The ‘Brave New World’ that may emerge from the crisis caused by COVID-19 is yet to be truly known. One thing that feels more likely than ever before though is that attention may finally be given to the pressing need for reform of adult social care.
Social care (especially care homes) has been thrust into the media spotlight in the last year and, therefore, the cracks in the system have been well and truly exposed. There seems to be universal support for the urgency for reform … but will it be radical enough?
Social care crisis
Across our working lives, social care has often been described as in crisis – arguably a permanent state of crisis. Crisis is an interesting word, defined by Wikipedia as: ‘A crisis (plural: ‘crises’; adjectival form: ‘critical’) is any event or period that will lead, or may lead, to an unstable and dangerous situation affecting an individual, group, or all of society. Crises are negative changes in the human or environmental affairs, especially when they occur abruptly, with little or no warning. More loosely, a crisis is a testing time or an emergency.
‘The noun is derived from the verb κρίνω krinō, which means ‘distinguish, choose, decide’.’ So, a crisis is essentially the decision point. The point where there is no option but to choose a path. Social care may well be in a permanent state of crisis; but the krino moment never seems to come. Perhaps it has now. The pandemic has certainly been a ‘crisis’, forcing uncomfortable choices between public health and the economy. Decisions to lock down, restrict liberties and freedoms, protect the NHS. Many decisions: some well made, others not. All forced by circumstances and made in order to avoid a catastrophe to health and health services.
There does appear to be a head of steam building for reform of social care. Every interest group within the sector is girding themselves for the debate. Thinktanks and Commissions are publishing reports setting out new visions. Green papers and grey papers, thinkpieces and blogs – take your pick.
At the same time there is a fear that the current Government sees social care in narrow terms, just about care homes and the fear of needing to sell your house to pay the cost. This lack of fundamental understanding could be a significant barrier to meaningful and effective reform.
#socialcarefuture, who so often nail it, describe the experience of social care as: ‘When organised well, social care acts as the glue that binds together relationships and support in our local communities that we can draw on to live our lives in the way that we want to, whatever our age or stage of life.’
This very eloquently places social care where it should be. A fundamental part of our economic and social infrastructure. It can support people to stay well, stay engaged, stay employed. It is as important as a good rail infrastructure and road network. Well organised social care can be an enabler to support a fair, secure and compassionate society which drives a dynamic economy. When we produced our report: ‘Power To People: Proposals to reboot adult social care in Northern Ireland’ in 2017, we argued in the introduction ’Social care is personal – and about all of us. A good system of social care can transform lives – it’s that simple. Not just for those who receive social care services but their families, friends and communities too.’
Since our report was published, there have been many more. One of the more recent – ‘The Lives we want to Lead’ – is from the Local Government Association (LGA).
The LGA’s headline message is that until the value of social care is fully recognised, the ‘krino’ moment may never arrive. The report also highlights the need to create a much more diverse and dynamic social care world. A world where quality support is personalised and community based. A social care world that has citizens’ wellbeing at its heart and that endows the conditions to truly enact the aspirations of the Care Act. In short, to create a system that, it seems to us, allows this vision. Again from #socialcarefuture:
’Don’t we all want to live in the place we call home with the people and things that we love, in communities where we look out for one another, doing the things that matter to us?’
Power to the citizens
Of course, social care needs more money, too. But money is not the only answer to the challenge of social care. It is necessary but not sufficient. Who holds the power that the money bestows is just as important for reform. Local authorities have, for 30 years, had a market shaping responsibility. The sovereignty in the market has primarily been theirs. The rate set for care has, in turn, kept staff on the minimum wage. Despite transformational changes in many markets driven by an expert generation of post-war consumers, social care’s offer has remained broadly the same. That’s not to say there aren’t individuals and organisations striving to innovate, striving to do new things in different ways who are, in many cases, succeeding. But you can’t ignore the dominance of time and task homecare and care homes in the market mix. If we don’t change the levers in the market, we are just going to get the same limited choices, larger care homes and shorter care visits.
Way back in 2005 the Joseph Rowntree Foundation (JRF) undertook ‘The Older People’s Enquiry’ and one of the outcomes was ’that little bit of help’ which set out the baker’s dozen of services that people valued most. It is well worth revisiting as it is exactly the kind of menu we should be looking to create.
If we want to aspire to a new vision, a future of community-based, preventative and highly personalised support, then we must question whether commissioning, as currently organised, is going to achieve it. This vision for a social care reform isn’t new, we’ve been talking about it for years. If commissioning worked, why are we where we are? Isn’t it time we introduced some real consumer sovereignty? Take the power from commissioners and give it to the citizens?
Consumer sovereignty was first defined by the economist William Harold Hutt (1936) as: ‘The controlling power exercised by free individuals, in choosing between ends, over the custodians of the community’s resources, when the resources by which those ends can be served are scarce.’
Ah but, you say, we’ve had direct payments for years, most of the care home market is now self-funders! They aren’t shaping the market. This is true but consumer power has more facets than just the cash. In order to have effective demand, the consumer needs to have the cash but also knowledge of the market and there must be meaningful choice. Direct payments have been around a long time. But without a diverse market of services and knowledge about the possibilities they haven’t been able to energise the market.
If individuals were given the power to buy whatever met their needs, then initially they would continue to buy what was on offer. But over time providers would offer new services, alternatives to existing models. Some will be popular, and others get no takers. Choice, though, would grow. Some existing models or services may also fall away as people embrace alternatives. This crucial dynamic is missing from the market as commissioner purchasing is embedding existing models and restricting new approaches. There may be efforts at co-production, but nothing beats holding the purse strings for being in control.
If adult social care is to use the crisis to bring about reform – it needs to be radical. The sector needs to be disrupted in the way other parts of the economy have had to make way for the ‘game changers’ such as Netflix, Uber, Airbnb, Deliveroo or Purple Bricks, which have brought new consumer control to home entertainment, travel, holidays, take-away food or selling your house.
Every one of us is different. Our families, friends and neighbourhood structures are different. Our housing, our outlook on life and risk appetite are different. No two people’s social care journey is the same. Which is why the market’s dynamic drivers must come directly from those who draw the services. In order to create the dynamic and diverse smorgasbord of services we need, it’s crucial that the customer and the money are put together.
There needs to be real choice. Every neighbourhood needs a good care home, a good home care service, a good community connector, handyperson service, community transport and who knows what new offers and innovations may follow.
Obviously, we need a framework for the systems necessary to stimulate change. There will need to be standards, procedures to regulate and monitor. Perhaps we need a new profession of neighbourhood navigators. Perhaps a sort of Independent Well-being Adviser or care concierges. Experts in what a neighbourhood offers and how to guide someone to the services that meet their needs. But crucially as servants – not gatekeepers.
We acknowledge that enabling consumer sovereignty is not a panacea. It should be seen as part of an approach to radically energise the social care offer. In order for consumer sovereignty to stimulate the creation of a vibrant social care market, other aspects of the system need to be addressed. It needs to be properly personalised, simpler to use and navigate, it needs to be fairer and universal, it needs to be sustainable. Reform cannot be done in a piecemeal way. A sustainable funding settlement is vital with some market oversight to protect the consumer and the public purse.
Only when our choices are under our control, only when we have true consumer sovereignty, will the market be freed to meet our needs. All our futures depend on it.
John Kennedy is an Independent Consultant and Commentator in adult social care and Des Kelly OBE is Chair at the Centre for Policy and Ageing. Email: email@example.com Twitter: @JohnnyCosmos Email: firstname.lastname@example.org Twitter: @DesKellyOBE
What does ‘radical’ social care reform look like to you? Share your thoughts and views on the article and social care reform in the comments below.