Author Archives: Stephen Lowe

Health Select Committee report – a compelling case for change

The Health Select Committee report on Social Care is clear and unequivocal in saying that current funding for social care is inadequate, and that planned efficiency gains cannot be achieved without fundamental reform. We agree.

The reforms which the committee has in mind are nothing if not radical. A single health and social care system for older people is proposed, with a new legal framework which should cover both health and social care.

To achieve this the committee proposes a single local commissioning process. This should set its sights beyond just health and social care to include other services such as housing. Integration of commissioning would be led by a single high powered commissioner, whose role would be to overcome conflicting local priorities and to ‘create agents within the system who have both the ability and the incentive to drive the necessary process of fundamental change in service provision’. The commissioner would be accountable to NHS Commissioning boards, Local Authorities, service users and to local democratic arrangements.  A single outcomes framework would replace the current Adult social Care and NHS outcome frameworks.

Integration is seen as being not an objective in itself but ‘an essential tool to improve outcomes for individuals and communities’. A pragmatic approach to integration, with the emphasis on integrated processes and outcomes, is very welcome. Proposals that the commissioner should be accountable to the local community and to services also deserve strong support. We look forward to taking part in the debate that this report is sure to stimulate.

In the meantime, we hope the government heeds the commission recommendtion that it should press on with reform, and should implement the Dilnot Commission’s recommendations on care funding as a matter of urgency. We couldn’t agree more.

Age UK are calling on the Government to reform the social care system. Find out more about Age UK’s Care in Crisis campaign and how to sign up to our petition.  

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