What should the vision be for adult social care

Featured article - 30 April 2021
By Alex Fox, Chief Executive of Shared Lives Plus, Vice Chair of Think Local Act Personal and a SCIE trustee

Alex Fox, Chief Executive of Shared Lives Plus, Vice Chair of Think Local Act Personal and a SCIE trustee

For decades, attempts to reform adult social care have failed because we have failed to convince the public and the politicians they elect, to make the huge investment needed simply to achieve a basic level of consistent care. We need to learn from the NHS, which in 2014 persuaded the Treasury to invest billions in its new models of care. The NHS needed huge investment just to stay still, but it made the case for radical change through its ‘new models of care’ instead of ‘more of the same’.

That 2014 plan started by setting out a new relationship with patients and communities. This is where the government’s much-trumpeted new vision and plan for adult social care should start, not with who pays, but what the public and government will be paying for. Not with an empty ambition to ‘raise the status’ of social care work, but by setting out support roles which will by their nature have a higher status than roles which at present are too often based on carrying out a narrow range of tasks in a tiny amount of time. Low pay and status are symptoms; we need to address causes.

Many current support relationships within adult social care are typically brief, transactional, highly-boundaried and delivered by a succession of time-pressured strangers. It doesn’t have to be this way. Shared Lives carers are recruited through an extended, relational process so that they can take on highly responsible, flexible and personally tailored support roles, inviting someone into their own family home and sharing their family and community life with them, often for years or decades. A crucial aspect of this is that Shared Lives carers and the people seeking support choose each other, rather than being put together by a manager or computer algorithm. These recruitment and ‘matching’ processes also happen in the best home care and care home services, which involve people in choosing who works with them, and which often have smaller, more stable staff teams. Some care and support services, like Buurtzorg and Wellbeing Teams, use self-managing teams approaches to embed that relational approach into organisations which can reach thousands through very flat structures. People who use direct payments to employ their own personal assistants also have the power to make those personal, long-lasting choices.

Compare that approach to the unacceptably high levels of safety and quality incidents, and the 25% staff turnover rates in some large, traditionally-run services. Each year, care inspectors CQC find that small care homes on average outperform large care businesses. This is not because small care homes have access to any resources or freedoms unavailable to larger businesses: quite the opposite in fact, small care businesses are going bust at an alarming rate because lowest-cost procurement of care by cash-starved councils is making providing small-scale social care economically impossible for many.

So if the common goal is a new core support relationship throughout every kind of social care, we then need our New Models of Care in each of those kinds of service which will shift us from the vicious circle of money spent on managing high turnover and unacceptable variations in quality, to the virtuous circle of investment in recruitment, training and savings in performance management, re-recruitment and avoidable crises.

Government can:

  • Create and publicise higher-status social care roles with more autonomy, and trial them across the range of care home, home care and community settings
  • Establish the adult social care equivalent of Teach First and Frontline to recruit people into these roles.
  • Trial self-managing teams approaches across the range of settings, drawing on learning from Buurtzorg dementia care, Wellbeing Teams, Cornerstone and others
  • Create a ring-fenced innovation fund to help councils manage decommissioning institutional care and growing the most effective emerging models like Shared Lives

Government call also trial co-commissioning with citizens and community groups to reshape local provider markets, and build this into the NHS-led Integrated Care System (ICS) programme, and into Social Prescribing, where preventative models like Homeshare are demonstrating they can tackle multiple challenges (in Homeshare’s case, housing, support and loneliness) at once.

These new relationships and new models will not be developed in a system which is equally challenged in all places and for all people. The need for social care is partly driven by societal inequalities and social care shortages in turn have as a differential impact upon people impacted by the inverse care law, particularly black and minority ethnic communities. To address this the overall goals for social care reform needs to include measuring reduction of inequalities across every long-term reform work programme and co-producing each reform with two key groups of people identified by the Joint VCSE Review: those who make most use of services and those most likely to be excluded from them.

The Think Local Act Personal partnership and Health and Wellbeing Alliance provide a starting point for meaningful citizens’ involvement. Local areas should be expected to do this as well, though, and to invest in the citizen-led organisations needed to do so (as Tower Hamlets’ strategic coproduction programme has with disabled people).

Finally, reforming adult social care is one of those huge challenges which can only be met by thinking even bigger: a transformed understanding of what we mean by social care support, and ambitious programmes to scale up the best models and scale down those we know do not work.

Success will not just be measured in the amount of money invested in one of the most austerity-hit public services, it will mean a large increase in the proportion of people with care and support needs living well at home, many of them using the ‘new models’, and a significant reductions in wellbeing inequalities for excluded groups and communities. Put simply, not just better services for some, but better lives for us all.

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