Why the purchaser/provider split is failing

Well, It's been quite a while since I've posted anything.. my excuses...life has been quite busy starting a new job and am finishing a dissertation among other things.

I've just spotted an excellent article on the Guardian which seems to hit the spot over just what is wrong in social care - in fact it echos a lot of what I said today to a new colleague who as it turns out his wife used to do some of my training when I was still in Social Services. It has led to me to post a response which I'd like to share here...



This is the real scandal in social care

The purchaser/provider split which came in in the 1990 act (but which has really come to maturity in the past 5-8 years as LAs ditched functions like in-house care providers and res. care homes) allows LAs to focus on driving down fees without having to worry themselves about the details of how this is achieved, or what corners are being cut to do this.The problem as pointed out is that lack of money in the system turns the purchaser/provider split into a destructive force which eats itself; it's not about getting quality care for a competitive price, but just about securing the lowest possible price to protect the diminished budget.

What we have is a failing market which is seeing a race to the bottom in terms of care standards.


A massive, massive issue to me, as I was only talking about someone to today is that the purchaser/provider split allows LAs to delegate responsibility and accountability. For instance if there is a scandal in a care home operated by a LA then the head of service and cabinet member are directly accountable... if it's with a private provider then they can simply blame a greedy owner, or bad management and point to the role of CQC.

Being able to escape this direct acvcountability means LAs can turn a blind-eye to just how margins are being cut and the impact of real cuts in the cost of care.

And being cut they are. I can't speak for now, but I began in Social Care in 2004 when providers were being paid £15 per hour for care...... when I left in 2009 the avearage was more like £10-12 per hour.

The real scandal in social care

I've always thought that an essential in any good system of social care provision is content staff.

Too often we ignore their needs and treat them as if they are invisible even if we're in the same room and I'll admit here that I've been as guilty as anyone else on a social services training course when the room divides into carers on one side and 'professionals' on the other. A few ex-colleagues of mine had worked, or even continued to work as carers, but this aside there was always to my view an element of snobbishness and power imbalance present in the many interactions between ourselves and carers.

Though a few of us did speak out about the conditions faced by carers it was a topic well down the list for us, far below issues like personalisation, or even the personality politics of the department.


But the treatment of carers is so integral to the system it should be the only issue we're talking about. Why? Well we really need to look at this holistically. If we want a system based on dignity and respect then that standard needs to apply to everyone. If care staff are treated with dignity and respect then we can in turn expect service users to be treated the same. Turning an indifferent eye to care staff being paid below the minimum wage endangers our ideals as much as mistreatment in a care home.

Communication strategies.

I've been planing to write about technology and social care for a few weeks now. I'm still formulating that one, but once again something written on the topic (in the Guardian as ever) has caught my attention and forced my hand. It was a call to harness the power of the Internet to aid communication between organisations and service users more of whom the article assumes will be using individual budgets.

The crux of the article is summarised neatly in one paragraph:

Complimenting this is the interaction between organisations and their clients, cementing online communication as superior to other mediums. The modern Internet holds the potential for service providers to reassure people by offering easy, quick and cheap methods of communication. Being able to receive and respond to feedback, offer online advice and allow vulnerable people to apply for help from their homes are now basic communication requirements in an inter-connected world.

As the commenter's (myself included) point out there are many issues around using the Internet, not least the fact that certain groups have greater access to it than others; Though the article suggests that more people, particularly in the older persons bracket are getting online, the phrase 'digital divide' still seems apt. Another issue is that in my experience for social care email is quite possibly the worst form of communication. Mainly because the conversation is one sided making it very hard to make a quick assessment of a situation. Much more preferable is a telephone call allowing you to get much more info in a shorter time as well as judging a persons state from their tone of voice; scared, upset, confused? Not so easy to tell by email. Top of the tree is a face-to-face visit where you can read a whole set of non-verbal cues and see a person in their surroundings.

The one thing the article does get right is that email is a cheap method of communication. I know a few years ago some authorities still visited almost everyone who asked for assistance to carry out a face-to-face assessment, but it became increasingly common to find 'contact centres' being set up where initial assessment was done by telephone, with some being 'screened-out' so never receiving a visit. Undoubtedly this trend was driven by a need to stretch resources so its quite possible that email or self-assessment via a website will prove hard to resist for cash strapped authority's and rather than helping "people feel closer to those who provide key services" it erects yet another barrier between them.

It's not that I'm some kind of Luddite. I believe that the Internet and email does have a valuable role to play in social care however, as usual I have a number of concerns. Just a couple of years ago for instance my authority announced it was phasing out information leaflets; those ones you see in racks on the wall of a GP's surgery waiting area, or just inside the door of a community centre. It reasoned that they were a costly and inefficient way of communicating with people, so save for a couple they were to be only available on the website in PDF format. In part the authority had a case, keeping the leaflets up to date was a costly exercise (also arguably environmentally unfriendly) and there was no control over the numbers of out-of-date leaflets in various locations all with the wrong information and old phone numbers belonging to teams which have since been re-organised at least 5 times. They also decided to pahse-out the leaflets in various languages, again they could well have had a point as in the office we did have a filing cabinet bursting with leaflets in Polish which never saw the light of day due to there being no demand for them. The councils proposal was that instead translations of all the leaflets would be carried out on request.

Clearly, apart from the cash saving, none of this been thought through. What if people don't have Internet access, and will people at possibly the most vulnerable time in their lives manage to navigate the complexities of a councils web site to find the right leaflet, or is it more likely that they'll spot it in a GP's surgery? Yet again an assumption has been made that the service user is an informed consumer just like someone shopping around for the best car insurance deal when often this is not the case. As for the language issue the situation is even worse. The piles of unused leaflets were not the problem, rather they were the symptom of a wholesale failure to engage with minority communities, particularly the most vulnerable among them; making leaflets only available on request (along with pulling funding from the jointly funded post of a sensory services minority outreach worker and cutting funding for neighbourhood advice centres - where face-to face advice and information leaflets both in a range of languages were easily available) would make matters much worse than they already were.

Fortunately I did notice a leaflet recently in a GP's surgery so unless its an out of date one there may well have been a u-turn on the leaflet policy. I hope so as for all it's promised advantages we need to be careful that new technology does not mean people are left behind.

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?