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.

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

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

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.

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.

No more Winterbourne Views

I’ve just returned from Butlins in Bognor Regis (who says working in the charity sector isn’t glamorous?) where, with lots of help from volunteers from local and not-so-local Shared Lives schemes, a group of Shared Lives carers and people who use Shared Lives are taking a week’s break. We usually do this in Blackpool, and recently our colleagues at Aberdeenshire Shared Lives have organised weekends in Aviemore, but we thought it was time we came down South for a change.

Even Bognor, the UK’s sunniest place, hasn’t escaped the rain this week, but no one is going to let that stop them having fun. We were also doing some work. Colleagues have been hearing from people who use Shared Lives about how it has transformed lives which in some cases have been led in residential care or other institutions. Shared Lives carers are a dedicated bunch, and twenty of them crammed into our chalet for a session on personalisation and personal budgets yesterday, when they could have been enjoying some brief moments of sunshine. We discussed how Shared Lives can help people have more control and choices in their lives and I heard from some Shared Lives carers who were combining Shared Lives support with micro-enteprise approaches. In one instance, the carer offers Shared Lives in her family home and then, for people who want to move into a more independent setting, supported lodgings close by, so that she can be the consistent source of support as someone moves towards their own place.

Perhaps it was because I’d had the (too rare!) opportunity to spend time with people at the front line, and to see people with learning disabilities having fun and joining in with all the holiday activities that others were enjoying, that I felt particularly strongly when I noticed the current Mencap / Challenging Behaviour Foundation campaign to close down the remaining long stay ‘hospitals’ for people with learning disabilities and ‘challenging behaviour’.

There is no reason for these places to exist. However well run they are, large institutions will never be the best way for people to move back towards ordinary family and community life. The campaign is based on you emailing your MP, to ask her or him: Please write to the Health Secretary Andrew Lansley MP, expressing concern about the continuing existence of long stay institutions and ‘hospitals’ for people with learning disabilities and recommending that they are replaced with community-based alternatives (such as small homes, supported living arrangements and Shared Lives) as soon as possible. Emailing your MP takes seconds, thanks to Writetothem.com.

What was suprising about the Winterbourne View scandal was not, sadly, that abuse took place. When people are placed out of sight and mind, in institutions designed to contain and control them, there will always be instances of abuse. What was suprising was that such places continue to swallow up vast sums of public money, when cheaper, better alternatives like Shared Lives are well established and widely available.

Taking gambles that pay off

This is the third blog I’m writing off the back of a seminar with social care leaders which looked at the question of citizen and community-led change. One of the debates we had on the day was the age old debate of whether change is all about changing systems, legislation and funding routes, or all about changing attitudes and culture. It’s one of a number of questions to which I think the answer is both.

We need to tell stories about, for instance, the lady in Wiltshire who was helped to maintain independence by the provision of a £100 grit bin for her hill, plus some encouragement from her neighbours to share the task of gritting, rather than the provision of a special transport service, or meals on wheels. The latter solution would have helped speed her isolation and reduced her mobility. The former could result in any number of knock-on positive impacts as the people involved got to know each better and thought about other ways they might be able to help.

Stories like that inspire. They illustrate the power of focusing on outcomes rather than mandating processes. A councillor who meets older people in their ward may well be more motivated by that story than by any number of cost benefit analyses and statistics.

But Department of Health Ministers can’t go to the Treasury to make the case for social care armed with anecdotes. They need a robust cost benefit case based on evidence gathered from thousands of people. They need to be able to show cashable savings to real services, not notional Social Returns on Investment.

But how do you quantify the economics of making changes like the grit bin example, without codifying and measuring it out of existence? One solution, I think, is for government to do what it does well Continue reading