Transformation or the next missed opportunity - the race is on

The Prime Minister’s firing of the starting gum to accelerate reform of social care has been broadly and warmly welcomed. In wanting a person centred system built on NHS principles and that addresses unmet need he has hit the right notes. Similarly, Louise Casey, entrusted to come up with a plan by next year, has hit another right note with her focus on the need for public support.

But there are serious questions about how much each of them has grasped the challenges.

NHS principles

The only reference to the NHS principle of need before resource that the PM has spoken of is at the individual level which refers to private resources. Care should be free at the point of use. But he has made no reference to the other side of that coin, of no less and possibly even greater significance to the character of the NHS – need before resource at the strategic level involving public resources. Since 1948 NHS professionals have been free to identify need leaving the political system with the responsibility to provide the resources to meet the needs the professionals identify. We have set out how that is not the case in social care.

Whilst of course all will welcome the ending of charging, we have set out previously the scale of the potential disaster of doing so without at the same addressing the principle of need before resource at the strategic level.

Person centred

In describing the need for a person centred system, the PM references the issue of rigid 15 minute home care calls. But is he aware this issue, one which has long been recognised but never resolved, is just the mere tip of the iceberg? These 15 minute calls are no more than the most visible example of a system that is institutionally institutionalising. We have set out previously how the national policy of putting resource before need forces councils to standardise needs, thus denying people agency in their own lives resulting in de-personalised services. To compound the felony, the depersonalisation results in the mis-use of public resources on an industrial scale. Only the small minority who have what it takes to escape the system with a cash payment to self direct their own support can be routinely relied on to know how make best use of resources to make their lives the best they can be.

Public support

Louise Casey lays responsibility for low investment in social care on public indifference and holds the public itself responsible for that indifference. She is looking to the The Big Conversation to change public perceptions. But are the majority of the people of England really so uncaring? The Coalition for the Roadmap to Independent Living has set out how the public narrative is shaped by the system itself. The system uses a narrative in its daily contact with the public built on risk, dependency and a legalistic approach completely unintelligible to the public.

The Roadmap agrees with Casey that a transformed system will require public engagement and support. However positively people react in the Big Conversation, there can surely be no hope of a sustained change in the public narrative until on a day to day, case to case basis the system’s own narrative changes. And that won’t change until a new narrative is required to deliver a new system.

At stake is whether the PM’s powerful desire for change results in change for change’s sake or even change that makes the situation worse. There will be powerful resistance to the real changes that are required.

Local authorities

For local authorities the situation is straightforward –  they believe more money will solve the problem. Butt, scratch just a little below the surface, and they encounter two problems that completely undermine their position:

1. They have no idea how much more money they actually require. They rely on projections from the think tanks. We have set out why these projections can have no credibility.

2. There is a post code of enormous proportions. The top spending 10% of councils spend double per person. But so much greater spending power makes no difference. We have set out how the only result is that the highest spending councils institutionalise people at a faster and greater rate whilst also paying providers far more to do so.

The Treasury

Social care is feared as a bottomless pit of demand. It is actually not the case. Once people are tuned in to their wellbeing with agency over their lives, they do not want a moments more support than they actually require. But, however misplaced the fear is dominant, the value to the Treasury of the system’s ability to keep the lid on demand cannot be under-estimated.  The very thought of transformational change will send jitters through the Treasury along with councils’ finance directors.

The provider sector

More money is the call from the provider sector too. They plead poverty and cannot pay their staff more than poverty wages. But this too flies in the face of the facts.

·      The average price paid to providers has increased over the past 5 years by 33% above inflation. Yet still providers pay poverty wages with poorly resourced front lines

·      There is a post code lottery of similar proportions in the prices councils pay with some paying more than double compared to others.

·      There is increasing evidence of draining of public money into excess profits through exploitation by predatory organisations.

We have set out how, while government policy says councils must pay providers no more than a fair price, thus creating a regulated market of providers committed to public service, the market in reality is little better than a wild west show.

The third sector

The past two decades has seen the nullifying of the third sector as a source of challenge to the system and advocacy for people who use it. The work of the independent sector has been almost entirely absorbed into the system through council awarded contracts. Their survival depends upon procuring and retaining council favour.

The social entrepreneurs

Social care has never lacked for entrepreneurs who promote their elixirs. However, none of them has challenged the problem at source, and therefore none of them has worked to transform the system.

Their work is, however, very attractive to the system, which provides them with both funding and influence. Their positive messaging provides a performative narrative that councils can use to promote an image far removed from the reality. While in reality decisions are made based on risk and dependency, the performative narrative claims it to be strengths and aspiration. While the decision making process is necessarily disempowering, the performative narrative claims it to be empowering.

The race is on

Both the Campaign for Real Care and the Coalition for the Roadmap to Independent Living believe a new Constitution to deliver independent living as a human right will deliver the person centred system built on NHS principles and address unmet needs that the PM wants and the public support Louise Casey believes necessary.

The race is on to get the case before the people who matter in the face of what will be huge resistance and opposition from the power blocks whose interests, contrary to their public statements, are served by the status quo.