Author Archives: Stephen Lowe

Citizens or consumers? How older people can influence care and support services

About fifteen years ago I worked for a local authority developing a ‘user involvement’ strategy for social services. It wasn’t an authority noted for gung ho radicalism, so I had to put my disability rights background on one side and adopt a ‘total quality’ approach focussed on how user empowerment could be part of a wider quality system.  I was then completely wrong footed when the Director of Housing and Social Services pointed out that in housing the local authority had been much more radical than anything I had advocated and were putting real power in the hands of residents by transferring all housing stock to a tenant management co-operative. The co-operative would take decisions about resource allocation including potentially sensitive issues such as which housing stock would be refurbished first.

So, fifteen years later, how far have we moved on? Are people who use social services in control of how those services are planned, managed and commissioned? The Joseph Rowntree Foundation published a new report ‘Involving Older People in Service Commissioning – more power to their elbow’’ last week.  (http://www.jrf.org.uk/publications/involving-older-people-more-power-to-their-elbow). The report concludes that, despite increased policy emphasis on user voice and choice, there are few examples of older people having a real say in commissioning or service planning.

Perhaps the most interesting part of the report is it’s analysis of how local authorities are involving older people. This analysis argues that, broadly speaking, local authorities take one of two approaches, viewing older people either as citizens or as consumers. Citizen involvement seeks to involve the whole community, including older people who are now in good health and might find it difficult to anticipate future needs. It is not focussed on services but on how councils can promote continued independence and wellbeing. In contrast consumer involvement is more limited. It seeks to involve existing service users and the focus is on improving the quality of services. Consumer user involvement is usually initiated and led by service providers.

Current government policy does indeed seem to reflect a dichotomy between ‘democratic’ involvement. Involving the community (citizens) in decision making as part of the localism agenda and a ‘consumerist’ approach to personalisation, turning ‘service users’ into ‘budget holders’ who will be able to exercise power as customers. Reliance on the latter approach alone has been criticised by some, including Age UK, for failing to take account of the imperfections of social care markets or the barriers to service users acting as empowered consumers. It’s also a far cry from the emphasis on mutual and peer support which underpinned the philosophy of ‘independent living’ developed by disabled people from the 1960’s onwards.

The other problem with this dual approach, based on wide democratic involvement and consumerism is that it leaves out a third group – people who do not meet eligibility criteria for local authority care but who need support to remain independent or know that they are likely to in the near future. This group do not qualify as ‘service users’ but neither is their perspective that of the general citizen – the availability of good social care services is a much more important and pressing issue.

The Rowntree report includes in depth studies of two local authorities, Salford and Dorset, who are seen as models of good practice. In both cases one of the keys to bridging the gap between ‘citizens’ and ‘service users’ seems to be the involvement of Older People’s forums and of organisations arising from the ‘POPPS’  (Partnerships with Older People Programme) projects. Older people were involved  influencing the planning and development of extra care housing, helping to redesign older people’s mental health services, and redesigning hospital and community services.

So there are a whole range of ways in which older people can take control of services. Rights, democratic control, involvement of service users and of groups representing a broader range of older people, personal budgets, good quality systems,  with effective mechanisms for giving a voice to service users, mutual and peer support, and outright service user control should all be on the agenda.

Care providers demand more regulation shock

What do care providers want from regulation? Less of it might be a glib answer, and in the past there might have been some truth in this. However the new Care Provider Alliance ‘vision’ of social care regulation is in many respects a plea for more and better Regulation.

Inspectors should look, say the Alliance, not just at whether services are fit to be registered, but at quality, and should grade services on the basis of quality and of the outcomes they achieve. Regulation should be sufficiently rigorous to stop local authorities feeling the need to carry out their own inspections of services that they contract with. Regulators should take time to talk to service users and their families, whose views should form the basis of inspection reports.

Inspectors should be prepared to consider individual complaints from service users and their families. There should be a national framework of regulation in order to prevent local inconsistency in regulation. Local links between providers and inspectors, fractured by reform of the system should be repaired. Poor performing providers should pay more towards the regulatory system.

All of this is strikingly at odds with the views of the current government (and in it’s latter years, the previous one) that providers simply want reduced ‘regulatory burdens’, that the market will drive quality, and that inspection and regulation is a prime area for making cuts. As a result of successive cuts in funding the current regulator, the Care Quality Commission, operates on a much reduced budget of £164.4 million in 2009-10 compared to the £240 million spent by its predecessor organisations in 2005.

The Health Select Committee report on the CQC concluded that the CQC should have been more vocal in pointing out that it did not have the resources to carry out its statutory duties.

CQC has asked for 10% additional funding to carry out it’s duties and seems to be gaining allies in unexpected quarters. However supporters do want improved performance in return for more resources – the Care Provider Alliance wants the CQC to take some of it’s own medicine and to publish evidence that it is meeting it’s own quality standards.

Find out more about our care in crisis campaign

Read our briefing on the Dilnot Commission report on social care

Roundup – National Children’s and Adults Services Conference

This year’s ‘National Children’s and Adults Services’ (social care) conference, saw contrasting perspectives on the changing role of local authorities. Peter Hay, the current President  of the Association of Directors of Adult social Services, speaking at the morning session, welcomed the new leadership role of local authorities with regard to public health.

In the afternoon, by contrast, Andy Burnham, the new shadow Secretary of State was concerned that current reforms would result in a loss of local authority powers and of local accountability. Concentrating on the NHS and on education, his view was that reforms were dominated by provider interests. They hand huge power to GP’s and Head Teachers and take it away from service users. ‘In a world with no PCT’s,’ asked Burnham ‘how can patients challenge decisions by GP commissioners?’. He concluded that Parliament has not yet woken up to the full implications of these reforms.

The current Localism bill includes proposals for independent social work practices to take over local authority social work functions, so this raises the question of whether Burnham’s concerns will be an issue for adult social care. Independent practices are already being piloted, and in August the Secretary of State for Health issued the Contracting Out (England) order 2011 to ensure that the delegation of local authority functions to these practices is lawful. The order can be found here.

Whether this order was strictly necessary depends on what independent social work practices will be expected to do. Older people for the most part do not receive extended social work interventions. Their contact with social work is more likely to be through assessment, arranging services, and if they are lucky, subsequent reviews of their care and support arrangements. Continue reading

Caring for our future; shared ambitions for care and support

Last month the Department of Health announced that it intended to ‘co-produce’ the proposed social care reform white paper. This month, on the 15th of September it has launched an ‘engagement’, entitled ‘Caring for our future; shared ambitions for care and support’ which is intended as the first step toward making good on this commitment.

The content of the engagement reveals that the scope of reform is meant to go well beyond responding to the proposals of the Dilnot Commission on long term care funding or the Law Commission review of adult social care law.  However the government does ask for people’s views on the recommendations of the Law Commission and the Dilnot Commission ‘and on ‘how we should assess these proposals, including in relation to other potential priorities for improvement’.  So the DH is still thinking about the extent to which they intend to implement the proposals of the two commissions.

The engagement focuses on six key areas. These are;

  • quality – including improving quality and developing the future workforce;
  • personalisation – giving people more choice and control and helping them to make informed decisions;
  • shaping local care services in order to ensure a wide range of innovative and responsive services;
  • prevention and early intervention;
  • integration, in particular better connections between the NHS and local services; and
  • the role of financial services.

The engagement runs for three months. There will be a series of events and meetings which will be attended by six ‘discussion leaders’ drawn from the ‘care and support community’ – one for each of the six key areas. The discussion leaders come from a variety of backgrounds representing service providers, local authorities and the NHS. Jeremy Hughes from the Alzheimer’s Society and Imelda Redmond from Carers UK represent service users and carers. There will also be a web based feedback form that people can use to respond directly. This can be found at www.caringforourfuture.dh.gov.uk. Written comments must be sent to the Department of Health by December 2nd.

Find out more about our Care in Crisis campaign