A Model of Social Care Fit for the People of Haringey
The Council is proposing new model of social care and has enthused about co-production as part of its consultation on what will result from the swingeing cuts which it has made in its budget. Many of us do not think these cuts necessary, and have put the case that other ways could have been found of dealing with the admittedly drastic reduction in finance demanded by the government [letters from Older Peoples Reference Group to Councillor Morton during first and second rounds of this consultation process]. Notwithstanding these differences, and with the over-riding impetus to continue to protect and improve the amount and quality of care which is available to older people, and indeed all adults, who are or may be at risk, the following points are made in the spirit of partnership.
1] Establish a principle of putting peoples needs first and of marshaling resources within the borough to be the primary agency of meeting these needs.
The social care market which has grown exponentially in the past two decades and now dominates the provider spectrum has the unfortunate driving tendency to hold down labour costs and cut corners on quality with a leveling down of actual care possible for individuals, and in too many cases resulting in real dereliction of care such as that evidenced by the CQC with Sevacare in Haringey. At the same time commercial providers business models are prone to being unsustainable and further instances of crashes such as that of Southern Cross in the residential market are likely, and in the domiciliary care market the UK Home Care Association’s own break-even marker of £15.70 per hour is seldom achieved. In Haringey we know that the vast bulk of contract or spot payments are significantly below that level. Day care has already been vastly reduced in the borough and is a much more specialized market for providers [for instance, a south Islington NGO providing support to families living with HIV survivors has its largest client base from Haringey].
In an environment where needs are acknowledged to be increasing through ageing, life expectancy, single occupancy, and circumstantial poverty at the same time as reductions in overall social care provided [see LGA and AgeUK for national overviews] since 2010, it must be highly likely that this commercially dominated market will only continue to drive down care standards and the pressure to tighten eligibility criteria by commissioners will also continue, even while the Care Act 2014 extends rights of assessment to all and gives new support to carers.
Instead of ‘this is what we can provide’ and ‘we shall see where you can fit into this’ we could move to a ‘what is it that will help you in your circumstances?’ and ‘ let’s see what resource and support we can build in which actually suits your needs’. The best practice of course already tries to do that. And the Council’s documentation suggests that it wants to make a transformative shift of this kind.
Examples such as Re-ablement and Shared Lives are indeed important and worthy of more development. Neighbourhood Connects services through better signposting and voluntary connection are also worth developing. These services can help plug gaps but are also confined by their own terms of reference and targeted groups and time periods. The bigger questions of what happens to people needing domiciliary, day care and –even if more preventive support takes place – residential care, remain to be confronted. The Better Care Fund allows for more working together of Council and health facilities through the CCG, but is not ‘new money’, and the Kings Fund has shown that cuts in social care are costing the NHS more. Planned hospital discharge, locality teams, named key workers [as for example at The Ark in Hackney] and Re-ablement where appropriate can all be vital, but none of themselves will necessarily change the social care market.
One example can show how leaving the social care market as it is to determine options for care will only bring further spending crises.
Care home charges are now on average 25% above that allowed for in block contracts. Those with sufficient means not covered by local authority payment pay the higher amount. But the Care Act now gives equal rights to all who need residential care and includes them within local authority responsibilities. Meanwhile care home companies, including at least one of those used by Haringey, have issued warnings of their precarious future in this sector.
Personalised budgets are one way that both legislation and local authority care have been able to open up ways of providing support to people at risk and work best for those with the self-confidence and competence to utilize them but outcomes across the country as well as in Haringey are far from demonstrating clear benefit to the majority of users or carers. However a co-operative model of using direct payments could overcome existing problems for many of employing their own care support person and pool some of the cost and knowledge issues which have discouraged many [research by Community Catalysts, Mutuo and Co-operatives UK].
There are various examples in the UK and further afield of co-operative working, social-public authority partnerships, and multi-stakeholder mutual structures as well as community interest companies contracted to provide services [many of these are well summarized in Ed Mayo [ed.] ‘The Cooperative Advantage’]. We understand that the Council may be open to a higher profile social enterprise contribution to social care. The point being made here however is not just ‘’tweaking’’ the mix, but that now is the time to re-determine the social care market locally so that it puts Haringey users and carers needs first.
A] A social co-operative, supported by the Council, but which within its governance arrangements gives voice to users and to staff, making the concept of ‘co-production’ much more than a consultation exercise but a real governing force in design and delivery, and with accountability built in towards all stakeholders. A working assumption is that there are economies of scale and cost benefits from local capacity realization to counteract the observation that co-operatives will not compete well in market terms. In an unpublished paper Robin Murray proposes it is entirely feasible ‘’to develop a model of care where co-operative costs are decisively lower and the standards of care higher, so that co-operative care outruns the private equity care chains’’. A home care co-operative could recruit locally, link with existing best practice and induction training, be more likely to retain workers and give continuity of care to individuals, and draw on mutual goodwill in providing services rather than the ever-changing turnover of staff with users, and lack of attention to basic need as at present with the dependence on private company providers. It is noteworthy that the director of health and social care at NICE has reported that their independent experts guidance is that home care visits should generally be at least half an hour [not fifteen minutes as is the current norm] and that regular training and recognition is essential [see The Guardian 23/09/15 – Gillian Leng]. There is no evidence that commissioner checks alone can achieve this.
B] An integrated health and social care co-operative. Both the CCG and Haringey Council currently agree to finding the means of jointly establishing more locally based preventive and restorative care while saving on high end costs wherever they can. The step not taken so far is creating a structure which can oversee, encourage and seed ways in which people will support each other, set up good neighbour networks of skills and time share, and create work opportunities for those living locally with under-utilised skills [including young people who could help older people, and optimizing older peoples under-used capacities].
C] Establishing a mutually owned social care agency, separately governed but initiated by the Council [and potentially the CCG as the other current commissioner of social care]. This would be the equivalent of a public-social partnership. One existing example in child care of such a model is the Foster Care Co-operative which works across numerous local authorities and has mechanisms for dealing with commissioner-provider conflicts of interest. The Council could consider with the CCG establishing a mutual community interest company [CIC] learning from the experience of Your Healthcare in Kingston and Richmond, and other CICs in Kent and Essex. Essex Cares for instance attracts investment for placements but has the local authority ethos and support. In this instance it is suggested that particularly for Haringey where there are differences between the readiness and reach of North Middlesex and Whittington Hospital community services [and neither of these health bases being in the borough] there is a strong imperative for a unified and publicly accountable adult care agency. The multi-stakeholder model gives full membership and accountability to service users. The continuity and projected mixed use of Osborne Grove could be managed within such a model.
The above by no means exhausts the potential array for social care, led from the perspective of putting the public good first. There are ways of connecting housing improvement and retrofitting with fuel poverty and social isolation initiatives which could be co-operatively organized and contribute to the social economy of Haringey while specifically helping the most vulnerable people. The Circle model of self-directed support and membership network building could be explored. The key issue however in re-configuring the services for users and carers in the borough will be the willingness of the Council to develop a trusting relationship with those who are most involved in representing people at risk as well as with direct users and carers.
2] Recognition that - in terms of the Care Act, the Human Rights Act and other relevant legislation, and the widely accepted best practice imperatives of dignity, respect, privacy, self determination and sociability as requisites for all people in need or receipt of care - the Council has a responsibility to make the best use of capacities at its disposal, physical spaces and human capabilities as well as financial ones.
In light of the above we again urge that bases such as The Haven and The Grange not be discarded. While networking and volunteer coordination are undoubtedly going to be of increasing importance, and digital communication too, the retention of place is fundamental to the sociability and most often the self determination of frailer older people who need continuity and known surroundings. At the same time the loss of such physical bases will impede the development of much-needed outreach and ‘go-to’ environments, whichever alternative models are adopted. And too much reliance on digital communication can exclude, not include, significant numbers of frail elders. In the words of the Joseph Rowntree Foundation in Widening Choice for Older People
where there are high support needs such as multiple long term health conditions or signs of dementia then what matters is ensuring reciprocity. People with diminishing capacities lose most, and can contribute least to their own welfare when what they know is taken away.
If the Council is serious about its commitment to a Living Wage and to equity and empowerment as well as an end to poor quality care then it can no longer afford to rely on private companies to be the main determinants of what kind of care, and wage, is paid. A mixed economy of care can be consolidated for greater benefit if the vision and infrastructure are negotiated in trust with all stakeholders.
Adopting Unison’s Ethical Care Charter, as have three other London boroughs to date, would be a significant step.