RCMs are ‘vital’
When it comes to a topic as important as mental health, it may well be worth starting with some statistics. Registered managers (RCMs) play a vital role in adult social care1. More than eight out of ten registered managers are female. Half are aged 50 or over, with just one in five under 40. Skills for Care estimates that ‘around 10,000 registered managers may retire within the next 15 years.’
They operate in a sector with a high turnover of staff. Rates for turnover in care homes with nursing are higher than care homes without nursing or domiciliary care1.
The Office of National Statistics data on Suicide by occupation 2011 – 2015 found that women working in healthcare were at higher risk of suicide (24% higher than the female average). There is, in particular, a high suicide risk among female nurses. So how can we look after those looking after the most vulnerable people in our society? What support is there to ensure they feel valued in their roles?
LCA-Facilitated Registered Care Managers Network
Lancashire Care Association (LCA) facilitates a support group for registered managers which meets in small-group, safe-space, meetings around the county. The group is designed to help registered managers feel less isolated and to build a support network promoting the Registered Care Managers Network (RCMN) as a leadership body in the care sector in and across Lancashire. Key issues from the small meetings also feed into the workshops at the LCA/CMM Lancashire Annual Care Conference in autumn each year.
Meetings tend to be dominated by a handful of issues: the low worth accorded RCMs, both in the public arena and by health and local authority staff; the burden (and ‘skew’) of regulation and the unnecessary duplication across a number of bodies with similar roles; the relative isolation of individual RCMs; and the ever-higher level of need and expectation to be met, with inadequate funding from cash-strapped and often antagonistic public sector commissioners.
There are a lot of positives and good ideas in the meetings, not just negative, but the issues of the poor image of the sector and relatively low-standing of the RCM profession loom large in the discussions.
At the September 2018 conference, the focus at the Annual RCMN meeting was on mental health and wellbeing. We made a conscious decision in planning the meeting to start from the place we were at, however uncomfortable.
The trigger for raising the topic with the group was the experience of one of the authors who learned of the suicide of a colleague who was struggling with a poor CQC inspection result. The author then learned the next day from another colleague that their partner had tried to take their own life under similar pressures and then heard from a third colleague, later the same day, that they had just before been speaking to another manager who vouched that they had recently had suicidal ruminations when under pressure from a very critical inspection.
We chose not to start the discussion at the meeting with euphemisms – ‘wellbeing’, ‘resilience’, ‘coping strategies’ – but with the stark fact that someone who was well-regarded and active in a community of providers found themselves at a lonely and inhospitable crossroads with nowhere to go and no-one to help them.
The point raised here is not to try to use these tragic and sensitive issues as some sort of weapon with which to ‘bash’ CQC. It is to argue that we can’t get a good care system from a culture of fear and blame and we need to build some supports for, and a sustaining narrative around, what it is to be a registered manager in the current political and organisational context of care.
We believe that part of that support structure requires recognition of, and open dialogue in relation to, a largely closed and taboo subject. It also requires a reappraisal of what it is to be a care manager in the independent sector.
Registered managers and small home owners, particularly, are often left isolated and exposed in the midst of a flawed system whose first response when things go wrong is not to look and learn but to apportion blame and move on as quickly as possible. We call for some manifest duty of care in the system (not just a flag to salute but some auditable processes that give expression to that duty) and other support mechanisms to ensure that ‘wherein the peril lies therein lies the remedy’.
From the RCMN meeting, and from our events and other member feedback, there is one thing those who run and manage services in the independent sector want and consistently see a lack of: respect. To be recognised, to be valued, to be included are the key features of that respect.3,4
To be respected is to experience positive regard, appreciation and role validation. It is destructive if just one part of that whole system feels they are uniquely held to account for whole-system failures. The NW ADASS Market Sustainability and Oversight Review 2018 sees the sector as unequivocally at a tipping point.
The CQC State of Health Care and Adult Social Care in England 2016/17 pointed out that, ‘The quality of health and social care has been maintained despite very real challenges. The majority of people are getting good, safe care. However, future quality is precarious…’ It added, ‘The efforts of staff have largely ensured that quality of care has been maintained – but staff resilience is not inexhaustible…the entire health and social care system is at full stretch.’
It goes on to say, ‘To truly coordinate care, local system leaders must ensure there is a golden thread linking vision to delivery, so that everyone involved can not only share the vision but see themselves as part of the team that delivers it…Leadership and support at all levels – system, organisation, service and practice – will be crucial.’
Research published in The Lancet has shown that ‘If [the] dependency and care home proportions remain constant in the future, further population ageing will require an extra 71,215 care home places by 2025.
‘…The current social care crisis is due not only to the increasing numbers of the very old, with their higher morbidity and greater health and social care use, but that current older people are spending more of their remaining life with low and high care needs. Low care needs have implications for family and friends who supply unpaid care because this low dependency is unlikely to meet eligibility criteria for publicly funded care. High care needs have considerable implications for future provision of community services and the state provision of funding for care.’
Registered managers are the carriers of the ‘golden thread’ through the system. The philosophical point is how we have a genuine debate about meeting ‘fourth age’ needs. The practical point is that the system needs the right leaders, workers and resources to step up to the plate.
Their leadership role is essential and, switching metaphors from threads to something more mechanical, they are the point of leverage in the system and if this body of professionals can’t meet the challenges because the challenges are too great and/or they are not supported by the whole system in the right way, the system will fail.
The Annual RCMN Workshop 2018
There was a heated debate around the issue of being valued – or rather not being valued – by other professionals in the system as well as in the context of the general public discourse. The lack of a counter-balancing positive narrative for registered managers, such as there is in relation to the NHS, was seen as a major factor in tipping the balance. The notion that personal ‘resilience’ was lacking in some way was strongly rejected. It was, indeed, the ability of RCMs to function under the most extreme pressure that helped ensure that the health and care system had not already collapsed under the weight of its contradictions.
Attendees on the day replied to a survey and everyone said they found their job stressful. Managing staffing, recruitment, workload and time pressures were the main components of day-to-day stress. Over two-thirds wanted more support from effective networks for RCMs.
The Annual Meeting agreed to focus on:
- Raising the profile of the issue of mental health and suicide in the context of RCMs as a professional network, locally and with partners, regionally and nationally.
- Giving the topic legitimacy and ‘air time’ and finding ways of giving it due recognition through the whole system so it is seen as something that can be talked about openly.
- Conducting some primary research about mental health and registered managers to get some picture of prevalence.
- Using this as leverage for influencing how the issue of mental health and care managers (and care workers) is regarded in the public discourse and in the realm of employment.
- This is to be set in the context of an emerging campaign from LCA and CMM with partners locally, regionally and nationally to recognise mental health in registered managers as a significant policy issue.
1. Wellbeing for registered managers, a practical survival guide.
An exclusive resource for registered manager members of Skills for Care.
2. The power of networks.
A survey from Skills for Care highlighting the value of network to registered managers.
Are you a registered manager who has a strong network of support around you? What were the steps you took to find it? Or do you feel more needs to be done to protect the mental health of those with high-pressure jobs in the care sector? Share your thoughts, experiences and ideas in the comments below.