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Is Brexit an Opportunity to Sort Out Social Care?

Author: Bob Rhodes

Don’t Incorporate Existing EC Procurement Regulations

Public procurement agencies, when challenged to explain the apparent contradictions and counter-productivity of their contracting and commissioning practices in social care, have over the years evaded the possibility of positive change by asserting that their hands are tied by European public procurement legislation.

Spurious as this defence appears to many practitioners, it is now clearly the case that the UK government has the opportunity to introduce its own public procurement regulations to give full force to its stated commitment to:

  • ensure choice, self-determination and facilitating support to citizens 
  • and to nurture connected and reciprocal communities ('Big Society').

Just in case you believe that this is fanciful, have a look at the stated goals of the DH inspired Think Local, Act Personal initiative (TLAP, 2017):

  • Co-producing solutions with people and families
  • Personal budgets working for all
  • Helping providers and the workforce deliver personalisation
  • Information to help people take control
  • Communities supporting each other
  • Sustainable social care

A first step would be to not incorporate the existing EU legislation into law – in relation to human services – as part of the proposed, oddly titled, transitional ‘Great Repeal’ legislation.

Why we should fundamentally change direction

From a generous stand point we might conclude that Margaret Thatchers’ 1980’s government – in common with all administrations, pre-occupied with controlling expenditure– were possessed of fundamental beliefs that ‘the market’ constitutes the best way to ‘transact’ all human affairs, including health and social services, and that private business provided the optimum model for the efficient implementation of this perception. Less forgivingly we might also conclude that they were also motivated by the lucrative possibilities attendant upon the privatisation or pseudo-voluntarisation of public services.

Suffice it to say that this ideology, triumphing repeatedly over the evidence, has not only survived but strengthened over the last three decades having been progressively reinforced by all succeeding governments. The consequence has been one of converting citizens into increasingly deskilled and dependent consumers, while community cohesion has been eroded by a plethora of influences.

By 1995 Professor John McKnight was observing (McKnight, 1995):

“We have reached the apogee of the modern serviced society when the professionals (and the government?) can say to the citizen…

  • We are the solution to your problem
  • We know what problem you have
  • You can’t understand the problem or the solution
  • Only we can decide whether the solution has dealt with your problem”

Hence, the logical consequence of this institutional ‘hegemony’ has been that procurers or commissioners have created new meanings for the stated principles that tend to introduce government policies in health and social care (NB. we no longer talk about social services) so that, for instance:

‘personal budgets working for all’ means ‘direct payments interpreted as support worker hours (funded appallingly)’

and

‘coproducing solutions with people and families’ equates to ‘eventually getting around to assessing to see whether needs are desperate enough to justify paying for something off a menu of task oriented services that we have already, at least in theory, organised.’

While it is reasonable to concede that most public authorities during the 1980’s, in comparison with their profits and dividends motivated business contemporaries, were not paragons of administrative and fiduciary excellence, that cannot excuse the government’s – and that has to include the Civil Service’s, seemingly wilful failure to understand the fundamental nature of social services and its relationship to the wider society and the citizens, families, neighbourhoods and communities served. This is all the more surprising, indeed disgraceful, given that early in that decade (1982) the Barclay Committee had reported and described achievable aspirations for optimum social services practice and performance, which may be summarized as needing to be attentive to:

  • Holistic approaches and coproduction
  • Devolved responsibility for decisions about resources to local level with real accountability to families and communities 
  • Promoting self-direction and self-help – personalisation
  • A strong focus on neighbourhoods 
  • Supporting family and neighbourly care – (we might say) “keeping people strong”
  • Community work, engaging with the strengths and talents in the neighbourhood and nurturing local voluntary organisations and associations – “helping communities be strong and resourceful”
  • Undertaking local social care planning on an inclusive basis
  • Balancing casework and community work
  • Coordinating access to mainstream and specialist services as necessary, and advocating for their availability when required

These criteria, ironically, have informed the repeated attempts to ameliorate the pernicious effects of the marketization and commoditization of social care ever since the mangled implementation of ‘Griffiths’.

Sir Roy Griffiths, ex-boss of Sainsbury’s, having introduced the ‘purchaser-provider split’ to the NHS, was asked to look at social care. He understandably responded to the brief from a managerial and entrepreneurial perspective and did not appreciate that such a construct should be utterly alien to the practice of, social work – an activity based in inter-relationships, voluntarism and a degree of altruism. His oft-quoted remark that, "community care is a poor relation; everybody’s distant relative but nobody’s baby" (Griffiths 1988), of course, from his standpoint, referred to the lack of clarity regarding roles and responsibilities between governmental institutions. 

Sir Roy, the ultimate managerialist and organisation guru, did not live long enough to appreciate the real irony in this insight. It is of course that true community care is primarily the business of every citizen, with government in support in enabling and facilitating, supplementary and complementary roles.

Inter alia, Griffiths recommended that local authorities should hold the budget for care services across the community (i.e. hold the budget for both residential and community care) as well as managing and assessing what services were required. Local authorities could then purchase appropriate care packages from a range of providers. It was thought that if local authorities were responsible for the budget, they would make a more realistic assessment as to whether someone needed residential care or community care – and that quickly became the core activity replacing the previous emphasis upon working with people to utilise a panoply of possible solutions to their circumstances. Before long, Norman Warner, Social Services Director in Kent, probably unwittingly began the demolition of relationship-based Social Work, introducing de-professionalised Care Managers to, in reality, administer a process of needs-based assessments and, for those found needful enough, service/placement brokerage.

In later years Bob Holman, one of the great practitioner luminaries of the Barclay Committee, was to observe:

“One of the great failings of social services departments was that they let community social work go.”

At this point the Social Services institutions, increasingly placed under the control of accountants and general managers, lost touch with reality and increasingly fell prey to serving their own fast evolving systems, procedures and, largely budgetary, priorities.

The understanding that had been lost related, and continues to be fundamental, to the inherent nature of social care and support and the most effective and efficient relationship that can possibly be forged between citizens (and their many relationships and associations) and the State (and its various institutions). Social Workers, and parallel community staff in Health, Housing and other disciplines, of the pre-Griffiths era knew full well that their work was focused upon assisting people in need to own and address their situations in the contexts of their families, friends, neighbours and communities. They understood, as Al Etmanski later put it, that the role of services is “supplementary and complementary” and that most of the care and resources we all depend upon and value most are beyond the diktat of public institutions and their professionals. In short, they implicitly understood that their role is based in problem solving relationships – in listening to understand, in advice and facilitation, in influencing, and coordination with the facility to pull in specialist help or services where these are truly relevant. These are hardly activities that a ‘Fordian’ politician can command and control, let alone value and comprehend.

As for ‘Joe Public’, most of us will both need care or be carers at times in our lives and masses of both evidence and common experience tell us that we manage best when we enjoy the support of family, friends and neighbours and the expansive social capital that derives from these relationships. Folk don’t manage anything like as well when disconnected, isolated and socially impoverished. The social work espoused in the Barclay recommendations addresses the necessity to address this head on in both preventative and ‘therapeutic’ ways. Griffiths sees this as peripheral, as we might adduce have politicians and their advisors ever since, and in doing so:

  • devalues and fails to make use of the huge potential resources brought into play when citizens and communities are enabled and nurtured by skilled and knowledgeable community social work practice, 
  • stimulates ever growing demand for funded services – linked to a very explicit marketing message that misleads when it asserts that services are the optimum response to social care needs and you (the customer) have the right to expect the optimum solution to be available to you at your point of need,
  • sets the scene for the establishment of systematized rationing, 
  • and the ultimate betrayal of political truth and integrity when, behind a shield of laudable principles – choice, self-direction, person centred, co-production, localism, and inclusion being just some of the goodies put on show – top down, finance-led, systems-constrained and frequently cynical ‘no-production’ are generally practiced in the names of the false gods of ‘economy of scale’ and ‘value for money’.
  • and, as Professor John Seddon and colleagues have repeatedly evidenced, the economic and organisational consequences of the Griffith’s ‘reforms’ have been massive ‘failure demand’– and a production-line, ‘Fordian’ approach to managerialism that has given rise to a functionalisation which is inimical to effective social work – which is a dynamic art form grounded in relationships and grass-roots co-production.

Above all, it is very apparent that the ‘reforms’ of the late 80’s onwards have been primarily directed at ‘saving’ money and focused upon costs. To deliver true efficiency and effectiveness the system should be focused upon value. Dressing up ‘markets’ as value is both cynical and disingenuous. All the evidence that anyone ought to need can found in Richard Davis’ Responsibility and Public Services  (Davis, 2016).

Sir Roy Griffiths came from retail business and was inevitably passionate about growing his customer base and nurturing customer loyalty (which we might rename as dependency?) with the object of continuously increasing demand. It should be no surprise that, as a consequence of the fervent interpretation of his recommendations, Social Care is in crisis. We need to go back to Barclay as a basis upon which leaders and practitioners who have known nothing other than the marketization and commodification of social care can begin to conceptualise alternatives.

As mentioned earlier, we have been doing just that throughout the three decades while our leaders could not confront the possibility that something implicit to Thatcherism was a burgeoning disaster and blatantly placed ideology above evidence. 

Here are just a sample of the many Barclay ‘compliant’ programmes that have been championed over the years:

  • Think Local Act Personal
  • Putting People First 
  • Local Area Coordination
  • Self Direction, Personal Budgets, In Control
  • Person Centred Approaches
  • Valuing People
  • Coproduction
  • ABCD
  • Community Building
  • Community-Based Work
  • Strengths-Based Practice
  • Circles or PLAN
  • Social Enterprise

Our problem however has resided in the impossibility of bolting a succession of powerful strengths-based practice solutions onto the broken needs and deficits focused social care market construct.

What can we do to put the heart (and impact) back into how we care for each other?

  • Promote a societal understanding that citizens, families, relatives, friends, neighbours and communities are the primary providers of care
  • Recognise that the roles of governments and their institutions/services/professionals are primarily supplementary and complementary
  • And that the most important generic professional service provided by the State is the provision of help to citizens and families in the planning and organisation of support arrangements and 

The fundamental societal role of citizens who aspire to political leadership is to develop, evolve and consult over a vision of a good society and, having described and adopted their purpose, to seek to bring it about. In the context of creating or evolving a society (of inter-connecting communities and neighbourhoods) where community care is highly prized this, of course, implies creating societal conditions which reinforce and reward communality, hospitality, social responsibility, self-reliance, resourcefulness and interdependency.

We can make a start by designing support arrangements that are:

  • Local by default
  • Help people to help themselves
  • Focus on purpose, not outcomes
  • Manage value, not cost

We must locate finances to be managed in the context of ALL the, often abundant, social capital resources implicit to dynamic and connected communities at the local, operational level. We must urgently develop an intensive programme of re-training for both leaders and front-line staff in Community Services to enable them to become experts in helping and problem-solving instead of resource rationing/control.

It is time to abolish Social Care commissioning and strengthen strategic operational management with an emphasis on the coproduction of communities and not solely services. We must end the culture of managerialism and functionalisation in human services. Targets and pre-determined KPI’s have no place in arrangements designed to assist citizens to be the captains of their own lives. They simply tell an organisation whether or not it is serving its priorities and these rarely correspond to those of the individuals, families and communities that institutions aspire to serve and are frequently oxymoronic. This means ensuring that senior leadership resides in the hands of proven community practitioners who continue to spend time in the work.

And, crucially, we must introduce funding regulations that support and enable creative, responsive and highly devolved community social work practice, and encourage and reward tailored innovation amongst providers of essential specialist services. A good start can be made by excluding those provisions in EC commercial, contracting law that are presently employed as an impediment to or justification for not 'doing the right thing' from 'The Great Repeal Bill' and immediately getting to grips with abolishing the Griffiths Reforms, the Social Care Market, and their pernicious consequences.

References:

TLAP (2017) www.thinklocalactpersonal.org.uk
McKnight J (1995) The Careless Society – Community and its Counterfeits. Basic Books.
Davis R (2016) Responsibility and Public Services. Triarchy Press.