by John Copps
The experience of the COVID-19 crisis has reminded us that people – old and young – want to be connected to where they live. Most of us have enjoyed the increased neighbourly contact, exploring our local parks and streets, and the chance to spend time at home. This desire to be rooted is an essential part of what makes us human.
I know that, if and when I need caring for, I want to be close to my family and friends, I want to be valued as part of my community, and I want to stay in my own home as long as I can.
But too many of our public services have become detached from the people and places they are there to serve. Adult social care – encompassing residential and home-based support for older people and disabled people – is among them.
Responsibility for services sits with local government, who commission care for vulnerable adults alongside a growing cohort of ‘self-funders’. The market to provide services is a mixture of organisations but, over recent years, has trended towards large operators as budgets have been squeezed. Among the residential homes sector, for example, the top four companies have around a 20% of beds. These providers work at scale, often backed by private equity finance hungry for a financial return.
The COVID-19 crisis has laid bare the problems with this model for adult social care. No-room-for-manoeuvre budgets, high levels of staffing vacancies and turnover, underdeveloped relationships with families, limited development opportunities for the workforce and low wages, all add up to service that fails too many people.
In particular, it is the fragility of providers that keeps commissioners awake at night. The collapse of Southern Cross in 2011, which had 9% of the care homes market nationally, still haunts the sector. The CQC remains on high alert and in 2019 issued their first ‘risk of failure’ notices, including one for one of the largest domiciliary care providers in England.
But as the calls for change grow there is not yet consensus about what the solution is.
Thankfully, I think we have part of the answer already: smaller providers, rooted in their community, with strong links to families and carers, showcase glimpses of what an effective system of adult social care looks like.
A good example is Heywood-based learning disability service PossAbilities. The service was ‘spun out’ of Rochdale Council in 2014 as a public service mutual, constituted as a Community Interest Company with its staff as members. Strong links with the community and families is central to how it works. A service-user forum, run by a non-executive board member, helps it to constantly adapt its services. It recruits locally and staff are encouraged to try new things using their professional judgement. None of its employees have far to travel to work. When you visit, the effect of these things is tangible: to its services users, families and staff it is a community of people, all with a stake in success and that are there to look after each other. Success has brought contracts in neighbouring areas but at heart it remains a community organisation.
Elsewhere, the Methodist Care Homes Association is the largest charitable provider of care homes for older people in the UK and known for its personalised and high quality care with ties to its local areas. In the West Midlands, social enterprise Agewell helps older people to maintain their independence at home, the Holy Grail of adult social care. Similarly, Leading Lives in Suffolk is an employee owned mutual that supports people with learning disabilities within residential homes or the community, with a focus on independence and friendships.
These models are not an answer to all of the problems faced by adult social care. There is no way round the need for more money in the system. But examples like these, embedded in local communities, can be the basis for stronger links with informal care and provide the care that we want to see for our loved ones.
An alternative vision, noted elsewhere on this blog, is to fully nationalise the provision of care. But centralising a service that needs to be sensitive to local and personal circumstances won’t provide the care that people say they want. Squaring individuals’ desire for connectedness with the inevitable standardisation of a national services is too much of a leap. The appeal of organisations rooted in their communities is precisely that they are not part of a national system.
So I think the focus of council commissioners should be on encouraging the development of local provision rooted in the community, including models of public service mutual, social enterprise, charities and publicly-owned companies. These organisations can provide a local, plural response to people’s needs that is as close to what people want as we can get.
Central government should support this by creating an environment that encourages entrants to the market, funds innovative models, gives new providers scope to build viable business models, and facilitates access to finance. Without this, the mega-providers will maintain their advantage. The national system must set the conditions for a plurality of local provision to flourish.
After the shock of COVID-19, there is both the opportunity and momentum for change. One of the contradictions of organising public services is that there is always an inclination to focus on the ‘system’ when services are about the experience of individuals, all of whom are unique. To succeed, adult social care needs to be an ecosystem of local providers, linked to their communities, that can ‘humanise’ care.
John Copps is Managing Consultant at Mutual Ventures, a consultancy that specialises in new models for public services, working with local authorities, NHS bodies and the third sector.