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 Voice of the Vulnerable

The Guardian’s Social Care Network has recently asked the question “How do we give service users a voice?” yet the fact that the question needs to be asked does, perhaps, highlight what is wrong with the current social care system and why we need wholesale reform to achieve social care that meets the needs of those who need it.

The most obvious answer to the question is, simply, that we ask those who use the services and, more importantly listen to what they say. But, unfortunately we have such a fragmented and somewhat territorialised system that any messages have to pass, in the manner of Chinese Whispers, upwards towards those who make policy decisions via the agendas of the various parties involved.

If we start with the individual the person who will listen to them the most and who probably has the best rapport with them is the frontline care worker. There may be occasional contact with a social worker but my general experience this will only happen once or twice a year at reviews, obviously families will probably also be involved in listening to what the individual thinks about their care package.

The route for the care worker is obviously their own line management but that would require the care worker be given the time (and be paid for it!) to sit down with the manager to outline their discussions with the care user, how things could be done differently to meet their needs and how the care service an improve their overall care delivery.

From there the route upwards means the care provider talking to the local authority funding the care to pass on the individual’s views and what they want from their care package. Yet there are probably very few opportunities to do this except where reviews take place and there is almost certainly not enough time to discuss everything the user may have said over the intervening period and be more focused on the care plan in place. It is also at this point the Chinese Whispers can begin with the agenda of the provider being set.

For example a care user might have said they would prefer to have their care at a particular time and the care worker would have passed this on, but if the care provider was unable to facilitate this because of staffing levels etc then would they necessarily pass this on to the local authority, especially if they feared the contract could be passed to another company who could accommodate that.

Once the care provider has passed on the views of the care user to the social worker then it will get passed along the upward line of the local authority where, to be brutally frank, it is likely to get lost or transform from the voice of an individual into a statistic aimed at proving why the authority should get more money from central Government. Of course the message may have to go through the NHS route and that is equally convoluted.

So by the time that the voice of the care service user gets to the Department of Health it has changed beyond recognition ceasing to be a voice and just one of many numbers that are processed by the bureaucracy of Westminster.

How do we stop this? Well the simply way is to ensure that all user comments about their care service are written down. This may seem a little old fashioned but it achieves one thing – the original message retains its value, unadulterated, on the way to the top. Yes it would generate a lot of paperwork (or e-paperwork!) but at least in Westminster they would have access to the qualitative data in addition to just the quantitative stuff!

In reality the problem is a fundamental one, the distance between the person using a service and the policy makers deciding what is best for individuals is an immense chasm with a rickety bridge connecting the two. The change in social care needs to address this, it needs to ensure there is a smoother, undistorted route for the users of care service to move up the line towards those who make the policy and hold the cash.

Not easy by any means but worthwhile it we are to achieve the best social care for those who need it.

62% of Care Users Extremely or Very Satisfied

           The recently published final report from the Health & Social Care Information Centre, entitled “Personal Social Services Adult Social Care Survey, England 2010-2011” actually paints a fairly good picture of social care and is perhaps worth highlighting to counter the general negative reporting we usually see.

            The survey, which had 61,115 respondents, found that 62% of those who responded were extremely or very satisfied with the care and support services they received, 28% were fairly satisfied, 7% neither satisfied or dissatisfied and just 3% said they were dissatisfied.

            Given that we are trying to achieve a person centred culture it seems odd that the constant criticism of the care system does not seem to be wholly reflected in the views of those who use care services.

            The survey also asked about individual’s quality of life. In this just over a quarter of the people who responded (26%) stated that their quality of life was so good it could not be bettered, 31% responded as it being good and 33% as alright with only 7% responding their quality of life was bad and 3% so bad that it could not be worse.

            We should also be singing the praises of social care workers. The survey asked “How happy are you with the way the staff help you?” A staggering 69.2% responded “I am very happy with the way the staff help me, it’s really good”.

            The overall picture of social care service delivery in England is a positive one.

            Yet more work needs to be done. The survey does not, unfortunately, fully identify where any differences in care delivery may occur. The responses are broadly uniform across the country and in terms of demographics the level of dissatisfaction with care services appears age related with younger people more likely to be dissatisfied and, I suspect, more detailed research would be needed to discover if this is because services are that much poorer for younger adults or whether it is purely because of age.

            We also need to be able to pick out what is the best practice that can be disseminated. What is being provided to the 62% who are extremely or very satisfied with their care package that can be translated into the care packages of the remaining 38% of care service users.

            We need to be able to identify what it is that makes care users happy with the way care workers help and support them, so we can disseminate this good practice throughout the social care workforce.

            Perhaps more importantly we need to raise the profile of this survey to show that the social care delivered in England is good, that the people who count – i.e. those who use the care and support services – are broadly happy with the service being received.

            Yes we do need a fundamental review of social care in the UK but we must be careful not to throw the baby out with the bath water and we should take the time to recognise that the bulk of care and support provision is good.