The Care Quality Commission (CQC) is to extend special measures ‘hit squads’ to solve the problems in care homes and homecare. We need less ‘hitting’ and more nurturing in our stance on care. We need to care for the sector in tackling fundamental and longstanding structural challenges. Change needs to come from within and be allowed to grow. The end of the 20th century saw the nurturing parent as the paradigm replacing the Victorian parent yet in relation to parenting our care services we retain that authoritarian model.
A recent Association of Directors of Adult Social Services report referred to Finding Common Purpose between providers and commissioners. Although the report was about learning disability services the principles are general to the relationship between commissioners and providers. In recent years, both in Lancashire and Greater Manchester where I have worked (through the Social Care Partnership with Lancashire County Council and the Care Sector Council with the Greater Manchester Chamber of Commerce and Association of Greater Manchester Authorities) we have tried to work with providers and commissioners, employing the notion that providers need help rather than just punishment when things go wrong.
No-one can knock quality into the system and the relationship between regulation and care quality is ambiguous. A senior local authority manager colleague noted recently that there are 21 organisations who have some overseeing role. How many does it take to change that light bulb? And, when will the light come on that the solutions are imminent as much as transcendent? Some argue that we should have a national health and social care service because the problem is the private sector, as if the mere fact that a service was in the public or third sector meant it was good; just because it wasn’t private. The economics and politics of it aside, those who make that argument make a giant leap in their presumptions about ethics, motivation and quality in relation to the different sectors.
There needs to be recognition that to make the system work well (and care is delivered through a system) we need the right environment. Regulation is just part of that but it sets the emotional tone. Nurturing should be a bigger part however touchy-feely that statement may sound. Why do we use ‘hit squad’ and ‘special measures’ terminology and thinking? What role is ‘fear’ meant to play? All we (the system ‘players’) should want is to look after people who need care and support well and look after those who look after them well, too. A culture of fear paralyses rather than mobilises through serving the wrong masters.
Commissioners need to be subject to critique, too, and – quis custodiet ipsos custodes – so do those who regulate and monitor care through quality and contract monitoring and through safeguarding. I’ve seen some terrible examples of poor regulation and monitoring but this avoids the limelight. All parts of the system – care delivery, commissioning, monitoring and regulation – should be subject to proper regulation, the most important feature of which is the means to have critical analysis feed shared learning. This will help protect against system ‘skew’ so we focus on care not on secondary functions of inter-organisational and inter-sectoral politics and back-watching.
Roy Lilley made the point well recently; there is a need for there to be resources in place that actually address problems before they occur not wait until afterwards when it’s too late. This requires more from within rather than more from without to correct. The sector is a fund of expertise and knowledge, why isn’t this tapped into? Why is the assumption that the Department of Health, CQC, local authority or CCG commissioners are the experts on care? Provider/clinical expertise can’t be left outside. Providers can setup joint working processes and structures to find effective ‘common purpose’ with commissioners and it isn’t costly.
Registered Managers (RM) are now, finally, being recognised as having the key leadership role the sector requires but we don’t have enough, they aren’t supported well and are overloaded. We’re developing our own Lancashire RM support network in recognition of this. As well as RMs, the upskilling and upsizing of the frontline care workforce is a vast challenge as we move towards needing some 2.5 million care workers over the next decade. They need to feel and be valued. This is a system task. Poor care happens and needs to be challenged and corrected but the public discourse uses selective sampling techniques: it selects only from failures never from successes. It’s as if everyone in the care sector has our own Jeremy Paxman avatar who follows us around all day. We wake to criticism and scorn, it shadows us waiting for the slightest failure and then keeps us awake hectoring us with what we failed to do well today and what mistakes we will make tomorrow until we fall into a fitful sleep hearing a perpetual narrative of failure.
A development culture, driven towards excellence from within, in a partnership between care providers, commissioners (and even regulators), is a more effective means of structural transformation than the ‘hit squad’ intervention paradigm and the Paxman persona as parent. We need to care for care through finding common purpose. This is much harder.
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