From care markets to care systems

Featured article - 05 May 2020
By Alex Khaldi, Consultant and Interim at Think.Do.Consulting

The lessons we learn and apply from COVID-19 are going to shape social policy for decades to come. But as with any shock (the 2008 financial crisis comes to mind) it is not at all a given that lessons will be learned well or heeded. Leaders in social care know this; while they work overtime to keep people safe, they are thinking hard about how the world will be different when the immediate danger subsides. They will play a pivotal role in shaping change, in challenging reversion and in building something better. One such topic exercising their minds will be the mechanisms for commissioning care, and the underpinning market for providers.

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I hope it is not too bold to say the crisis has laid bare the fault lines in social care markets and the broader design of our regulatory and commissioning system. Whether framed by PPE shortages, low pay, understaffing, lack of oversight of vulnerable children or morbidity/mortality recording, there is a growing public appreciation that the safety and happiness of our loved ones extends beyond hospitals and the NHS brand. All can now see that social care and our system of social support is worth much higher esteem; but how or whether we translate a new mood into a new system is uncertain.

Based on conversations in recent days, three themes seem to be emerging from the current crisis that relate to care markets:

Recovery and renewal

The most obvious and practical activity for care leaders concerns the post-lockdown weeks and months. The role of the council in working more directly to the citizen has been a huge success, challenging the perhaps purer commissioning framing of its role previously. Many will welcome the chance to move the council closer to the care system, particularly in relation to long-term care.

Resilience

: Local public service resilience was frankly not a priority in the years of austerity, of course now we consider it essential. But the resilience opportunity in social care goes beyond gowns and medicines. Those encouraging strength-based working and prevention have new impetus to their work. In place of individual provider viability, we should consider system viability. Systems are about complex interconnections; and what could be more complex and unique than a support for a good life?

System change

As with 2008, system change hangs in the balance, because it requires many actors to work together, often with competing interests. But it is the biggest prize from the post crisis environment. If we think clearly about the market for social care, we must recognise it is dysfunctional, driving low pay, an understaffed workforce, speculative and sharp business practices, a lack of innovation, and most damningly of all, care as a transaction. Value for money and a caring society have sometimes been treated as necessary trade offs. Perhaps it is time to challenge that assumption. Whilst our market shaping and sufficiency regulation is far too weak, we all know the danger of waiting for central government to provide the answers.

Our change from markets to local systems will be messy. It can also be charged with politics and bureaucratic thinking, and there are dangers in using the crisis to reinforce agendas. Shifting to systems is simply about better care and support, where locally power is rebalanced, care is coproduced and the system itself – not the transaction engine – works to close gaps and meet needs. Whilst councils might seek to invest more in provision, good systems are not really about replacing one monopoly with another. Stewardship is preferable to control.

The difficulty for many will be in knowing where to start. There is no blueprint and of course money, regulation and the needs of the short term do not help. But a good place to begin is in the reflection of leaders as they begin to process their experience. I doubt there is a care leader in the country without a fresh perspective on recovery, resilience and system change. Their learning through this adversity is too rich, too powerful, and too important not to apply it in practice.

Alex Khaldi is an independent consultant to local government and social care and a SCIE associate.