Reading the Care Quality Commission’s (CQC’s) recent State of Care report gives me a significant feeling of ‘Groundhog Day’. Not just in what it says but also in what I am going to say. Apologies for boring you to tears.
Five years ago, I wrote a Personal Inquiry into the state of social care. Much of what I discovered, what people told me (in fact all of it), is worse now than it was then. And for more and more people in England it is, or is going to be soon, very personal. 1.4 million older people are no longer receiving support that they would have. Huddled at home alone, unvisited, lonely, at risk. We do not have a system that is offering safety, responsiveness, effectiveness or care. In short, it’s not well led.
We need to take a radically different approach to how we do social care. Yes, of course the sector needs more money; it’s wrong that we expect many services to operate on a shoestring. But we are also forcing stress and unreasonable pressure on people who entered the sector to care and find themselves emotionally and morally compromised by race-to-the-bottom-commissioning and heavy regulation. Social care is about human relations; for staff and managers too. We have to soften the culture, make it more human for everyone, including inspectors!
There needs to be safe space to innovate, there needs to be adequate resources, the system should be more preventative and enabling and yes, the system needs to be responsive to people’s actual wants and needs. So why hasn’t change happened? As I often ask, why is my mobile transformed from the ‘bleep’ I had in the 80s when social care remains in a perpetual state of paralysis?
There are significant barriers that prevent change. We suffer from a commissioning sclerosis. A market characterised by Commissioner Sovereignty where the Groundhog approach inhibits and suppresses change. The care homes get bigger, the home visits get shorter, the consumer gets more powerless. The machine is rigged to deliver what we don’t want. The tools need resetting.
Power is in the wrong place. We need consumer sovereignty – the situation in an economy where the desires and needs of consumers control the output of producers.
One paragraph from State of Care really stood out for me, ‘The challenge for government, Parliament, commissioners, national organisations and providers is to change the way services work together so that the right services are being commissioned to deliver what people need in their local area. Leaders need to have a more urgent focus on delivering care in innovative, collaborative ways.’
Absolutely true. We need a system working together and we need to better deliver what people want in the right way, the right place, at the right time.
I agree with the insights in the report. Everyone has a role to play in improving care. But surely the omission in the list is the regulator itself.
A bit of self-reflection and inquiry would reveal that, for most providers (not all – some are very brave), the biggest single impact on their day-to-day work and headspace is the regulator. Chasing the paper, fearing the knock on the door. Maybe some do need to feel fear, but the vast majority desperately want to do a good job. A major reason that innovation is in silos is the perception of people on the ground that they can’t do anything without permission, that if they innovate and something goes wrong, they will be pilloried. This is no doubt not the intention, but it is the perception.
For people to innovate, explore, react and question, there must be a supportive and engaged system; ready to take on and share risk. A whole system with skin in the game. I hear the ‘Independence’ cry. But in a truly integrated system, no one can be independent.
There are a couple of things that I think CQC could do which would be enormously helpful, one of which might be having at least one person on the Board with experience of working in social care, but also:
Conduct a fundamental review of the inspection methodology – A number of reports, including from government, have concluded that care is sclerotic with paper and bureaucracy, stealing time from human relationships and dominating the culture. There doesn’t appear to be any actual evidence or evaluations that justifies this festival of pulp. No fundamental review questioning what it is we are trying to measure, assure and the SMART way to do that. There may well be a correlation between good care and paperwork compliance but that doesn’t prove a causation. We must have evidence and causative justification. We have got to re-inject the human reality back into the culture.
Become inquisitive – Search out innovation, work with it and share it. Take a share of the risk of innovation and help develop and assure new approaches. For example, HMRC accredits software for making tax digital. Why not in care?
It really is time to come off the touchline and onto the pitch. We need you on the team.