Power to people, the future of adult social care

15 Dec 2017 Nick Garbutt    Last updated: 15 Dec 2017

This week the Department of Health published the Expert Advisory Panel’s Review into Adult Social Care, Power to People. 

It is an exciting, potentially transformational paper which has the unusual distinction of being well written and jargon-free. It is important that it is read by as many as possible because inevitably media coverage has concentrated on one aspect without summarising the whole.

This article attempts to address the balance.

The report has been available for some time, but publication has been delayed. We now know why – one of the 18 recommendations is that those who can afford it should contribute to the cost of care. Civil servants would not have wanted such a sensitive and contentious issue to surface at a time when we have no minister in place and correctly predicted that this would be the main focus of the media.

The fact that they have gone ahead anyway demonstrates that the Department realises the urgency of the matter and the frailty of a system in danger of collapse. That is to its credit.

The debate about contributing to care is important, but it is surely, also important to consider what the panel believes people should be contributing to.

Secondly any discussion is hard to hold when we have no idea of what the proposals will cost. There should have been a parallel costing of the report’s recommendations – this is acknowledged in the report - but there is no explanation as to why it did not happen.

This is the report’s fundamental weakness. Costing what has been tabled is an urgent necessity – and the measures put forward come with a price, even if they will lead to medium and long terms savings elsewhere in the system.

Recent history has shown very clearly that reform proposals are generally greeted with great enthusiasm until it comes down to Trusts making budgetary choices. That is when the wheels can fall off – and is a major contributory factor to why adult social care is in such a parlous state in the first place.

Given that, the report is thoughtful, well-constructed and authoritative. It starts from the premise that incremental change is not going to be effective if the social care system is to be protected from total collapse. This is critical because as social care is the bedrock on which the entire health system rests, if it fails, the rest will follow with unimaginably catastrophic consequences.

In management speak this is a “burning platform”. Inaction cannot be an option.

The principle that underpins the paper is that it should be people themselves that need to be at the centre of care. This sort of language has become commonplace in official documents but the report spells out unequivocally what that principle means by stressing the “fundamental importance of a human rights approach in which people with care and support needs enjoy the same entitlements to quality of life and wellbeing as all other citizens.”

Therefore future initiatives all need to shift from the current focus on services offered, whether acute or institutionalised to the people who receive them and what it is that they need.

Few would disagree with this but it is not the way the system currently works and change will be difficult to achieve. The report outlines how its authors think this should be done. Its first recommendation is for an awareness-raising programme to help people understand the purpose and value of adult care and support.

This is closely linked to the second which seeks to put people, service users at the centre of their own care. This involves a sort of quiet revolution which would shift power away from health and social care professionals – a formidable challenge given the deference traditionally enjoyed by the medical profession.

 So Power to People wants to see self-directed care as the norm and self-directed care funds developed to encourage it. There are risks attached to switching the direction of care from professionals to often vulnerable patients but the principle is sound and it seems perverse to say you want to improve peoples’ dignity and independence and yet cut them out from deciding how this should be achieved.

The third is about recognising the role of carers and putting their rights on a legal footing.

Strong communities can and do much to help the vulnerable within them, and community and voluntary organisations have much encouragement in the next two proposals which are around strengthening and empowering community initiatives. The North Belfast CLARE initiative highlighted by Scope is specifically cited It is suggested funding should be provided for them through Social Impact Bonds.

There has been much publicity about staff shortages in social care and the linked issue of poor pay and conditions. It does seem perverse that people who carry out such sensitive and important work should get paid the same or less as supermarket shelf stackers. This is recognised by the report which wants to see social care workers receive the Living Wage as a minimum and the service professionalised.

This in turn links into the way that home care currently works Even though independent providers dominate both domiciliary and residential services the market is controlled by the Trusts through their commissioning processes which have been designed to create a “race to the bottom” of which a poorly-paid workforce is an inevitable consequence. Power to People envisages a more sensible model based on agreement on the true cost of care which will then be subject to price regulation. It also wants to see a greater diversity of suppliers, especially from the voluntary and community sector. It is in this context that the idea of people contributing to the cost of care emerges.

There follows the inevitable series of recommendations around the integration of services to support people – an oft cited need whose delivery is notoriously elusive everywhere – an inevitable consequence of how government traditionally works.

However siloed delivery of services by different agencies is incompatible with a new system based around a person’s requirements. Fortunately – and this is good news – this is recognised by the Programme for Government which stresses the importance of partnership working to achieve outcomes.

Of great interest to Housing Associations and charities that work with older people is the emphasis on the need for specialist housing for vulnerable and older people – surely a major growth area over the next few years.

Finally there is a call for a “concordat” – a conversation between government and citizens about how social care should work. The report states: “This new settlement between the citizen and the state is offered as the most effective way to build public understanding of the purpose of adult social care and recognition of its value. It would also clarify personal responsibility and enable proper consideration of risks. Through greater awareness a shared vision can be agreed and the steps to implementing change can be put in place.”

This seems eminently sensible and of course, ensuring a positive public debate about the future of social care is of vital importance – especially in the face of media coverage.

However there is an irony in the authors stating that they do not want this to become another report, and presumably degenerate into another talking shop, and then propose to set up a talking shop.

Here history is not in our favour - debate on health reform has traditionally been coloured by exchanges of highly emotive misinformation which renders necessary change politically impossible. What we really need is change, change now, not an endless discussion about change. The word urgent seems too weak to characterise how quickly this needs to happen.


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