What was proposed and how much progress has been made?
Now I know very little about music, but I do love a good analogy. But since I make them up sometimes, they don’t work! The reform of social care is always playing in the background. It’s always part of the background music but never the headline act. In music terminology there is the term ‘Ostinato’ or ‘stubborn’ in Italian. It describes a piece of music where a phrase or rhythm is repeated throughout; think Ravel’s Bolero. Never quite building, never reaching a crescendo. Rolling back on itself over and over again.
Just like the debate on the reform of social care. How many reports? How many White papers? How many Green papers? How much bluster, how many times must we hear: ‘We’re going to “fix” social care’?!
Reform of social care is evidently ‘Ostinato’.
Irish insights
In 2017 the Northern Ireland Assembly published Power to People: Proposals to reboot adult care and support in N.I.
Des Kelly OBE and I were privileged to have been asked, by the then Health Minister Michelle O’Neil, to write the report following months of touring the province, talking to all manner of folk and seeing many excellent examples of forward-thinking enterprises and innovation.
We were encouraged to be ‘radical’ in our proposals from almost everyone we met. The report defined the need for change as ‘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’. The aim of the panel’s report was ‘to challenge the current approaches, attitudes and established ways of delivering adult care and support to embolden a genuine public movement for change and transformation.’
In the final report we tried to look above the detail of the current and instead to look at the principles and values that a good social care system would value. We marshalled our proposals into seven main themes, as follows.
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. Social care needs to be elevated to a far higher status in Government priorities as well as in the minds of citizens, families and communities.
The citizen at the heart
Putting people, rather than structures and systems, at the centre of all. How do we challenge the power relationships in social care and ensure a far greater degree of Consumer Sovereignty?
Family carers – vital partners for social care
The bedrock of social care, as their contribution is the principal 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. 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 workforce in social care
The people who care for us may be doing it for a living, but they are people too. They need to be valued, not exploited.
The ‘market’ for care and support
The market doesn’t function in the way we need it to do. What might be done so that an effective and responsive market can be sustained and thrive?
System alignment – making integration meaningful
The need for the various systems relevant to adult care and support to be properly aligned.
Towards a new concordat
A new settlement between individuals and the State with a recognition that rights are balanced by risks and responsibilities on both sides.
Alas despite a broadly positive critical response and several lively radio phone ins, no fundamental change has yet resulted. However, there are some unique reasons why this has occurred. The NI Assembly has only been in session for 13 months of the 58 months since the report was published. There is only so much a civil service can do about fundamental reform.
There has been, however, some clear evidence of a level of Ostinato: stubbornness in the form of tenacity. When the assembly reconvened in January 2020 it was preceded by the publication of A New Decade, New Approach: Priorities of the restored Executive. Up there in the top three is Power to People.
On the first page of the report, it details that ‘the parties have agreed that the immediate priorities for the Restored Executive should be: Transforming our health service with a long-term funding strategy.’ The Executive will:
- Immediately settle the ongoing pay dispute.
- Introduce a new action plan on waiting times.
- Deliver reforms on health and social care as set out in the Bengoa, Delivering Together and Power to People
Despite political difference of a significant nature all parties could agree on the urgent need to reform social care. So, the dust was blown off and in January 2022 a public consultation on the reform of social care was launched. The consultation ran to July 2022.
Summary and evaluation of responses was published in May this year. The consultation was detailed and extensive and I’m not going to bore you with following every point (admittedly you may already be!).
But you may be curious to see how much of the key recommendations in Power to People made it through to the consultation and how they were received. The fundamental message from Power to People was to shift the power from the ‘system’ to people and families. The proposals within tried to set out the levers of control and to move them into different hands.
Distilled down to the paraphrased basics, Power to People proposed:
- Make the use of direct payments the norm. Put the purchasing power in the hands of the consumer. Allow consumers to shape the market. Shape the market through consumer sovereignty and not commissioner sovereignty.
- Elevate the status of informal care. After all it’s the majority of social care by far.
- Radicalise communities to discover their assets and catalyse neighbourhoods.
- Respect and value the social care workforce. How can we expect them to care for us if we don’t care for them?
- Enable a mixed economy of care to energise innovation and create the space for new ideas and ways of doing things.
- Regulate the profit motive. There is plenty of room for ‘profit with purpose’ in social care but no room for ‘profit maximisers’. Level the market conditions to ensure fair play.
Level of engagement
The consultation was detailed, and the evaluation summary report has a lot to read through. However, there is lots to be encouraged by. Some headline picks:
The Department proposes increasing Direct Payment rates to broadly match the cost of equivalent directly commissioned services.
The Department proposes the introduction of increased powers of inspection and regulation in relation to overheads and management costs and levels of profit.
The Department proposes to improve the pay, terms and conditions of the lowest paid in the social care workforce.
The Department proposes strengthening the capacity of the social work profession to support community-focused practice.
The Department proposes the introduction of an independent Carers’ Champion role. Carers will be supported in their caring duties and entitled to support in their own right.
The consultation period was extended due to the level of engagement. The evaluation summary cites high levels of support for the direction of travel of the proposals. The majority of respondents (70%) agreed or mostly agreed to the proposals. So, room for optimism?
More to come
Leading by example, Northern Ireland, along with all the parts of these islands, is struggling to grasp the nettle of reform. Demands, needs and expectations are changing, and the system needs to reform. It is collapsing in slow motion. Will anyone be able to break free of the Ostinato? Break out a riff or maybe we might just have to be content with a Poco a Poco Crescendo!
I was over recently and met with a couple of folks who had been involved in the original report. Despite the consultation there is still no political representation, so unfortunately expectations of any imminent move towards implementation of reform are somewhat low.