Social Care Culture Wars

One of the changes promised by the Care Quality Commission in their “Fresh Start” document published yesterday (http://www.cqc.org.uk/public/news/new-approach-inspecting-social-care-services) was that they will be “checking providers who apply to be registered have the right values and motives, as well as ability and experience.”

This could be challenging!

Whether we like it or not the bulk of social care provision, at present, is delivered by companies, large and small (and every size in between!) who are out to make a profit, because without profitability the business will fail. Therefore private company that applies to register a care service has, naturally, to have the right business values and motives to be profitable in order to be able to deliver the care service.

This fact highlights one of the issues with social care in England and why integration seems such a difficult thing to achieve.

The word ‘silos’ is often used to describe the way in which different parts of the care system are isolated but, in reality, we should see them as different cultures and, as often happens with cultures, the existence of that particular culture is built on difference rather than commonality and those within a culture will defend the values and motives that underpin that culture.

So at the front line of social care provision we have providers who have to make money, even charities and not for profit companies have to ensure their income in order to carry on their business, so they have to exist in a ‘market’ culture where income must exceed (or at least match) expenditure, their actual provision of care is limited by the monies they receive, however good their values and motives are in terms of wanting to care they are constrained by economics. There are over 12,000 registered care providers and each one will have a different organisational culture based on the values and motives of the company owners.

Another culture within the system are the Local Authorities, 152 with social services responsibilities. Each on will have their own ‘corporate’ identity, influenced by working practices, senior leadership and, importantly, politics. All local authorities are over seen by elected councillors and this, obviously, impacts on the organisational culture. Somewhat like the EU, the heads of social services departments gather together to discuss overarching policy but, again like the EU, these can be implemented slightly differently in each council because of the values and motives of those who lead the council.

Within the local authority system are other elements that those who need care services also need to access, e.g. housing. In many areas these are located within a different authority than the one responsible for social care which, again, has its own particular organisational culture.

Then there is the NHS, another completely different organisational culture, founded on a basis totally different from care providers and local authorities. Health services (either NHS or private) have grown from medical science with a fairly rigid hierarchy of who is allowed to do what and developed a clinical culture that is different from other fields of work. The NHS itself is more fragmented now, which is why individual hospitals or trusts have failed because of inadequate leadership, but the overall structure is the same. In this realm we have the Royal Colleges which underpin the professional expertise of those who work in health, and which elevate the roles they undertake, all of this creates the values and motives of the NHS and other health services.

The problem for those who need care services is that all of these different cultures have different languages and practices, all have different values and motives that underpin their roles.

Because different cultures defend their identity through maintaining difference with other cultures, the integration needed by those who need care services is hampered and will continuously be so unless we develop a culture which recognises that the individual is more important than any of the organisational cultures involved.

To achieve connected services for people who need care services all involved need to recognise the commonalities in their services and who they benefit the individual.

Before care providers can be judged on their values and motives we need to establish what those values and motives are and how they benefit the individual rather than imposing values and motives that cannot be achieved at the ‘market’ end of the system and which, ultimately, impact negatively on the care service provided.

The Culture of Culture Blame

            Many of the failings of Mid Staffordshire NHS trust were blamed on the culture within the service, similarly the abuse at Winterbourne View saw the culture word used to describe how and why abuse was allowed to happen. Blame on ‘culture’ is not limited to health and social care. The rail franchise fiasco last year was blamed on a culture of fear, and the banking crisis which sparked the current financial crisis is often blamed on the culture within those institutions.

            Yet does blaming the culture in an organisation really solve the issue and what does it really mean?

            The culture within an organisation is the result of the leadership, or lack of, and the way those in the organisation react to that leadership. What ensues is a group mentality that becomes self-perpetuating and, if it goes unchecked, something that descends to the lowest possible denominator and is often directed by dominance rather than leadership. Once embroiled within the group mentality it is far easier for members to dismiss personal responsibility and place all responsibility on the culture within the organisation.

            It also makes it harder to challenge the group mentality. People fear being ostracised by colleagues, fear they may lose their job or, in extreme circumstances, fear particularly dominant individuals. Those who believe that something is wrong but fear to speak up eventually feel they have become complicate in the wrong doing, “I will be blamed because I did not speak up earlier”. Others will just ignore what they believe is wrong and reconcile it in their own minds by saying to themselves “that is just the way it is done here”.

            The real blame is not on the culture of the organisation but on the leadership of the organisation and the lack of responsibility and accountability throughout the organisation. People in such cultures prefer to pass the buck about failings, blaming others or the policy framework they have to work in or, indeed, the culture of the organisation rather than being prepared to stand up and say I got this wrong. Those who set the tone for the organisational culture, including those in Westminster, must start to take responsibility for the organisations under their control, they must encourage accountability and they must ensure the culture of responsibility and accountability reaches right down through the organisation.

            In social care we must be aware of and ward against the possibility of a lack of responsibility and accountability and promote effective leadership.

            For example, multi-disciplinary working is common place now but we often hear of ineffectiveness because of people working ‘in silos’ (a jargon term I don’t really like) and the danger is everyone trying to work together defers leadership and responsibility to other agencies with the result nothing gets achieved and the only person to lose out is the person who needs joined up services.

            Effective leadership, responsibility and accountability are the best ways to promote good practice and if we are to provide the best possible care services they are the things that need to be at the top of the Health & Social Care agenda.

Social Care: A Culture of Unimportance

The Government’s Winterbourne View final report talks of a ‘culture of abuse’ being allowed to flourish within the establishment. This is nothing new there have been plenty of cases where this has happened and many commentators have mentioned this, we have periodic exposes of abusive culture within social care settings followed by a brief blustering of politicians yet these things keep happening.

The real issue that needs to be addressed in adult social care is the culture of unimportance that pervades society when it comes to the needs of the elderly and disabled in the country.

                                          

The Winterbourne report highlights this culture of unimportance. There is no Prime Ministerial forward promising whole Government action, there is not even a signature from the Cabinet Minister for Health. This should not distract from many of the good proposals in the report yet it, in terms of promoting social care as a national important area of policy it fails.

This is, obviously, only the latest in the line of things were the Government continues to cultivate the culture of unimportance around adult social care. The Dilnot Commission , set up as part of the coalition agreement,  submitted its final report in July 2011 and, since then, has largely been scrupulously avoided aside from the odd burst of political gusto when it seemed convenient. In the meantime the reality for many older people remains the same, sell your house to pay for your care.

Naturally Dilnot is itself a product of the culture of unimportance. The Commission was set up to tackle only how care is paid for, what has not been tackled is the ever tightening eligibility criteria for state support with care nor has the needs of other vulnerable adults, such as those with learning disabilities, had any consideration.

The social care culture of unimportance cannot just be ascribed to this Government, the previous Labour Government prevaricated and delayed taking action on social care producing a White Paper on 30 March 2010 just weeks before an inevitable General Election, and even then their ideas where merely a tinkering of what already existed rather than wholesale reform.  

The culture of unimportance that is allowed to flourish at Westminster inevitably and naturally trickles down to the rest of society. Undoubtedly if many average people in the street were to be asked what has been the most important issue discussed at Westminster this week the answer, inevitably, will be that of same sex marriage. While that is important in its own right surely the needs of the most vulnerable in society should take precedence and, although I don’t know the exact numbers, I suspect that the issue of same sex marriage will have a direct impact on far fewer members of the population than social care reform would.

The culture of unimportance MUST end and social care must take its rightful place alongside the other major areas of social policy. As society continues to age the implications for social care are significant, more and more people will need social care services and it is societies duty to ensure those needs are met.

Personally I feel it is obviously right that social care should have its own Cabinet Minister and Department for Social Care and have started a e-petition to this effect (click here to sign) as I believe that this will be a start to raising the importance of social care nationally. Yet beyond this we do need those in charge now to stop treating social care as a side issue to other areas of social policy and start treating social care with the importance it needs in order to ensure the well-being of the millions who need social care services.