Learning the economics of the economy of regard

35 social care professionals, local authority representatives and policymakers discussed reforms to the draft Care and Support Bill at an event hosted by the Royal Society of Art’s 2020 Public Services Hub. My guest blog about the event and Bill is now on the RSA website:

There can be few people unaware that there are NHS reforms afoot in the UK. Yet few are aware that the most sweeping social care reforms in post-war history are now taking place, with existing ‘poor-law’ based social care law to be replaced by new legislation outlined in the draft Care and Support Bill. The Care and Support White Paper which preceded the Bill set out a new vision for the ‘personalisation’ of social care. This takes the idea of individuals having an individual choice of service and control over their lives as read, but recognises that even a well-funded, well-tailored service does not always add up to a good life, particularly if your support needs are social rather than entirely physical…

Read the full article here: http://bit.ly/XU0Vgx

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

A Shared Lives Social Impact Bond?

Eight promising social ventures, including Shared Lives are sharing in a £1m government funding boost: http://t.co/NDvFjDJ3 We are working with Community Catalysts, Social Finance and Royal Society of Arts to model and scope a social impact bond to accelerate Shared Lives development, as part of our aim to quadruple our sector and reach thousands more people with high quality Shared Lives support in place of expensive and ineffective alternatives.

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.

Keep on co-producing

At the back of the social care White Paper is a note on how the vision will be implemented. Two new committees are announced: a transformation group, which sounds like it will be quite broad in membership, and a transformation board, which will be for representatives of those bodies with a responsibility to deliver the white paper. Who does have the responsibility to deliver the White Paper. I’m guessing that the board’s membership will include the association of directors of social services and other similar bodies. But if we take the co-production messages of the White Paper at face value, the messages of the paper attempts to reflect the views of people who use services and carers. The paper sets out a vision for a social care system which is co-designed and co-produced with service users and families at every stage. So, to my mind, it is essential that that board does not meet without service user representatives in the room, sharing that responsibility. There is always a risk of tokenism when that happens, but the risks of not co-producing at every level are much more serious.

White Paper highlights Shared Lives and micro-enterprises

Today’s social care White Paper highlights our members’ Shared Lives and micro-enterprise work as ways in which the social care system can move from a crisis-only service, to one which is preventative and focuses on people’s well-being and how connected they are with those around them. It also notes that Shared Lives can help people live better lives whilst saving on average £13k per person, per year. If every region used Shared Lives as much as the North West of England, the saving in England alone would be £155m per year.

Here’s our press release:

New figures show opportunity to save £155m pa when people with learning disabilities move out of Winterbourne View style ‘hospitals’ into family homes.

Social care White Paper endorses the Shared Lives approach.

Although little-known, around 8,000 registered Shared Lives carers now share their family and community life with an adult who visits them instead of visiting a day centre, or moves in with them instead of living in a care home. Shared Lives outperforms all other forms of adult care in government inspections and is also cheaper, but remains scandalously under-utilised.

Today’s social care White Paper highlights Shared Lives as a key part of achieving a more community-based care and support system, which relies less on traditional paid-by-the-hour services.

New analysis of NHS figures by Shared Lives Plus shows huge regional variation in the use of Shared Lives. In the North West, Shared Lives represents 18% of all live-in/ residential learning disability support, whereas in Eastern England the proportion is only 2.5%. With each Shared Lives arrangement creating an average annual saving of £13,000, bringing every region up to the level of the best would quadruple the number of people with learning disabilities and other long term conditions living in Shared Lives to 16,000, saving the health and care system £155m every year and creating enough capacity to enable the closure of virtually all remaining ‘special hospitals’ of the kind seen in last year’s exposé of the Winterbourne View facility.

Alex Fox, Shared Lives Plus Chief Executive said: “Whilst social care often only makes the news for the wrong reasons, Shared Lives remains the sector’s best-kept secret. We know that people with learning disabilities can live happier, more fulfilled lives in ordinary family households than in large institutions, so it is scandalous that the NHS and some councils continue to spend our money on completely inappropriate institutions. In one recent example, a Shared Lives arrangement costing around £400 per week was used instead of a secure facility costing £5,000 per week. In another, a man previously labelled ‘too challenging’ to live outside of a residential unit he said he hated, moved to live successfully with a Shared Lives carer, saving the council £45,000 a year in the process.”

There is also huge untapped potential for developing Shared Lives with new groups of service users to make even greater savings. Whilst 23% of Shared Lives users in London have a mental health problem, five English regions offer no Shared Lives arrangements whatsoever to people with severe and enduring mental health problems, with institutional services still the norm.

Sian Lockwood, Chief Executive of Community Catalysts said: “The Shared Lives sector has doubled in size over six years but there are still only 4,310 people living in Shared Lives households. Half a million people live in residential care homes. Some councils predict that the cost of adult social care alone will represent 100% of their budgets within a few years, unless they make radical changes to the way they support vulnerable people. There is a Shared Lives scheme in nearly every council area in the UK but whilst some areas are currently doubling the size of their local scheme, others remain largely unknown and under-used.”

Alex Fox added:

A better front door for social care

This week we’re really pleased to be publishing, with some of our closest allies, a paper which sets out how the government could make a better ‘front end’ for social care. In other words, what happens when someone first encounters the social care system. It uses real people’s experiences of assessments and discussion about eligibility for services to ask what those processes do to a person’s independence and to their relationships with their family and community. At the moment, whilst most of use the NHS fairly regularly, and our local GP is often a familiar and friendly face for the NHS, our first experience of social care is usually in a crisis, and can be first and foremost about how much money we have (Are you poor enough to be our problem?) and about our needs, rather than our choices and the resources and relationships we might be able to draw on (Are you needy and vulnerable enough to be our problem?).

The imminent (early July now??!) White Paper is an opportunity to create a system which feels more like a partnership, and less like a battle.

The partners in the paper include ourselves, our sister organisation Community Catalysts, In Control, Inclusive Neighbourhoods and Partners in Policymaking. We’d all be interested in your reaction to these ideas – if the government is really going to create a friendlier, more cooperative and collaborative social care system out of the funding-squeezed battleground many experience, they are going to need all the ideas and help they can get.

See “Redesigning the front end of social care” here: http://www.sharedlivesplus.org.uk/en/publications-resources/free-publications/policy-research-campaigns/

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

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

Local Area Coordination

How can we kick start radical change in a care and support system which is suddenly starved of money? Perhaps an equally valid question is, “How can we not?” This second question can only be asked if we genuinely believe that there are ways for communities to face their challenges which aren’t entirely reliant upon services.

Local Area Coordination (LAC) is now at the core of care and support in Australia, after twenty years of development and numerous evaluations. Ralph Broad, who has worked in Australia and the UK remarks upon the fact that outcomes in Western Australia are better than those in the UK, despite the fact that even a recession-hit UK is still better resourced than Western Australia has ever been. LAC is a way of recognising that people are not passive “clients”, “service users” or “customers” of a social care system. It puts professionals in new roles: working alongside people. Local Area Coordinators in each small locality have an open door, access to information and small amounts of funding, but most importantly a remit to nurture local solutions and keep people strong. They help people to access services where they are the only option, but they see services as the last thing to consider, not the first.

LAC is not an initiative to ‘drop in to’ the existing system, with its preoccupation with gatekeeping services for those deemed needy and vulnerable enough to qualify. It is best used as a way to transform the whole system, starting with