The third Sector online newsletter has an interesting interview with Julian Le Grand – people may know him as a social policy professor at LSE. But he has also been recruited by the government lead a ‘task force’ to help staff in NHS and social care develop mutuals, small scale social enterprises, along the lines of GP practices, to provide local health and social care services.

You can just imagine Clare in the Community, Harry Venning’s comic strip social worker setting up a social enterprise to run her local child protection or learning disability social work service can’t you? However, the government is keen on this, and Le Grand has had some experience with pilot projects helping social work teams to do it. You can see why they might want to do this; a group that wants to provide a quality social work service can get out from under the more stupid excrescences of local government management. As he says: ‘We developed five pilot projects with the Labour government, which involved social workers spinning out into independent practices, and we discovered that they had more flexibility and were able to make better decisions. It has worked well so far.’

However, they foundsome problems.

Social workers don’t like getting into business planning, he says; that is, working out their decisions according to what people will pay for rather than what they think as professionals should be done, and selling what they think social services agencies should pay for, like quality and well-trained staff. I think this is not where social workers are now, but as soon as you start up the greasy pole in local government or voluntary organisations nowadays, you soon get into business planning anyway. And when as professionals they can see greater influence on the quality of what they do coming through independence, many more imaginative social workers will leap at the chance. You can business plan for quality . GPs have never had trouble persuading the public to pay for a good quality service, and people will value social work more as they see practitioners getting a grasp on a flexible response, instead of a local authority ‘no’.

I recently edited a very interesting article by a private care home operator who was reviewing her experience over 20 years or so. She was very clearly focused on financial and business planning, but had the same sort of professional aims as most social workers would have and had achieved them, even though her approach to what she was doing was very much: what makes business sense. We can all learn from this kind of experience. One of the benefits of this sort of business approach is when a ’small is beautiful’ philosophy is possible, because this leads to good influence for service users and flexibility for staff. To her, and to me, a strong focus on training and staff development is crucial to good quality, and you can provide for this is you plan a business effectively. Thinking about it as a business quality issue is just as valuable as thinking about it as a local authority policy issue and small business operatos are closer to people’s real care needs that a lot of policy-makers, who are only intereeested in political ideas.

The article: Patricia Prior (2011) developing srervices, knowledge and skillls; the 21st century challenge. in Brągiel, J., Dąbrowska-Jabłońska, I. and Payne, M. (eds) Social work in adult services in the European Union. London: College publications: 21-8. http://www.collegepublications.co.uk/other/?00018 or from Amazon.

However, we will lose this benefit if we go into giant businesses like the troubled Southern Cross care home group, where the motivation is financial manipulation rather than concern for the people who need care. So I’m up for the mutual social enterprise model if it stays small-scale.

Another of Le Grand’s problems is that unions and management oppose it. Le Grand says this is because of self-interest (on the part of unions, they lose membership and can’t use collective power so easily) and management (they are into telling people what to do, not commissioning them for flexibility). I think this is wrong. I’m sure some people in trade unions are concerned about maintaining their influence, but the main reason most people are opposed to this move is that they are opposed in principle to the break-down of state responsibility for the people most in need in our societies. A crucial requirement of developing mutual social enterprises as providers of social care is to set up the system so that it is absolutely clear that this is a way of providing a comprehensive public service, responding to democratic decision-making.

As for management, my thirty years or so experience of management is that a lot of it is about being relaxed when people do things in ways different from the way in which you would do it. while trying to help them. Only sometimes do you need to say, that won’t do, and that’s ususally about quality of response most social workers don;t start out from a ‘can’t be bothered’ attitude that you get from servers in low-budget cafes. Social work is a personal thing and needs to respond to the personalities, practitioners and clients, involved in it, otherwise it won’t work.

He also comments on pensions: staff won’t be able to pay for expensive, defined benefit local authority pensions with them. I think you have to accept that a lot of people come into social work because it provides a secure local authority job – society is always going to want social workers and we’ve never produced enough of them, it’s an interesting, stimulating job and it’s reasonably flexible when you have child care responsibilities. As an academic, I’ve seen a lot of people going through social work courses for these reasons, not for reasons of dedication to the public sector or social concern; nothing wrong with that. So you do have to respect people who want to make sure they and their families are properly looked after. But most people in the voluntary sector have not had a defined benefit pension scheme for years. And most people have a collection of pensions from a variety of places. If you have a reasonable start in a defined benefit scheme from your period of local authority work and you pay a sensible sum into a money-payment pension scheme, you’ll still get a reasonable outcome. The crucial thing is paying in a reasonable sum. Le Grand should be making a start on his task force that by ensuring that it is accepted that a good employer contribution is paid into staff pension schemes by mutual social enterprises. Because if not, he’s not going to get very far. And quite right too.

The interview here: http://www.thirdsector.co.uk/news/Article/1075751/Interview-Julian-Le-Grand/

Starting point: older people are the main issue in the NHS reforms

There’s been a flurry of activity on the NHS Reforms, which have been becalmed by a listening exercise after a lot of political and professional protest. Of course, it’s a Health and Social Care Bill that’s been held up, and is apparently going to be reconsidered in House of Commons Committee in (probably) July, but the concern about social care has been sotto voce; the main social care element is to get rid of the GSCC. However, do not be deceived: all this has considerable significance for the political position of social care, and probably also of palliative care.

Let’s start from a social care/palliative care view of the issues. The big client group in both areas is older people; and it’s a growing client group. Not growing quickly, but by 2030 the post-war baby boomers will be well into the age range that uses health and social care in a big way (myself among them if I last that long – I’m planning to be a charmingly dotty old social care client – this is the best personality style to get people to provide services for you). As we saw when looking at the Nuffield study last week, typical usage of social care in the last year of life grows slowly in the latter phase of your old age, and in the last few months you become very expensive because you get lots of in-patient treatments. So it is cheap to provide for most people until they get near the end, although there will be some hips, knees, heart bypasses and boomps-a-daisy (injuries through falls) to be coped with in the meantime, but that can be a bit more planned and strung out. Then if you do the end of life well (look back at my posts on the end-of-life social care framework) you can stop a lot of emergency admissions to hospital care and cut down the costs of healthcare substantially and everyone would still think the care was wonderful.

Unfortunately, although voters would doubtless be very pleased to see improved social care, the political problem there is that people have to contribute to the cost of it and don’t like whittling away their family’s wealth in doing so. They much prefer an NHS model of free care, but are realising that this is not possible. So they don’t like to think about the government spending the money on social care, even though this would be the best option for most people. they want to have as much through the NHS as possible. The political problem has pushed back genuine integration of social care into this legislation because we are waiting for the Dilnot report in the next few months, which is going to have yet another go at suggesting how to get round the social care costs issue. Until that one is sorted out, you cannot have a rational discussion about where we’re going with NHS care, because the only rational way to think about it is in tandem with social care for older people, particularly those who are nearing the end of life.

But even so, the reality is that for the NHS, as well as social care, the big client group of odler people will mainly need community and primary healthcare from their GPs and a modicum of social care for a minority. Also, a lot of mentally ill, learning and physically disabled people have long-term care needs, which are relatively expensive because they’re long-term but are fairly predictable and do not cost a lot per person. These are the groups of people who the NHS should be concentrating on. However because the voters think that what they need to worry about is the hi-tech care they get if they are in a road accident or have a heart attack or some other serious illness when young, and they want to be sure that all the drugs and clever doctor things are available pronto from their local hospital, we are getting all this suspicion about these plans. It is clear that it would be fine it they got them more efficiently from a less local hospital that has properly geared up emergency department to do the skilled job of dealing with these occasional problems, but that feels a bit less certain, and the picture of the local place closing raises insecurity.

It may seem impossibly romantic to hanker after your local NHS hospital, but actually I wonder if people who think this way are reflecting a genuine preference that we should be thinking about. Lord Darzi (remember him? a doctor recruited as a minister to support New Labour’s attempt to promote local care) had an idea of community-based polyclinics for London and beyond which does reflect the need for a well-planned system of local care. My friends in European countries are not so worried about local general hospitals, happily accepting the regional specialist provision, because they have access to nearly everything but the seriously hi-tech quite locally.

Look at the mortality statistics: mostly people don’t die between 1 and 65. And, looking at the budgets, mostly they cost the NHS very little until they are in their upper 70s. So, it is a reasonable aim to save money by putting the clever doctor things a bit further away, getting us fitter and giving us all statins so that we don’t have heart attacks. Unfortunately, the voting public seems to think this is all a trick to take away the comfort blanket of their local NHS hospital. We should go back to Lord Darzi, because local general-purpose treatment and investigation provision would be genuinely welcomed, even though the hi-tech doctors don’t like it – it’s not whizzy enough for them. But my two recent cataract operations did not, I fancy, need to be done within the boundary of a large general hospital. A polyclinic would have been ideal.

So, the main problems that lead Lansley, the Secretary of State for Health, the coalition and people such as Alan Milburn (the former New Labour Health Secretary who emphasised competition when he was in power) to want substantial reforms are to deal with the real issues of:

-         demographic change (a growing population of older people making more extensive demands on the NHS), and

-         medical advance (the demand for ever more costly medical interventions as the doctors get cleverer at managing more serious illness).

There are some doubts about the importance of these. For a start, the big increases in the older population are a decade or more away, although o courfse, we have to work up to them. More important, if community care and end-of-life services for older people were really made to work, the demand on hospitals would be much lessened. And research that allowed doctors to manage older people’s many physical conditions better over the long-term are likely to reduce the cost of long-term conditions to the NHS, because most of it would be done in the community or in care homes. So what the Bill should actually be about is improving social care, including a good dollop of effective advance care planning for the end of life, with a little bit of NHS fiddling around the edges. But the political commitment to the NHS means a focus on convincing people that the nasty Tories not going to take away the beloved local hospital, that most people are probably not going to use much. As well as that, their eneds could probably be met by specilaised regional centres and better local investigation and treatment.

Substantial increases in much cheaper age-proofing of general public and commercial services, so that older people could carry on under their own steam for much longer than they can now would delay and reduce demand for expensive social and health care. Really effective social care provision would also reduce the demand on expensive hospital provision. The reason for the focus on GP control in the NHS reforms was that the GPs are the centre of providing for the massive number of people needing long-term care, most of which can be provided in the community, and a lot more of which could be provided if we stopped sending people to expensive hospitals. Incentivising GPs to provide community health care for older people would hold back the rising costs of NHS hospitals. It was just this that the hospital doctors and nurses feared: their status, and some of the elite status of medicine over the denigrated social care comes from the scientific status of constant medical advance. We should be spending some of this research money finding out how we can improve community provision for long-term care.

So what’s been going on? There have been three events within the last week or so:

- The Prime Minister made a speech confirming the political support for rowing back on the complained-about aspects of the reforms

- The NHS Future Forum reported on the ‘listening’ exercise, in which views on how to adjust the reforms were collected

- The government responded officially to these, accepting the main import of them. Of course, we don’t know the detail of how they’ll change the Bill to take account of them. Also, there have been some more individual reactions from Lansley and from Alan Milburn.

Cameron accepting the main changes

Cameron’s speech confirming the acceptance of the main points of the proposed changes, given on 7^th June 2011, in advance of the Report of the Future Commission being published, is at:

http://www.conservatives.com/News/Speeches/2011/06/David_Cameron_Protecting_the_NHS_for_tomorrow.aspx

His argument is for getting the best possible value for money and big variations in quality across the country. These current problems are forerunners of significant difficulties of over-stretch if we don’t plan for larger demands from older people and medical advance in the future. As people have thought about it, there is a lot of support for these plans, but we need to get them right…’our vision of an NHS that is more productive, more patient-friendly, more professionally-driven and more diverse is clear’.

On competition: I do believe competition is a good thing. But not as an end in itself. It is a means to give doctors more choice to get the best possible care for their patients, and for patients to have that choice too. It is a means of bringing in fresh thinking, new ideas, different ways of doing things that deliver better and better value for money. Put simply: competition is one way we can make things work better for patients.

On the pace of change: We will make sure local commissioning only goes ahead when groups of GPs are good and ready, and we will give them the help they need to get there.

On integrated care: patients…are keen to make sure that whatever happens their care is joined up, that they don’t have to put up with the frustrations they have today – with different appointments in different places, with different people, all to discuss the same thing…professionals who have dedicated their lives to the NHS who are desperate that clinical decision making should replace bureaucratic decision making …but worry that only GPs will have responsibility and that will lead to a fundamental break and juncture between primary and secondary care…

Hospital doctors and nurses will be involved in clinical commissioning. We will also introduce clinical senates where groups of doctors and healthcare professionals come together to take an overview of the integration of care across a wide area. And of course, where effective networks of clinicians already exist, we will support them, not reinvent the wheel…Monitor will now have a new duty to support the integration of services – whether that’s between primary and secondary care, mental and physical care, or health and social care.

On waiting times: Patients tell me just how big an impact the time they wait for their healthcare can have on their well-being, and how they worry that by scrapping the old targets we might lose control of waiting times…The whole reason why transparency and choice are so important is so that patients can hold the health service to account and get the care they demand, where they want, when they want. That’s why we’re releasing a whole raft of information so you can compare and contrast different providers within the NHS – and make your decisions based no real solid evidence. And that includes evidence and information on waiting times. But we’re not going to leave anything to chance, especially as our changes are working their way through the system. So we’re keeping the 18 week limit…And we’re not going to lose control of waiting times in A&E either.

On NHS budgets: There will be no cuts in NHS spending…This year, and the year after, and the year after that, the money going into the NHS will actually increase in real terms with £11.5 billion more in cash for the NHS in 2015 than in 2010.

But…every year without modernisation the costs escalate. Demand pressures increase, driven by an ageing population and drug and alcohol abuse. At the same time, there are supply-side pressures too, driven by new and expensive drugs and technologies. We can’t pretend that the extra money we are putting in will be enough to meet the challenges. We need modernization of the NHS to do that.

The listening exercise

The NHS Future Forum reports and documents are at:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127443

There is also a website that offers some criticisms of the Future Forum proposals:

http://healthandcare.dh.gov.uk/category/conversations/future-forum

The introductory material mentions voluntary organisations and hospices as having a clear role:

To provide this choice for people at the end of life will require an integrated approach in health and social care with greater involvement of the third sector, including the hospice movement. (p 8: Summary; Chair’s letter to the Secretary of State)

There’s also a comment on integration with social care, using the Health and Well-being Boards (p 12):

Local government and NHS staff see huge potential in health and wellbeing boards becoming the generators of health and social care integration and in ensuring the needs of local populations and vulnerable people are met. The legislation should strengthen the role and influence of health and wellbeing boards in this respect, giving them stronger powers to require commissioners of both local NHS and social care services to account if their commissioning plans are not in line with the joint health and wellbeing strategy.

Avoiding boundary disputes is also included (p 12):

Better integration of commissioning across health and social care should be the ambition for all local areas. To support the system to make progress towards this, the boundaries of local commissioning consortia should not normally cross those of local authorities, with any departure needing to be clearly justified. The Government and the NHS Commissioning Board should enable a set of joint commissioning demonstration sites between health, social care and public health and evaluate their effectiveness.

There are five main areas of discussion:

Choice and competition – broadly it promotes the availability of choice, in the context of patients’ and public security that local services are good. Since in an emergency, you have to go to the local provision and most people do not want to travel massively, choice about where to go is not so relevant as being able to influence the quality and style of the provision you experience. For me, it is a relief to see this point made, when the private sector commentators are all keen to get you to go to their local private hospital. Most people are perfectly well aware than in an emergency, the best place is the NHS. Of course the attitude is different for residential social care – people have got used to private sector provdiers there. Rather than the finance watchdog, Monitor, encouraging competition, the Future Forum says it should ensure that people should have the right to challenge commissioners if they are not getting adequate choice about how they are being provided for. Cherry-picking by private providers that would mean that integrated local services are not viable should be unacceptable.

Patient involvement and public accountability – it argues for integration as the main objective, delivered by patients having a strong say in how they are cared for, and stronger public accountability for the quality of provision at local and national level. Doubters think that health and wellbeing boards and local government generally are being cut so much there is little chance of htis happening.

Clinical advice and leadership – it should be wider, thus allowing the hospital doctors and nurses (no mention of social care) to stymie seriously community-oriented priorities.

Education and training – this is included to respond to problems about how the system will integrate with medical education; the comment is really ‘don’t know, we’ll have to work on it’. No attempt of course to connect this with training needs in social care.

The pace of change – set up the NHS Commissioning Board to give clear leadership, but don’t press too hard to get everything done by deadlines.

Government acceptance of the Future Forum recommendations and afterwards…

You can read the positive announcement (and a statement that the Future Forum is going to carry on listening) here:

http://www.conservatives.com/News/News_stories/2011/06/Government_accepts_recommendations_for_NHS_reforms.aspx

As usual, the King’s Fund has a good analysis of the announcements:

http://www.kingsfund.org.uk/current_projects/the_health_and_social_care_bill/nhs_future_forum.html

and Anna Dixon on their blog makes some useful comments:

http://www.kingsfund.org.uk/blog/nhs_privatisation.html

They also have a chunky report on the role of the voluntary sector in the reforms, done with NCVO. I’m going to return to this:

http://www.kingsfund.org.uk/publications/voluntary_sector.html

The Financial Times has a good in-depth briefing (but be careful how many times you click on the FT website; after a while their paywall looms up to hit you).

http://www.ft.com/indepth/nhs-reform

A useful briefing by the NHS Confederation (the health organisations’ organisation) on the government response and what they thought. Generally, they were pleased by the government’s report.

http://www.nhsconfed.org/Documents/110614%20member%20briefing%20govt%20response%20to%20FF%20-%20FINAL%20FOR%20WEBSITE.pdf

A video of Lansley addressing GPs yesterday, carried by the Telegraph from ITN, makes clear that GPs are going to be well on the way to their commissioning role by 2013, even if they’re not quite there yet. Clinical commissioning groups will cover all England by the due date, even if they’re not fully functioning. This was probably inevitable anyway before the pause for listening. So the claimed slowing up of the process until people are good and ready is largely non-existent.

Link to the Lansley video: http://www.telegraph.co.uk/health/healthnews/8576849/Andrew-Lansley-NHS-reform-consultation-not-a-PR-exercise.html

Alan Milburn’s Daily Telegraph article attacking the government’s proposed changes to the reforms is at:

http://www.telegraph.co.uk/news/politics/8578226/This-NHS-debacle-sets-us-back-a-generation.html

Milburn’s analysis is that quietly going ahead on the present track would have delivered many of the improvements, but that Lansley was inept in claiming that there would be a revolution in competition and a ‘free-for-all’ in who was allowed to provide NHS care, encouraging private providers. If we accept this judgment, it is easy to guess that Lansley might have done this to promote his position politically in the right-wing of the Conservative Party. More important, probably he actually believes that this would be a better way of running the NHS; lots of people do.

For people who are doubtful about how the private sector is going to react to the possible loss of opportunities for profit, I also like this Spinwatch diagram, which shows how people with political influence and private sector organisations favouring private sector involvement in the NHS are connected:

http://www.powerbase.info/index.php/File:Private_Healthcare_Network_SpinWatch.jpg

Conclusion

Actually, I don’t think the private sector has much to worry about. I don’t think competition red in tooth and claw was ever going to operate, and I think Lansley was ramping this up for political reasons, and has come a cropper as a result. There will continue to be steady increases in competition where it makes sense and in some places where it doesn’t. It is clear that the proposed changes are going to make the commissioning groups more difficult to manage, but it is clear that the process of reorganising is going ahead apace. I recently gave a talk to some pct managers, some of whom could remember their new job title, some of whom had been made redundant and some of whom had new jobs but didn’t know what they were going to be doing. Already, we’re beyond the point where the present system can carry on, so the question really is: how can we make the new system work well?

This is my third discussion of current policy fads and fashions and their consequences for health and social care, and in particular end-of-life care: this time the focus is on Bog Society policy. In it, I argue that Big Society policy is underdeveloped, but reveals important features of Conservative thinking about society, in particular the wish to move away from public service approaches to service provision towards service provision that reflects the asumed ‘enterprise’ of the private sector.

Like most people, I’ve spent a bit of time struggling with BigSoc (this is what I call it), and you can see my struggle represented in my BigSoc blog (http://bigsoccommsw.blogspot.com/). I keep this separate from my St Christopher’s blog, partly because it deals more directly with party political issues (which is a no-no for St C’s). Also, it includes a lot of detail unrelated to end-of-life care and blogs need to stay with one main subject, so that people know what they’re getting. Hence the separation. However, struggling with BigSoc elsewhere does mean that I have a stash of material to ground my thinking in relation to palliative care. That’s what I’m doing in this post.

The contradictions in BigSoc policy

Why is BigSoc a struggle? For two main reasons. One is because its political focus and objectives are claimed to be unclear, by political commentators in the press. My stance in my BigSoc blog is ‘details tell all’: that is, if you dig around in what people actually say and do in some detail, you can get a picture of the whole, because what they are doing in practice informs you about the big ideas behind it. The picture reflects Conservative ways of thinking: they want a more private sector ethos in public services.

The other reason is that the BigSoc idea seems attractive to those of us who have always been committed to community work. Community work is the practice (sometimes it’s  an element of social work and sometimes broader) which seeks to facilitate people from communities, both local communities and communities of people who share interests, to come together, work collectively on issues that they share and create solutions that they put into action themselves. BigSoc seems to want to encourage this; groups of local people are encouraged to find their own solutions.However, the engagement with people at the grass-roots that is typical of community workdoes not usually produce the kinds of initiatives and engagements that can be presented as colourful, imaginative developments demonstrating an important political idea likfe BigSoc. Consequently, activities selected to represent BigSoc, in order to promote the policy, are often quite untypical of what is actually done in community work and of what local government will achieve by decentralising and localising decision-making.

Therefore, contradictions seem to grow out of how the ConDem coalition has tried to implement BigSoc. I have pointed out before in this blog and elsewhere that the history of attempts to encourage community endeavour through government action is littered with government finding out that community action often leads very rapidly to protest about what government is doing, and rapid squashing of what communities want. It often also leads to communities creating responses that government does not expect. Governments (or the politicians in them) tend to think that their political views are widely shared, whereas they are often only shared by the people those politicians meet. The people who come together to share views and work on things together often find that their views and what they want to do about them differ from the political assumptions. Their public response is often protest or resistance, rather than imaginative development, or development of local services which do not offer a lot of zip-zap for someone who wants to promote a new BigSoc policy.

The main aims of BigSoc policy

BigSoc seems to have two main drivers. One is a conception that government is too big. There are at least two elements to this: one is that it is too large as part of the UK economic system, and that if you reduced its economic role, it would leave space for non-government sectors of the economy to be creative, expand and get us out of economic problems. The second element is that government looms too large in people’s minds as the solution to social problems and that if you reduced its role in providing services and responding to social issues, people would sort out answers on their own. These are broad objectives for cultural change, based in broad political philosophies. Can encouraging local engagement in quite prosaic local government decisions or developing responses to small-scale local issues achieve such change?

The first concern driving the policy is that government is too big in the economy, leads to an economic policy which reduces government expenditure and tax, and associated political policies such as the ‘bonfire of the quangos’ and the ‘bonfire of red tape’, with the aim of reducing the burden that government places on the economic capacity of other sectors of the economy to innovate and expand.

The second driver, people should be enabled to become more active in resolving social issues, rather than relying on government, leads to attempts to reduce the role that government takes in providing many services and encouraging citizen activism.

Both these diagnoses and prescriptions might be questioned in serious economics and sociology, but I leave that aside. Also, critics from the left would say that these are just new formulations of a conventional liberal position, which argues on economic grounds for a small state. I’m leaving that on one side, too. The ConDem government has given these ideas importance in BigSoc, and so that is what we are playing with. In ConDem policy they are connected because reducing government expenditure and activity inevitably means present services or activities disappearing altogether, or being replaced by something less extensive. Making space for non-government enterprise at the level of the whole economy can also mean making space for individual activism in responding to social issues.

In a speech reported by the BBC, David Cameron, the UK Prime Minister, connects these two things: ‘My mission is social recovery as well as economic recovery’.

The BBC report, including a clip of Cameron speaking: http://www.bbc.co.uk/news/uk-politics-12443396

Another good political report from the BBC looks more comprehensively at the concept: http://www.bbc.co.uk/news/uk-politics-12163624 , and includes a lot of comments from viewers and listeners.

Existing activism and BigSoc?

As this report makes clear, virtually anything that has to do with activism, such as volunteering or people demonstrating commitment to and involvement in their locality or some other social interest, may be seen as BigSoc. Since in the UK a lot of such activism goes on, the government might be able to claim wide support for its concept and the press might be able to identify lots of BigSoc activity. In one of my BigSoc blog posts, I looked at the claimed evidence for ‘broken Britain’ and the need for greater volunteering, and came to the conclusion that the government was overstating its case: a lot of community involvement and volunteering goes on, more than the government claims. This post is at: http://bigsoccommsw.blogspot.com/2011/03/good-evidence-exists-for-strong.html

Similarly, an earlier post looking at stated Conservative Party policy on BigSoc found that this rather naively seemed to be unaware of a lot that goes on in local community activity:

http://bigsoccommsw.blogspot.com/2011/03/bigsoc-minnie-mouse-policy-minimal-and.html.

The problem with this approach to BigSoc is twofold. First, it demonstrates a general ignorance and naivety or, alternatively, complete denial about what valuable things are going on in local communities and suggests that the policy is based on ignorance and denial. Second, it will allow Conservatives to claim all sorts of activities as the product of its policy initiative, when they were there anyway.

Palliative care organisations such as hospices fall into this category: they are there, they are successful, they substantially fund themselves. They are therefore a good example of what BigSoc policy might achieve. However, as I argue below, hospices are rather unusual voluntary organisations, and their size and funding cannot transfer all that easily to other comunity activties. So people in hospices should not be too forward in claiming either that what they do can be replicated elsewhere, or that they are some wonderful example to others: that is calculated to irritate lots of local government and the voluntary sector, who do not have the same advantages.

Claims that BigSoc is everywhere are already happening. In another BigSoc blog post, I examined all the projects that had received a BigSoc award from the Cabinet Office, at the time twelve, although the details of one of these was missing from the Cabinet Office website http://bigsoccommsw.blogspot.com/2011/03/details-tell-all-analysis-of-number-10.html. There were, of course, a variety. But an interesting feature was that many of them were for really rather ordinary community activities, carried out with pizzazz. In my later post, I listed the top ten words for putting into your applications for a BigSoc award, things like inspiration, passion, life-changing: the whole list here: http://bigsoccommsw.blogspot.com/2011/03/top-10-words-for-getting-number-10.html.

BigSoc as chutzpah

In many respects then, the government is treating BigSoc as a marketing tool for things that it wants to encourage. You’ll have gathered from many comments in this blog that I’m unhappy about marketing as an approach to health and social care. In another BigSoc blog post (http://bigsoccommsw.blogspot.com/2011/02/bigsoc-is-not-pr-message-it-demands.html), I pointed to a PR wonk’s take on BigSoc; she was saying that people in government were treating it as a way of conveying a warm friendly image, in the face of criticism about cuts.

I connect this with Steve Burghardt’s recently published book on macro social work (Macro Practice in Social Wokr for the 21st Century Los Angeles, Sage, 2011), in which he describes community work as being ‘chutzpah meets humility’. The point is: if you are going to facilitate people to come together and make their own decisions, you have to take a step back out of the limelight and help them to work things through in their own way. One the other hand, you also have to have a certain amount of zip-a-dee-doo-dah to promote new ideas, get people engaged and push things along. It’s a difficult balance to achieve, and one of the skills of community work is achieving this.

I think the Conservatives understand the chutzpah bit, but not the humility. You can see this in the kinds of things that they support as BigSoc.

BigSoc is (in the Conservative mind)…

So what is BigSoc as the government sees it? Cameron has made a number of attempts to describe this.

The first general presentation of the ideas is the Hugo Young lecture in 2009: http://www.conservatives.com/News/Speeches/2009/11/David_Cameron_The_Big_Society.aspx

The conclusion of my analysis on this in the BigSoc blog (http://bit.ly/i3pD3L) is as follows.

To sum up the argument, Cameron is arguing that the size of the state leeches away personal and shared social responsibility. BigSoc policy aims to provide government to action to reverse that. Subsidiarity is the thing, giving responsibility to the lowest possible level in society. They will try to give individuals the responsibility and capacity for helping themselves, through family, education and welfare reforms. Where that is inappropriate, they will encourage shared action in neighbourhoods, and when that is not possible they will make the lowest level of government, local government responsible, and make it more transparent, accessible and responsive to active citizens.

In an article in the Observer, after some criticism of BigSoc, he says:

The big society is about changing the way our country is run. No more of a government treating everyone like children who are incapable of taking their own decisions. Instead, let’s treat adults like adults and give them more responsibility over their lives. That’s why, in reality, this is quite different from what politicians have offered in the past.

This is not another government initiative – it’s about giving you the initiative to take control of your life and work with those around you to improve things. It has the power to transform our country. That’s why the big society is here to stay.

The article here: http://www.guardian.co.uk/commentisfree/2011/feb/12/david-cameron-big-society-good

An article in the Observer recently claimed that some of Cameron’s ideas are from Schumacher’s famous book of the 1970s, ‘Small is Beautiful’. Quoting extensively from the book, I argued in the BigSoc blog http://bit.ly/dN1rvU , that, if so, it is a complete misunderstanding of Schumacher’s point. He is arguing that a policy of pursuing economic growth to achieve larger economies, with larger economic units consuming larger finite natural resources, is unsustainable. The outcomes of this growth model are the increasing use of finite natural resources to achieve merely transitory consumption. Present Conservative policies clearly aim at this kind of economic growth, which Schumacher criticises. Conservative BigSoc policy is completely antithetical to Schumacher’s position. It seeks to reduce constraints on big business in order to achieve higher economic growth. It sees the main constraint as big government, and so it wants to remove big government in favour of localism, because it thinks this will release economic growth. Schumacher does not talk about localism so much as the small and the human.

The BigSoc critics

In his Observer article, Cameron notes, fairly accurately, the criticism of the concept, and these are his answers:

It’s too vague: he rejects this because he is against creating one central design

It’s a cover for cuts: he says supporting social responsibility is a different matter and he has supported that for a long time; anyway, greater social responsibility will benefit society.

It will work in rich areas, but not where there are no resources: he rejects this because there is evidence of activism in poor communities.

It’s not new: yes, but he wants to encourage more of it.

Voluntary bodies are being squeezed: no, they will be restructured because the Conservatives will open up opportunities for voluntary bodies to bid for contracts for public sector activities. (To the extent, I would say, that they demonstrate emterprise thinking and chutzpah.)

Polly Toynbee and a range of commentators on her article cover most of the issues about cuts to voluntary groups. She distinguishes between small very local social groups and the organisations providing services, often under contract from the government already, although it may limit their preparedness to criticise government.  The fact that small groups fund themselves is irrelevant to support for that part of the voluntary sector that provide useful serviecs. She also criticises the concept of the BigSoc bank, providing development loans at commercial rates to help voluntary organisations compete for government contracts as part of her argument that government support is central to succesfsul voluntary endeavour.

http://www.guardian.co.uk/commentisfree/2011/feb/14/david-cameron-big-society-charities?intcmp=239

Similarly, a Jackie Ashley article sums up well the critics who say you cannot achieve BigSoc if you simultaneously cut funding to charities and voluntary organisations, because they are the major existing aspect of BigSoc. If you cut local government, those cuts will have a disproportionate effect on voluntary organisations, since local government will priorities its own staff and services.

http://www.guardian.co.uk/commentisfree/2011/feb/13/big-society-destruction-david-cameron?intcmp=239

BigSoc in practice

So what does BigSoc seem to involve in practice? To work that out I looked at a number of policies and practices, and you can follow the detail in the following  BigSoc blog posts.

What’s happening in the three continuing BigSoc ‘vanguard’ local authorities (one, Liverpool, gave up in a shower of sparks because local government cuts was preventing it from developing BigSoc policies and had reducing funding for voluntary sector BigSoc activities):

Sutton, in south London: http://bigsoccommsw.blogspot.com/2011/02/suttons-bigsoc-vanguard-tells-us-what.html

Windsor and Maidenhead, to the west of London: http://bigsoccommsw.blogspot.com/2011/02/details-tell-all-windsor-maidenhead.html

Eden, in the Lake District: http://bigsoccommsw.blogspot.com/2011/02/details-tell-all-windsor-maidenhead.html

Overall, what is going on in local government is not very impressive and not very imaginative – no chutzpah there. First, most of what they were doing they were doing anyway, they were just relabelling it BigSoc. sometimes openly. Second, many of the initiatives were about local involvement in planning; nice, but probably they should have been doing that anyway. The problem with participation in decision-making is that it is not very attractive to local politicians, because they feel they have been elected to make decisions and achieve their political objectives, not have them questioned by every Tom, Dick and Harry that turns up to public meetings.  Third, there were meetings with local citizens or with voluntary organisations to discuss what BigSoc might mean. These seemed to be part of getting more volunteers for things, especially if it meant reduced local council costs.

Another important aspect of BigSoc policy is what I call ‘enterprise’ thinking, and I have sometimes called it ‘businessification’, following John Harris’s critique of treating social work as though it was a business activity.  In many Conservative eyes, an important objective of BigSoc is that it is a local arm of the government’s aim to encourage the private sector to be engaged in what is now public sector activity; this is inherent in many of the government’s policies. Part of the reasoning for this is an opposition to bureaucratisation, by which Conservatives often mean unimaginative thinking which opposes change of the kind that Conservative politians would like to achieve. The answer to this is being enterprising, imaginative, creative and all these traits are assumed to be associated with the private sector, rather than the public sector. To the extent that voluntary organisations emulate that, they are good and not part of the public sector. To the extent that they just take government money for providing government services, they are bad, and just another aspect of the public sector.

It’s back to chutzpah again.  Conservatives like to see community activity that demonstrates chutzpah; humility and participation are not enterprising; they do not understand why you would need it. So only particular kinds of community activity are required, therefore, and activities such as continuing to build and provide end-of-life care through professional integrated community services (to give one example) do not have it.

Much of the rest of my blog has been about the debate on voluntary organisations. Here, the pattern is quite clear. Conservative commentary is anti the ‘establishment’ of the voluntary sector, which receives government money for providing services (http://bigsoccommsw.blogspot.com/2011/03/tories-reject-establishment-charities.html) they are really hoping for radical, enterprise oriented voluntary organisations with right-leaning policies enabling disabled people and single mothers into employment, for example. And chutzpah. A ‘society of the second chance’ is an Iain Duncan Smith phrase which seems to mean forcing people to take whatever second chances they can get, instead of staying comfortably on social security benefits.

BigSoc and palliative care

What does all this mean for palliative care? It’s a complicated picture. Most palliative care is in hospices in the UK, whereas a lot of non-specialist end-of-life care is with GPs and general health and social care services and BigSoc policy is different in these two areas.

Hospices are talked up by the Conservatives, including Cameron. I have commented before in this blog that this seems to be for two reasons. First, hospices raise a high proportion of their own funding, so they are not ‘establishment’ charities, in the sense that the government supports all their activities. However, they are not enterprising; they do not have chutzpah. The need for chutzpah if you want to appeal to the government is the reason for the success of organisations such as Marie Curie and Macmillan: they employ high-profile senior staff who trumpet successes in a glossy, businesslike way with lots of advertising and image. Solid service provision from your local hospice is a lesser priority.

Second, there is a sentimentality about end-of-life care, which politicians pick up from general public attitudes. Most people have little to do with the end of life, don’t like to think about it and support organisations that make them feel that it’s all going to be handled very nicely and kept out of their way.

On these two counts, BigSoc will have little impact on hospices, for so long as they are able to continue raising their own funding and put up some people with chutzpah. This means that the government does not actually have to make clear decisions about the extent to which they support end-of-life care as against other priorities, and it all sounds jolly good. I suspect that if they did have to think about it, they might not be so supportive, and might in particular want to see a reduction in the high costs of quality palliative care. The distance means that everyone can feel a warm glow of doing something nice with a little bit of funding and expressing support.

End-of-life care is not much involved in local authority and voluntary sector funding cuts, so it neither irritates government supporters by whingeing about cuts nor engages with the problems of local health and social care organisations. That will last until local service changes begin to affect hospices’ capacity to achieve home care.

Another factor is that most hospices, although theoretically voluntary organisations, and locally committed, are really part of the health service, and BigSoc does not talk a lot about the NHS. Health promotion and well-being are good things, but actual services are part of the public sector bureaucracy. Hospices do not generally have a lot to do with the local voluntary sector establishment, or with local government, and are much more affected by NHS policy. The more generous funding of the health sector tends to insulate them from the debates about BigSoc, at the same time as being a potentially desirable element of BigSoc.

So BigSoc is not a big deal for palliative care yet, but BigSoc policy is going to permeate lots of thinking about public services. This will have a particular impact on palliative care as the health and social care reforms that I discussed on Tuesday begin to affect palliative care. My next post will try to bring together health and social care reform, BigSoc thinking and end-of-life care.

Links to some recent cartoons on the cuts, the anti-cuts march and the big society. These links are as of today: some of the newspapers have a time-limited gallery of their cartoons, so if you click after today, you may have to move along the gallery to find the right one:

A Martin Rowson epic, along the lines of the old Giles cartoons, in which hooligan coalition Cabinet members and a fat cat wreck a main street of public sector services.

http://www.guardian.co.uk/commentisfree/cartoon/2011/mar/28/cartoon-steve-bell-tuc-rally

A small cartoon by Tim Sanders in the Independent has two anarchists speculating how they would have done in Fortnum and Masons if they’d had air cover:

http://www.independent.co.uk/opinion/by-tim-sanders-771959.html

The Independent has had a series on the cuts by Dave Brown: this one has Osbourne looking out of the window at anti-cuts marchers and pointing out that the Big Society does exist: while Cameron opens his Fortnum and Mason hamper-style lunch box to find his (red) lobster flourishing a no-cuts sign:

http://www.independent.co.uk/opinion/the-daily-cartoon-760940.html?ino=2

Two days previously, Dave Brown has fireman Osbourne dowsing a public sector on fire with the hose from a petrol pump:

http://www.independent.co.uk/opinion/the-daily-cartoon-760940.html?ino=4

A rather nice Alex Hughes cartoon, in which David Cameron rewrites the public sector as the big society.

http://alexhughescartoons.co.uk/2010/07/big-society

Another Alex Hughes, which social workers might like, of George Osbourne as the child catcher in Chitty Chitty Bang Bang, recast as a child cutter with an axe dripping with the blood of children’s benefits.

http://alexhughescartoons.co.uk/2010/10/the-child-cutter/

There are several small Matt cartoons on various financial matters from the Telegraph: my favourites:

Here a pensioner has renamed his retirement home ‘Dun Eating’.

http://www.telegraph.co.uk/finance/personalfinance/8411166/Matts-money-cartoons-since-David-Cameron-came-to-power.html?image=1

Here, a tanned charitable child in Africa has sponsored the child of a higher rate tax payer in the UK:

http://www.telegraph.co.uk/finance/personalfinance/8411166/Matts-money-cartoons-since-David-Cameron-came-to-power.html?image=9

On the same theme, a Kerber and Black cartoon from the Mirror (for 14th March, scroll along) has two red-nosed African kids collecting to buy the people of Britain some petrol:

http://www.mirror.co.uk/opinion/cartoons

And here, a man suffering the ‘morning after’ receives a warning via his mirror:

http://www.telegraph.co.uk/finance/personalfinance/8411166/Matts-money-cartoons-since-David-Cameron-came-to-power.html?image=8

My favourite Big Society cartoon (from the Independent): the good Samaritan tells the unfortunate victim of the robbery that he should organise his own rescue:

http://www.independent.co.uk/opinion/by-tim-sanders-771959.html?ino=14

…and on the same theme, Kipper Williams in the Guardian shows that in the new Thatcher- and Heseltine-like Enterprise Zones you have to fill your own potholes:

http://www.guardian.co.uk/business/cartoon/2011/mar/23/kipper-williams-budget

…and one on the NHS: Cameron misses out the top-down reform, and just gets rid of the NHS:

http://www.independent.co.uk/opinion/by-tim-sanders-771959.html?ino=19

I think we should replace the rhetoric about ‘cuts’, from the government as well as from its critics, with something more sensible. In this first post of a series on the Big Society and health and social care reforms and budgets, I argue that we must change the culture of our society away from the love of money (by big government, big finance and big anti-cuts campaigns) and towards the love of providing quality services.

After the weekend of the large TUC-organised anti-cuts march in London, I suppose I should say that I am not an enthusiast for the ‘cuts’ rhetoric. This starts up in the press, among right-wing enthusiasts for the small state and among people with genuine concerns about public provision whenever an international financial crisis leads to our government retrenching on its financing of public services. I sympathise, but I think we have to look at the bigger picture.

The bigger picture is, first, to understand the role of the economy in balancing the public and private sectors in health and social care provision. Second, the bigger picture involves understanding and achieving the complex balance of professional standards, regulation and economic drivers that maintain good quality care. I’ve said before in the blog that, for me, if I’m up against it, no organised care can ever possibly replace my lovely wife’s care, and this will not be available 24 hours for weeks or years ahead, no matter how hard she tries. So the reality is that all care is not the best we would want. The problem is to make sure that it’s good enough.

Economic drivers: the positives

Look, for example, at Southern Cross, the private sector nursing and care home organisation that has been in trouble for some months. It’s in the news again today, with the chief executive having achieved the honour or ignominy of being interviewed about his troubles on the Today programme, although he was treated very kindly.

What’s the problem here? There are two points, according to the Financial Times. One is that during the good times, they have agreed high rents with their landlords, which they now can’t afford, and are having to renegotiate them. The CEO was sanguine about this on the radio: it’s in the landlords’ interest that Southern Cross doesn’t go bust, so they’ll have to do a deal. His relaxed style on this was probably a bit of show for his worried investors, but nonetheless what you are seeing here is the impact of economic drivers on a private sector company. They did not drive hard bargains in the good times, but they’re now being forced to do so. The FT suggests that good quality providers might replace Southern Cross in some of these homes, if they can make the maths work, so in some cases quality for the residents might actually improve.

You can see a fairly comprehensive diagnosis in the FT: http://www.ft.com/cms/s/0/d550d81c-4e82-11e0-98eb-00144feab49a.html#axzz1HBYad3p9

The second problem is that one of the reasons why the high rents don’t stack up is that local authorities and health trusts have been cutting back on their placements and cutting back on the charges they are prepared to pay. There are also some good points about this. First, it’s the economic drivers again. The public sector commissioners of care did not drive hard enough bargains in the good times, now they’re doing so. Both they and Southern Cross are being forced into doing the job for the minimum possible expenditure.

Second, one of the things the health and social care commissioners are probably doing is providing alternative packages in people’s own homes, rather than shoving people who don’t need it into care homes. Everyone, including the people being cared for, would agree that this is a good outcome. However, there’s a ‘but’ there, which I’m coming to.

Economic drivers: the negatives

There are also some negatives that we should factor in. Ask the question why Southern Cross is in this mess. Some of its troubles have to do with the fact that for several decades running care homes has primarily been a property-oriented business. A lot of money has been made from the properties, rather than giving priority to care. Because of this, it has now hit the buffers as the property bubble has collapsed. If everyone involved (including the landlords) were less concerned with extracting money from the property and more on giving an absolutely first class care service, you can’t help feeling they would not have lumbered themselves with inappropriate property costs, and instead would be focused on how they can provide the best care.

I think of the Railtrack debacle, when the privatised providers of railway track came a cropper because they spent their time extracting money from the property rather than focusing on running a safe railway. Or the numerous high street shops that have gone west because their private equity fund owners were extracting so much money from buying and selling companies and properties that they took on big loans and property costs that, with a retail downturn, they cannot afford. Perfectly good chains of shops have disappeared because of this.

And the lesson from this is not, as our anarchist rioters would have us believe, the evil of capitalism, or at least not directly. The problem is that the people who are doing capitalism these days think it’s only about making money for themselves, instead of the boring old job of running a good service. They get the money to run good shops and care homes, not to line their pockets. I feel I have to mention in passing bankers’ bonuses: there’s another lot of people who think it’s about making money for themselves instead of making the economy run properly by doing their job.

People I know who run businesses, but do not get big bonuses, work very hard to provide a good service. It’s these businesses that people go back to and will survive and build from the recession. But once they are big enough to get into the hands of the money men, their job becomes making money instead of providing a good service. Wrong priorities immediately result. One of my friends who was running an expanding business decided to reduce his expansion so that he didn’t need to get any loans from the banks, because the bank started getting too interested in telling him what he should be doing instead of leaving it to him. Sitting back with no bank loan, he’s living well enough, and nobody interferes with him.

What this tells me is that an overweaning interest in making money is actually a negative in providing all kinds of services, and also I suspect in manufacturing as well.

It’s a bit like Colonel Gadafy, also in the news this week. I can’t help thinking that if he decided to do a really good job of running Libya over the last 40 years, instead of lining his pockets and the pockets of his relatives, he would be generally regarded as an all round good egg and nobody would be wanting to rebel or bomb him.

As the Bible (or at least 1 Timothy 6:10) says: the love of money is the root of all evil. So it is in health and social care. It’s not the economic drivers, but the love of the money that economic drivers bring, that is the problem.

The other negative we should think about is that the downside of pressure from economic drivers, even if they have positive effects, is sometimes to drive down quality. Of course, Southern Cross will have to drive down the rent it pays, but it may also be forced to drive down the quality or amount of care it provides. The people on the streets this weekend, who are concerned about the use of economic drivers in public care, are the most concerned about that and rightly so.

Why economic drivers drive down quality in health and social care

Of course, it does not have to be. You only have to look at John Lewis to realise that people will pay more and flock to an organisation that focuses on providing a reasonable service rather than just the minimum. The problem is that care service users often do not have enough money to go to the John Lewis of care provision. Instead they have to use Poundland health and social care. I go to Poundland a lot, for a look round. It’s efficient at what it does, but a lot of the goods it provides (once you go beyond the small packets of big name goods at the front) are tat; they look glittery and something like what John Lewis offers, but in their manufacture and ingredients, they are cheaper and nastier. I do not want Poundland health and social care. Neither do I want Curry’s health and social care; their products are as good as in John Lewis, but the staff are so ignorant or unpleasant that you positively want to avoid the place.

Quality of care, then, is about the product – in care, the environment and the care processes –  but it’s also about the attitude of the people providing the product. These two aspects interact, in a complex way. Economic drivers do not deal with that complexity: you need other factors.

One problem with economic drivers in the complexity of care is that the people who pay, local health and social care commissioners, are not the people receiving the service, so they have no economic interest in good quality service. That comes from the professional standards of the people providing the service, but the split between commissioner and service provider in health and social care also splits the people who pay from the people who provide the quality. Previous governments have so twisted the organisation of health and social care that ‘effective commissioning’ and similar clap-trap, has become the marker of professional standards in health and social care management rather than the best service. The end product of ‘effective commissioning’ is Poundland health and social care, good if you’re lucky but tat that only looks like good care if you’re not.

The problem of workers’ interests

The second reason for the difficulty over economic drivers in health and social care is that people worry that the definition of quality is too bound up with the personal interests of the professionals. I’m in favour of discretion in applying professional standards for deciding what good care provision ought to be like, because in the end having high professional standards is the only way of ensuring good services in every detail. That has to be alongside genuine rights to decision-making by service users, so that services can be clear what they want and are driven by their choices. However, back to the anti-cuts march this weekend, it is hard to avoid the accusation that trade unions are using the ‘good standards of care’ banner mainly to support good pickings for health and social care staff. I’m one myself, and I think it’s right for us to be paid a fair salary and to have good conditions of work. This ultimately benefits the people we serve, and I’m happy for trade unions to work for improvements.

The problem is that nobody, but nobody (and including me), will believe that focusing on the wish to employ more public sector staff, pay them better and give them good conditions of employment will necessarily lead to improved quality of provision. Lots of very good people aim to provide the best services for service users work in health and social care. In the long run, history shows that if you run down pay and conditions in the public sector as compared with the private sector demoralisation results. People who can will make their exit, while people who can go elsewhere before getting involved in health and socila care never work for the public sector in the first place. But as we’ve seen, there are economic drivers, and they do prodce some benefits. The problem is to mitigate the downside of using economic drivers and boost the upsides.

What does make a difference

Several friends where I live have elderly parents in a local care home – we’re all that age. They were all worried a little while ago when a new manager was appointed and the standards slipped – they all became quite anxious about the safety and quality of life of their parents. The economic drivers didn’t change, the overall management didn’t change. What changed was the skill and professional ability of the manager.  Being middle class, they applied pressure. The regulator seemed suddenly interested. The external management took action, the manager was replaced, standards shot up again. Economic drivers didn’t change, the overall management didn’t change. Checks and balances led to improvements.

You could say this was an example of the Big Society in action. At least, it’s an example of the John Lewis contingent in action. But in Poundland health and social care, services can’t afford enough good people to maintain quality; you get what there is, mostly it’s okish cheap and cheerful, sometimes it’s less good, now and then you’re lucky and it’s great. Economic drivers don’t work because the people who are affected (isolated older people or inexperienced or inarticulate relatives) are not well involved in making caring choices and so don’t have the power of their active engagement in the services.

Would personal budgets make a difference? They are not a good economic driver, because they are about minimalist provision. The aim of introducing personal budgets is to provide the basic; you add to it, if you want a reasonable standard. You cannot use a personal budget to get improvements from an unsatisfactory care home unless you can assess quality of life, negotiate for improvements, and have the self-confidence and choices to move your budget elsewhere. There is just not that much choice in care homes at the lower end of the market, so unless you are rich enough and middle-class enough to add to the basic amount and get extras or you have good negotiating skills, you cannot get improvement or change.

We need to change the culture of our care systems. The only thing that provides good quality care is good quality people trying to achieve the best possible professional standard, well-regulated and, yes, encouraged to be as economical as possible by the economic drivers, because in the end that means more service for more people. And with social workers advocating on behalf of the people who cannot get what they need. Getting the balance between all these factors right is complex, but it’s twisted by an emphasis on economic drivers, because that encourages people to focus on loving money rather than quality. And that’s why cuts rhetoric is also wrong. It also focuses on financial rewards instead of quality of service.

Love quality not money. That will be the basis for my prescription for good palliative health and social care during this week’s series of posts.

Today: replacing the cuts rhetoric. This week I am going to post every day about some aspect of the Big Society policy, NHS reform and palliative care. The topics to be covered are too vast and complex to be dealt with in one post; but I will put them all together at the end on my Scribd website, where you can see past documents from this website and past publications, together with information about me.

Malcolm Payne’s Scribd website: http://www.scribd.com/m_payne5153

If you’re not used to Scribd, when the page comes up, click on ‘Shelf’ then on ‘+ See All’ for a complete listing of the papers and publications available.

Regular readers of this blog will know I’m a keen supporter of advance care planning, a voluntary discussion between people approaching the end of life with their carers, doctors, nurses care homes and relevant others about how they would like to be cared for at the end of life. It makes clear how you want the services to handle the time when you might get inappropriately blue-lighted into the local accident and emergency unit. By saying what you want, you have a better chance of achieving it, particularly if you involve your relatives and informal carers in the planning, because people will be less frightened of being blamed for doing something wrong.

I go further than this. I support the Scottish system of anticipatory care planning which extends this planning process back to when someone first enters the care system, and updates it all the way along. There are less surprises for everyone as you go along, and social care and health services can also plan more in advance and don’t feel the duty to do the max when you want something else, because they’re clear what you want, even if they come upon you in an emergency.

This is an international debate of course, and some interesting debates have recently been going on in the US; you can see something of what happened by looking at this account in  the New York Times:

http://www.nytimes.com/2011/01/05/health/policy/05health.html?_r=1

What seems to have happened is that, following the trend to promote advance care planning, the Obama administration included it in the options open to Medicare patients, the older people who currently get some help from the US state with their healthcare. Then there were objections from some Neanderthals about ‘death panels’, so lacking the courage of good sense and thoughtful care, the administration withdrew the proposal, to the fury of people involved in palliative and hospice care.

Why am I bothering to tell you about this? Because this is the sort of thing that is going to happen in the Lansley-proposed NHS. The elements of care that provide good quality, such as voluntary end-of-life care planning, are going to disappear under efficiency-driven financing. Of course, as the American example shows, it’s perfectly possible for doctors to have voluntary discussions of this kind with their patients, and for social care staff to have such discussions throughout care. But if the commissioner of the service wants a tight definition of what is to be provided and is not prepared to pay, there will be pressure on the quality elements of palliative care, particularly if they’re a bit controversial, or there is no wide agreement that they should be pursued. This example shows how that happens in a competitive, funding-strapped system.

The Department of Health has a website on the Health and Social Care Bill:

http://healthandcare.dh.gov.uk/

And it contains currently some statements from interested organisations about the proposed reforms, mostly brief excerpts from longer statements and links to them. Nothing reallly on palliative care, but there’s an Age UK comment.

And now, the Health and Social Care Bill and end-of-life and palliative care.

First, there is no specific coverage of end-of-life or palliative care, so we have to surmise what the issues might be for us.

Second, there is a focus on greater integration between health and social care systems, and this is given particular force by the role of local authorities in keeping an eye on healthcare services in their area and supporting advocacy and policy advice for healthcare providers and commissioners. There are no more guarantees of reducing health-think blindness than in the present system, and the strong role of GPs in the new system, many of whom are ignorant and want to remain ignorant and moralistic about social issues does not give much hope either. However, not all GPs are totally hidebound, and some are positively thoughtful, so this coordinated commentary and advisory local authority role offers some hope in more imaginative local authorities (as opposed to the Neanderthal ‘we do care management assessments – duh’ places; local authorities can be as, if not more, hidebound than GPs) that social care services and social thinking might have a greater impact on the inward-looking tendency in health services. Also the removal of the PCTs and even more the arrogant SHAs (‘oh, we’re so much more important than you pygmies’) has some hope of removing some of the more blighted buro-think in the NHS; most of them are in PCTs. The impact assessments say that perhaps 40% of PCT and SHA staff will transfer to consortia: let’s hope it’s the imaginatve ones.

The combined impact assessments here: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123635.pdf

Therefore, we might hope for better influence in social care on end-of-life issues and better understanding of social care from GPs. And social work thinking might infiltrate at least some of the commissioning consortia.

Third, since a lot of palliative care in the UK is in the voluntary sector, existing non-NHS palliative care providers will have a clearer role of being licensed providers and will be able to compete. They are likely to be more experienced in getting in on the act than nursing and social care staff setting up social enterprises, and they have a track record.

The problem is gauging what the attitude of consortia will be. You can imagine that GPs will want to do as much end-of-life care as they can themselves, gearing up their own nurses to doing it. This would probably be cheaper, nearer to the community and liked by patients, who of course don’t know how much better it might be with their local hospice. Because patients and families will have a higher degree of choice, assuming a hospice provider is not too expensive, marketing the quality of hospice provision will become more important. However, the local reputation of many hospices and the fact that many GPs and community nurses like the help and support that home care services offer might encourage them to do a deal.

Fourth, however, there is the matter of the tariff, which will set the levels that consortia can pay for a service, unless there are specific arrangements. There is no national tariff at the moment, and previous efforts to create one descended into disorder. But we might move into the American situation in which there may be limits on what the consortia will agree is palliative care, and set requirements for admission, as the American insurance companies do.

Fifth, will private providers come into this? It’s hard to imagine the private hospitals aiming for this sort of thing, they will focus initially on providing predictable elective surgery. But you may well get private nursing homes and residential care homes competing to do end-of-life and palliative care on the cheap compared with the multi-talented hospices. After all, we’ve been working hard to train them to do this better, so they’ve been upping their skills in this area. And you might get private community care agencies moving into end-of-life homecare; it would be a natural extension of their domestic and domiciliary care markets.

One of the worrying things this points to is the advantage, in a competitive system, of not sharing knowledge and expertise. We would perhaps do a lot better not to train hospital and care home staff in palliative care, then they would have to come to us for services. Or are we going to focus on being training and development agencies? That would go against the Cicely Saunders principle of gaining the expertise to train and develop from actually doing the job.

Sixth, I think one of the important developments of recent years is hospital palliative care. To me, it is really important that end-of-life care in hospitals is the best quality, because so many people come to the end of their treatment or are admitted in emergencies and need good end-of-life care because they cannot be moved elsewhere. Are GP consortia going to be prepared to pay for this? They will want quick cure and out into cheaper accommodation. Perhaps the aim for hospices is to get themselves seen as cheaper providers of high-end end-of-life care to get people out of hospitals to cut costs. Here, the nursing home market will be strong competitors.

Finally, there is the general aura of competition in the Bill. Reading the Bill gives you a very clear impression that it is setting up the system to be strongly competitive; the arrangements for competition are there in every section, and priority is given to it wherever they can achieve this.

What is going to be the unique selling proposition of hospices? And how are they going to market themselves?

Guardian summary of the Bill:

http://www.guardian.co.uk/society/2011/jan/19/health-bill-main-points?CMP=twt_gu

The Guardian and its commentators on the ‘chorus of concern’:

http://www.guardian.co.uk/politics/2011/jan/20/andrew-lansley-health-bill

The Campaign Company blog comments on the increased role envisaged for local government:

http://thecampaigncompany.wordpress.com/2011/01/20/health-and-social-care-bill-the-increasing-role-for-local-government-within-health

Health Policy Insight blog critique of missing features (e.g. post implementation evaluation):

http://www.healthpolicyinsight.com/?q=node/917

Health Policy Insight blog on risks of the reforms:

http://www.healthpolicyinsight.com/?q=node/914

This is based on a more lengthy comment by Sir David Varney (who has experience running a Foundation Trust) for Civitas (but HPI covers the main points):

http://www.civitas.org.uk/pdf/VarneyRiskequity.pdf