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A National Care Service?

Sian Lockwood responds to questions posed by The Fabian Society in its report for the Labour Party on a roadmap to a National Care Service (first published in August 2022)

By Sian Lockwood

(first published August 2022)

The Fabian Society recently launched a consultation on social care (closing date Monday 12 September 2022), with responses to the consultation being used to help ‘develop a roadmap to a national care service for England’. While they are not clear about what this national care service would look like -anything from national standards for ‘care’ (whatever ‘care’ is) to a national service to deliver care – they are clear that this is the solution to a care system that is crumbling.   The questions in the consultation are, however, broadly framed and allow different responses – ones that are not tied to the idea of a national care service.

I have had a long career helping support local people to set up services and enterprise to help other people in their community. My submission drew on that experience but also my experience as a 67-year-old woman with a body that doesn’t work as well as it did and who may need social care at some point in the future. I know what I want, and what I think will work – and that is not (or is not just) a national care service. This was my response.

What should care and support for adults in England should look like in 10 to 15 years’ time? ‘What should it achieve? What values should inform it? How should it be run?’

We need to understand what we mean by ‘care and support.’

People facing physical, intellectual or mental barriers to complete independence are also people with gifts who want to be able to use those gifts to contribute, feel valuable and valued. They may need help with physical tasks (staying clean, eating, using the loo, getting in and out of bed) but they also need help to stay connected and contributing. The best supports to stay connected and contributing are human, delivered locally by family, friends, neighbours, community groups. These local supports are also often best at delivering help with physical tasks, even when that help is very specialised (with the right training and aids). I have seen Shared Lives families brilliantly support people with complex challenges to be a valued member of a loving family and supportive community. In Somerset I have seen 600+ people set up community micro-enterprises, each supporting 3 or 4 people locally to stay at home. I have seen faith communities and community businesses provide channels for volunteering and gift for people seen by many as a bundle of needs – older frail people, people with learning disabilities, people working to overcome addiction or with a mental illness.

These kinds of supports are based on the same set of values, which I think are summed up in the recent Archbishop’s Commission on reimagining Social Care. That all people are ‘created equal’ and have equal worth. The providers I have worked with take that as given, working with each of the people they are helping to co-design the help they need to do the things they want to do and have joy in their lives. They are not time-and-task or care-by-the-clock. They are local, relationship-based, and human-sized. Their ‘professionalism’ allows them to do what they do well but does not define them or separate them from the people they are supporting. Those providers that want to be paid (and not everyone does) receive proper payment for their work, at a level which they dictate. All are motivated by their sense of doing something valuable for someone in their community and by the relationships they form with the people they support.

For these kinds of local small-scale supports to be available for everyone and provide comprehensive support there needs to be investment in:

  • Community infrastructures with the expertise to help local people set up sustainable, competent, and legally compliant local solutions for other local people – and with knowledge of what is needed and the skills to encourage new sustainable solutions not currently available in that community.
  • Community connectors such as local area coordinators who can help people work out what they need to live the life they want and secure those supports.

Each community solution is self-managing and responsible for ensuring their own quality. The local authority works with these community solutions to support quality assurance and address quality or safeguarding concerns. For this to work well, channels for reporting concerns need to be well publicised and easy to use and response to concerns should be quick and efficient. The regulator has an additional responsibility for ensuring quality in larger services delivering personal care. In the future I would like to see the regulator involved in oversight of all services delivering personal care but, as with Shared Lives, in a way that is appropriate to the size and values of the service.

In the future as now these numerous, small-scale community-based services will be supplemented by larger more formal organisations delivering domiciliary and residential care. Unlike now, the business structure of these organisations should ensure that as much money as possible is channelled to front-line workers, who should be well-paid and enabled to work in ways that are emotionally satisfying – with a small regular group of people drawing on services to whom they can provide consistent care and with whom they can form mutually satisfying relationships. Organisations that adopt the cooperative structure should ensure that shares are offered to people drawing on their services as well as workers and that all can shape the organisation and its offer. Ideally the domiciliary care organisations will have a local presence and will be well connected into the local community. There will be a variety of accessible housing solutions and many more supported housing arrangements including ‘villages’ offering different levels of support and opportunities to connect and contribute. Residential care homes will be comparatively small, will consciously work to be homely and to enable the people living there to have the same independence and ownership as if they were in their own home and will be well connected into the local community.

The variety of supports and services needed to enable people to get the support they need in the way they want it to live the lives they want, means that all this needs to be invested in and coordinated at a place level with strong involvement from communities and local people.

What level of demand will there be for care and support in England over the coming years? What will be the costs and benefits of adequately meeting this need? What will happen if it isn’t met?

Demographic predictions show that our society is ageing and that the proportion of people over 80 with one or more long-term conditions is increasing. The proportion of people living with dementia is predicted to rise. People born with long-term conditions are living longer. The proportion of children with an autism diagnosis is rising.

The current system for care and support is reactive and generally only offers support when people are in crisis. That support is often limited to help with physical tasks, or in the case of some children with autism and people with advanced dementia, containment. It is expensive. Much of it is delivered by for-profit providers with an unsustainable level of debt. Public funding is used to service that debt, with front-line workers paid far too little and forced to work in ways that produce poor outcomes for them and the people they support.

With the right mix of community-based preventative and care services and good housing solutions many people who need some help to live their life (including those with complex needs) can stay connected and contributing to their community and avoid falling into crisis

People with deteriorating conditions can be helped to plan well for the future, with good choice of human-sized and homely options that allow them to stay connected and contributing. People working in care are properly paid and can work in ways that are satisfying for them as well as delivering good outcomes for the people they support.

What reforms to care and support in England should be initiated in the first year of a new government elected in 2024? What further reforms should be initiated or planned over the course of one parliament?

The new government should work with people who draw on services and their families as well as care professionals to identify preventative and care solutions that have a strong value base, work co-productively with the people they support to co-design their own help, demonstrably deliver good outcomes for people and are cost-efficient. The new government should then identify 10 places where one or more of these solutions are already operating and work with them and local communities to design and invest in a comprehensive system of prevention and care that includes a range of the identified solutions as well as others developed with local communities. Evaluation should be embedded in this system and an independent evaluator appointed to report on the impact of this system on outcomes for people and workers, cost, and the local economy. The new government will need to accept the need for double funding while each place moves away from a reactive crisis system to one that is preventative, offering support and care differently and in a way that produces better outcomes. The new government will also need to accept that change will happen slowly, and impact can only properly be judged after 5 years. Learning from these places will be disseminated, and an investment programme developed that will enable all places to move from crisis care to one with a better balance of prevention and local care solutions.

The government should work with the regulator to develop approaches to regulation that are appropriate to very small-scale human-sized support and services.

Specifically, what changes should an incoming government consider with respect to boundaries, interactions, and integration with other parts of government, and with the rest of society.

The best local authorities (e.g., Thurrock) recognise that the wellbeing of people is impacted upon by every function of local authority including air quality, economic regeneration and job creation, community safety, community development and of course housing as well as more formal health and care supports and services.

Supporting a variety of community support and care solutions does not just deliver better outcomes for people drawing on their services but also impacts positively on the local economy. Good quality local jobs are created, and more public money remains locally for longer. Air quality improves as fewer people must travel for work or services.

What do other members of the #socialcarefuture movement think?

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