We spent a lot of time on the title of the report and concluded that Power to People really did sum up what we believe needs to happen to kick-start new ways of thinking and behaving around the provision of adult care and support.
Every day in Northern Ireland, tens of thousands of people rely on care and support services including domiciliary care, day provision, and care in residential and nursing home settings. Such services support people with the activities of daily living that many of us take for granted, and they can enable people to live more fulfilled and happier lives. Many thousands of people work to provide this care which is underpinned by the invaluable contribution of family carers.
There can be little doubt that the current system of adult care and support in Northern Ireland is beginning to falter and is not sustainable, just as in England, or elsewhere in the UK. That is why the former Minister for Health, Michelle O’Neill MLA commissioned the authors of this article to form an Expert Advisory Panel on Adult Care and Support, and tasked us with identifying priority areas for reform. With the publication of our report Power to People: proposals to reboot adult care and support in NI in December 2017, this analysis is complete.
During our time in Northern Ireland, it has been clear that there are positives to be recognised: an appetite for change, an enthused workforce, examples of innovative services and family carers dedicated to the welfare of their loved ones. It was also clear, however, that much of this exists in spite of the system and not because of it, and if we are to build on the positives, fundamental change is necessary.
Future reform of social care in Northern Ireland
The report outlines those areas we think should be the focus of future reform. We believe fundamentally that citizens should be at the heart of care and support, with the choice and control to determine how best their own needs are met. We also believe that there is room for much improved joined-up working, not just within and across health and social care, but also with housing and community planning.
Underpinning everything, the building blocks of the system need to be revisited: how best to support family carers without whose contribution the system would collapse; how the key role played by the social care workforce is reflected in its terms, conditions and reward; how we know that we are paying sufficient rates to ensure quality care; and crucially, how we contribute to the costs of care and support to ensure it is sustainable in the long term.
In our view, this requires not only a new way of doing things, but a radical new culture; one which can only be delivered with a new Concordat. A new agreement between citizens, families, carers, communities, providers and government about our respective roles, rights and responsibilities within a reformed system. No major change is easy, and we recognise that some of our proposals are particularly challenging.
The report is part of the wider Reform of Adult Care and Support project in Northern Ireland. Our terms of reference covered care and support for all adults: older people, people with physical, sensory or learning disabilities, and those experiencing mental distress – a considerable task, particularly in a limited timescale of only six months. Of course, we recognise that there are significant differences between the needs of people who receive adult care and support services and the specialist provision designed to support them. For example, a young person with a learning disability experiencing the transition to adult services, a person with mental ill-health moving from a long-stay hospital setting to supported living, and someone living with dementia in a care home will have very different needs and receive different services under the care and support umbrella. But, we also firmly believe that our need for care and support should not define us.
We are all different as individuals, more than we are different because of our age, abilities or care and health needs. We are ourselves because of who we are and we argue in our report that who we are as people should be the starting point for a transformed adult care and support system. One that recognises, and celebrates, our ambitions and contribution. One that values who we are regardless of our age, gender, ability, sexuality or ethnicity and our individual unique value and human rights.
It is important that the report is considered within the wider Department of Health reform programme emerging from Health and Wellbeing 2026: Delivering Together. We set out clearly the principles that we believe should both underpin and guide the transformation process to reform adult care and support services in Northern Ireland. It is our view that, as the full force of continued public spending constraints combine with changing demographics and rising demand and expectations, the context for adult care and support will be forced to change.
An unassailable case for reform
We were encouraged often to be radical in our proposals. The challenges are great and arguably the solutions have been resisted for some decades. There is now no choice but to be radical. A mixture of incremental adjustments is no longer sufficient to keep an unsustainable system working. This requires both leadership and ownership across the whole system of care and support.
Furthermore, we argue within the report that a ‘pick and mix’ approach to the proposals is not appropriate. Systematic reform of the whole system of adult care and support is necessary to achieve the ambitious commitment in Delivering Together to tackle the pressing issues facing the social care and health system in Northern Ireland. Of course, Northern Ireland is not alone in these challenges. The same pressures and the pressing need for reform are true for most developed countries.
The scale and scope of the review, and the time available to complete it, meant that our proposals could not be fine-grained and detailed. Substantial further work will be necessary, particularly for the proposals to be developed into actions. We argue that the proposals we make should be seen as part of a potential package of measures designed to bring about a transformation in adult care and support. Furthermore, the proposals are not intended to stand alone. The policy consultation from the Department of Health that will follow our report, together with the public response, engagement and discussions obviously need to be a part of shaping the proposals into steps for action that fundamentally change the way that services are operated and delivered.
During the review, we met with a range of stakeholders and visited innovative services around Northern Ireland. We were impressed by everyone we met, by their willingness to engage, their hospitality and their readiness for change. The conversations we had, the people we met and the services we visited, played a significant part in shaping our thinking.
The structure of the report
We believe that the principles are relevant to all adult groups receiving care and support, although we are mindful that specific policy will need to be agreed to ensure that individuals receive services that are appropriate to their specific needs, for which more detail will be necessary.
The value of social care
The nature and importance of adult care and support and the contribution it makes to personal wellbeing, health services, society and the economy is outlined.
Why we believe social care needs to be elevated to a far higher status in both government priorities and in the minds of citizens, families and communities is also discussed.
The citizen at the heart
We set out our thinking in relation to a human rights approach to care and support. Putting people, rather than structures and systems, at the centre of our interests. We explore ways in which self-directed support could become the organising norm for adult care and support services.
Family carers – vital partners for social care
This section acknowledges the significant contribution made by family, friends and other informal carers to the health, wellbeing and human rights of adults with support needs. They may be seen as the bedrock of care as their contribution is the principle way that most people experience care. It is vital that they are treated as partners.
Building resilient communities
People live in homes and communities, not in social care systems. Here, we consider how an asset-based community approach could be fundamental in underpinning the structure of a transformed approach to care and support with a crucial role for social workers.
The professional social care workforce
Whilst we believe that adult social care is, and should be, much more than ‘paid’ and formalised services, these will always be required. The people who care for us may be doing it for a living but they are people too. We outline how the workforce should be supported and valued.
The market for care and support
Much was said and reported to us in relation to the inadequacies and dysfunction of the social care market. It doesn’t function in the way we need it to. We set out what might be done so that an effective and responsive market can be sustained and thrive.
System alignment – making integration meaningful
The fragmented arrangements that are a common feature of adult social care services as it relates to health, housing and other disciplines have long been seen as problematic. Policy exhortations to bring about a joined-up response and partnership working have pointed to the benefits of achieving more integrated working. There is a clear need for the various systems relevant to adult care and support to be properly aligned.
A new Concordat
The final section sets out the underpinning principles of a new Concordat. This is envisaged as a new settlement between individuals and the State with a recognition that rights are balanced by risks and responsibilities on both sides.
It is our sincere hope that Power to People will not be read as ‘just another report’, but that it will help to encourage the radical rethink or ‘reboot’ we believe is necessary to challenge the current approaches, attitudes and established ways of delivering adult care and support. In this way, we hope it can embolden a genuine public movement for change and transformation in the way adult care and support in Northern Ireland is organised, delivered and funded – a real shift in ‘power to people’.
Des Kelly OBE is Chair of the Centre for Policy on Ageing. Email: [email protected] Twitter: @DesKellyOBE
John Kennedy is an Independent Consultant and Commentator on Adult Social Care. Email: [email protected] Twitter: @JohnnyCosmos
With special thanks to Dean Looney, Reform of Adult Care and Support at the Department of Health in Northern Ireland, who led the team supporting the Expert Advisory Panel, for his assistance with this article.
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More from Des Kelly OBE and John Kennedy:
Report on adult care and support in Northern Ireland