result he is loved and can give love. He matters and can contribute to family life. He is part of that family’s holidays, weddings and funerals. He has the opportunity to feel responsible for those around him, not just reliant on them.

We had our board and team planning day this week. It was fantastic to be part of a group of people bringing the same passion, but from very different viewpoints, to thinking about Shared Lives and other small community approaches to care and support. Part of the thinking was about how we ensured that Shared Lives and micro-enterprises became much better understood. We decided that our offer was about citizens, communities and costs: our members help people to become citizens, who can contribute in all kinds of ways, as well as receive great support. Our members build upon relationships and communities. And doing this isn’t more expensive than traditional care: increasing numbers of areas are using it as a way of bringing down costs whilst helping people to live better lives.

Some of the discussion was about the place of Shared Lives and micro-enterprises within the personalisation reforms (which I’ve written about a number of times below).

 I’m not sure it’s a coincidence that we latched onto personal budgets as the key driver for personalisation at a time when we are all more consumerist than we’ve ever been. And I’m sure it’s no coincidence that the rise of consumerism has been accompanied by a rise in loneliness and isolation Continue reading