The rotten state of residential care

Well it seems a Social Care story has finally appeared...

Southern Cross Healthcare who own and operate 31 000 residential homes are in serious financial difficulty. The chairman has quit and the firm is threatened with possible insolvency.

According to the Guardian article Southern Cross came unstuck due to greed:

The company's problems stem from heady expansion when it was owned by the US private equity group Blackstone, which undertook the sale and leaseback of homes to bankroll a number of expensive acquisitions. Many leaseback agreements included upward-only rent reviews of up to 2.6% annually.

As the article also explains whilst this may have seemed like a good idea at the time it doesn't seem so good in the face of local government cutbacks. I know my old authourity a couple of years back went with a 1% increase in the maximum funding levels two years in a row, and for all I know this situation probably continued after I left. What this means is that as far as local authority clients went a company like Southern Cross could only expect the price they received per resident to rise by 1% Makes those 2.6% rent reviews seem like a very bad idea indeed.

But, isn't that the way markets work? Risk and Reward. Southern Cross won't be the first firm to have collapsed after overstretching itself to meet ambitious targets. Maybe we could shrug it off if it wasn't for the following passage of the article:

Paul Saper, chief executive of LCS International, the healthcare consultants, said that the cash-strapped group had not "invested properly in some of its homes, with doors falling off the hinges at some properties". He added that, a year ago, about 40 of the company's homes faced embargos from the regulator and that several had been the target of enforcement orders linked to issues such as hygiene and standards of safety.

This is the crucial difference. The state of the residential care sector affects lives; the lives of residents, of staff and of families. This episode serves as a reminder of just how rotten things are in the sector and just how thoroughly rotten the whole system is.

I don't think many people in social care would rush to defend the status quo. In the one corner we have the capitalists seeking to make a profit, in the other we have local authorities keen to cut costs.

Between these two implulses the standard of care in the sector, particularly for those least able to top-up with their own resources, is being driven down. Residents are put at risk and staff are expected to do a tough and demanding job for a pittance and without the right support and training.

There is an irony here that in the event of Southern Cross folding Local Authorities, most of whom have spent the past few years closing down their own homes to a great deal of local resistance, may well end up taking on responsibility for the homes.

Gadaffi and the LSE

This may of course just be an isolated case, but am I alone in wondering whether the much vaunted and terminally embarrasing link between Gaddafi regime and the LSE rings alarm bells when it comes to the plans of exposing much more of the public sector to market imperitives and the influence of filthy lucre?

What if..... the 'Big Society' worked

Just for a second, if I shut my eyes tightly enough, I can imagine a world where the 'Big Society' works (This is despite coming to the end of the excellent 'The Spirit Level: Why Equality is Better for Everyone' which convincingly argues that the level of inequality in the UK and U.S is a major impediment for a sharing and cooperative society). Yes, I can force myself into a state of optimism. I can see innovations like the Ministry of Stories and other stories of individuals and groups being creatively empowered to improved services.

It seems to me that we are all too focused on the many reasons why the 'Big Society' will not work that we are failing to considering what will happen if it does work.
When I say 'work' this is of course somewhat subjective as if the plan does take off I am far from optimistic.

The reason for this is that there are two visions of what may happen if the 'Big Society' idea really gets off the ground. The first is the vision of 'bungling amateurs' which Francis Maude may be relaxed about, but as someone with five years experience in social care I can say I am definately terrified about. Even providing basic services is a complex matter and if something either goes wrong, or more likely something is omitted then the consequences can be dire indeed.

It is however, not just failiure that is the problem. Success is perhaps an even bigger issue for the 'Big Society'. According to the market logic of the likes of Maude, good services will flourish whilst poor ones will disappear through lack of demand. That this can be a problem may seem counter-intuitive; after all if services improve that can only be a good thing, right? The problem though is that when it comes to applying the supply and demand economics of the market to the voluntary and community sector there is a key difference. As Harvard Business School academics James Austin, Howard Stevenson and Jane Wei-Skillern point out both sectors have very different opportunity structures:

In comparing the nature of opportunities in the commercial and social sectors, clearly, there are abundant opportunities in the latter relative to the former. The demand for social entrepreneurial programmes and services usually far exceed the capacity of the social enterprises to serve these needs. Initial successes often lead to increased demand for the social enterprise's programmes, products or services, or even requests to scale or replicate the organization in some form. For many employees and for the outside funders, the growth imperitive often becomes paramount.

So unlike the commercial sector the demmand for services provided by the voluntary and community sector is virtually unlimited. On the face of it this would seem to suggest the need for an initiative like the 'Big Society', but the academics warn the pressures to meet the sheer scale of demand can be detrimental to voluntary and community organisations:

In some cases, growth may not be the best approach to achieve the organization's goals or to have the greatest social impact. Growth for the sake of growth has the potential to squander organizational resources and can actually detract from the organization's overall impact.

This leaves succesful organisations in a bind. Although Austin, Stevenson and Wei-Skillern are not saying that growth is intrinsically a bad thing, they provide a reminder that growth is not necessarily a logical outcome for a succesful organisation. This suggestion ties in with the view expressed by former Shelter Chief Executive Adam Sampson that some charities had grown too large, buracratic, commercial and in the process distant from their beneficiaries in a way which was threatening to undermine the sectors claims to distinctiveness.

This issue boils down to this. If voluntary organisations grow they may in the process of restructuring lose what it was which made them succesful in the first place, but if they choose to remain the same size they must cope with huge levels of demand which they could not possibly hope to meet. How do voluntary organizations cope with excess demand? The market mechanism of increasing price is out of reach to them, so they must choose between having a huge waiting list or develop criteria. The role of the criteria is simply to discriminate between who receives a service and who does not. This could be based on an assessment of need, on geographic residence criteria, financial circumstances, or any other combination of measurable characteristics. In some circumstances criteria my be formal, but in some cases it has been shown that informal arbitary rationing criteria have been used by voluntary ortganisations keen to safeguard limited resources.

What this all leaves is an opaque system where a person in need must approach multiple organisations and satisfy various sets of criteria, becoming as one academic, Caroline Knowles, referred to as "welfare Nomads"; persons spending the day wandering from location to location to piece together a patchwork quilt of support.

Set this against a backdrop of a welfare-state in retreat and you have a potentially toxic combination should the 'Big Society' actually work.

Big Society Fortnight

I've decided that this is now going to be big society fortnight(backdated to last week). It's been a such a long time since I've had so much to say on one topic and I know I'm not the only one as apparently at the Uni some big-name academics also came together to hold a debate. When I heard this I reflected that it was curious why we're all now devoting so much time to what most of us seem to beleive was just an election gimmick, but here we are and the discussion goes on....

It seems that all of us, even Dave himself, reached a consensus last week; namely that the cuts dished out to the voluntary and community sector by town halls across the country seemed to be anomolous to the aims of the 'big society' programme.

Sensing that the policy was on the verge of turning on its heels and running, to be ruthlesley pursued by the oppositions cavalry it seems the Government will this week be attempting to set a rallying point. Some of the details which have been announced featured in the Guardian over the weekend. Though I am tempted to pick it apart in minute detail I will restrict myself to commenting briefly on the main features.

Firstly there is the announcement that a £100m fund will be available to enable "charities" and "social enterprises" to "compete" for government contracts. Also available will be £200 million in loans from high street banks.

My first impression is, what's new? This is something which was being done under the last Government through programmes such as Change Up and Futurebuilders. I also wonder how the £100 million figure measures up to the cutbacks. As I have previously mentioned in my area alone £400k is expected to be shaved off the main Day Care services contract(currently provided by a nonprofit) alongside 700k or so in funding for voluntary sector organisations in the area. These figures are also per year, it is not clear in the article how many years the £100 million will be spread over. The Guardian piece does rather well in dealing with the issue of the £200 million from the banks, which it states will be on a commercial basis, and again, what's particularly new about this? There has been nothing stopping a non-profit organisation seeking finance in this way before.

A key feature of Cameron's defence of the big society has been how it embodies a philosophy of bottom-up as opposed to top-down action. Leaving aside the fact that this is quite a paradox for a policy being pushed by central government I wonder how the above funding arrangements fit with this philosophy. The reason I ask this is that the current round of local government cuts are likely to bring into question the viability of small locally based voluntary organisations as opposed to large regional or national organisations which will have more diverse funding streams. It is these small organisations which are often credited with being closer to their beneficiaries wheras larger organisations have been critiqued for becoming too buracratic and distant from their beneficiaries I also wonder how shifting the decisions over which charities to fund from democratically elected local authourities to high street banks and central government quangos is in keeping with the bottom-up philosophy?

Something which also seems to run counter to this is the whole process surrounding the 5000 'big society' workers and the establishing of what looks like a central college with what seems to be remit for deciding on a curriculum for a set of community work qualifications. All this at a time when Community Development Workers across the country are in fear of their jobs and department budgets. If this does not smack of top-down centralisation I really don't know what does!

Day Care part 2

It seems the writing is on the wall for Day Care in my area. A council document published on the website of a local paper projects a budget saving of £400 000 from 'reviewing' the service which reading between the lines involves reducing demand through a two pronged strategy of individual budgets and tightening up eligibility criteria.

This can probably be achieved as there are probably a fair few people going to Day Centre who strictly speaking wouldn't meet the eligibility criteria as it stands today. I remeber in my time assessing people for this service I had the unenviable task of explaining to a lady why she couldn't have a second day at the Day Centre despite the fact that other people had three days there. Quite simply the bar for the service has been raised year-on-year and Care Managers doing reviews don't like taking services away as this involves potential for conflict with the service user and the risk of getting things wrong not to mention more paperwork. This created a two-tier system where existing service users assessed in more lenient times had their privelages maintained whilst potential new ones had to meet much tougher criteria which often saw people with possibly greater levels of need being turned down for services.

This two-tier nature of the system is bad in itself, but also problematic is what happens to people who now don't now meet the eligibility criteria. Will they be able to obtain the service elsewhere? The answer is probably not, if a person isn't eligible for Day Care under FACS (Fair Access to Care Services)they won't be eligible for an Individual Budget either. Can they obtain the services from the voluntary sector? Possibly however, this depends where a person lives and whether they have the resources to access transport. Groups which do exist tend to meet on a fortnightly basis so will also be unlikely to meet demand. As the service in the area is also currently provided by the Voluntary Sector, but funded on a contract basis by the authourity it is much more likely that the Voluntary Sectors ability to provide good quality Day Care services will collapse.

A reason for the bar being set low for access to Day Care was that, as our senior managers were fond of saying, was what was termed a 'preventative service'. It was seen as a form of early-intervention which would prevent someone needing more services at a later stage. This was clearly logical whether it was giving a carer a break, extending a persons support network, improving someones mood, or just being able to tell when something is wrong Day Care did work in this respect.

Our Head of Service used to bemoan how we had so little to invest in such preventative services and how this undoubtedly increased the costs we had to pay now and in the future. A cycle occoured where less money on prevention meant higher costs and even less for prevention.

Reducing Day Care provision seems to be a leap along this cycle, but even more troubling later in the document is the following passage detailing a planned budget saving of £776 000 across the council. The passage reads:

All voluntary sector contracts which are identified as providing non
statutory preventative services are included and will be ended. The
loss of these services will impact on later costs where early
intervention would have reduced service need. Such cuts may
result in some organisations becoming unviable which will impact
on their use by other areas of the Council and partner
organisations.

Which all leaves me wondering what happens in the future?

The end of day care?

The local rag in my area today carried a story about how the day centres in the district are under threat due to budget cuts. It's made the front page, but to anyone anywhere near the world of social care it's not news at all.

Day care has long been considered to be the weakest gazelle among local authourities portfolio of services. Caught in a pincer movement between cost-conscious authourities who regard day care as an unecessary luxury on one hand and by modernisers who see it as hopelessley out of date the real surprise is how long it's managed to survive.

It could well be that attacking services out in the open is difficult at the best of times as the local rags dedication of their front page testifies, but I distinctly remember talk years ago of a more subtle approach using individual budgets as a way of phasing out day care. The arguement was that people would prefer to buy a football season ticket or do something, anything, other than a jigsaw with missing pieces and a sing-a-long in a church hall. The logic dictated that in the face of greater choice day centres just wouldn't cut it.

Another important argument is that day care is just not inclusive. Social care has a progressive element to it and day care has just got too much of a segregationalist whiff about it. Why should a person not enjoy the kind of leisure activities the rest of us enjoy, football, nights out with friends, watching a gig, just because they have a disability, and hasn't the DDA made all these things more accesable anyway?

There are however, problems with this view. The first being that a lot of people actually like day care. Most centres had a waiting list for spaces and a fair number of people once they had started enjoyed it so much they then asked for a second or third day. This was perfectly understandable as for a lot of people, particularly older people, day centre represented a vital link to the world outside their living rooms. As care managers our day centres also proved invaluable. Their staff could build good relationships with service users meaning they could detect a change in someone which might indicate something was wrong.

Second there is the issue of costs. A football season ticket can cost a lot. Day care on the other hand is cheap. In my area we had a block contract with a voluntary organisation. Most of the premises were also purpose built common rooms at council owned warden assisted accomodation so overheads were low. There may well be better alternatives, but there aren't cheaper ones.

It almost seems like another age, but around four years ago we even offered the service for free and had given days away without any kind of real assessment. Those days are long gone and unlikely to ever return, but I wonder will it be the same for day care?