social care

Collaborative management in the face of government response to COVID-19? Evidence from care home staff and stakeholder experiences in West England.

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Luke Bradbury

Picture credit: https://socialvalueportal.com/support-national-effort-covid-19/resources/news/social-value-in-action/support-national-effort-covid-19/

As a student on the MSc Public Management course at INLOGOV and having worked part-time in care for a number of years, I felt my final dissertation project was an opportunity to investigate the impact of COVID-19 on adult social care and the implications of government intervention. The works of organisations such as SCIE (Social Care Institute for Excellence) have already shown that inaccurate government guidance – combined with years of underfunding – resulted in the sector being ill-prepared for dealing with a pandemic and that care policy and practices had to rapidly adapt to unforeseen circumstances with limited support.

This case study aimed to explore this in the context of two care homes in West England during the early months of the pandemic. It was also interested in the role of collaborative management between care homes and their surrounding communities including local authorities, charities, businesses etc. ‘Collaboration’, in this context, took some influence from Helen Sullivan and Chris Skelcher’s conceptualisation of a collaborative agenda governing the (often mutually) beneficial cooperation between different public bodies and community agencies. One might consider how care homes may have banded together with their own local communities to ensure they still had the means to provide quality care in the face of COVID-19. Indeed, recent research by Fiona Marshall et al. has shown that, where government support was scarce, many care homes formed resource networks with external stakeholders such as local businesses, dentists, veterinaries, and domiciliary care agencies to source vital materials including personal protective equipment (PPE), electronics, toiletries, bedding and even food.

This study used semi-structured interviews and recruited five participants via a combination of snowball and non-probability purposive sampling. This included two deputy care home managers representing two different care homes in West England as well as a carer, a local parish councillor, and a co-owner of a local chemicals firm. The latter two participants were recruited as active members of the local community for one of the two participating care homes (or ‘external stakeholders’). Thematic analysis and grounded theory-based coding was then used to interpret the data.

The analysis firstly uncovered a strong dissatisfaction with the central government response to COVID-19 amongst all participants. Care staff spoke about how the implementation of the Coronavirus Act forced them to take on extra patients from hospital without an effective COVID-19 testing system in place and that inconsistencies between government guidance and company policy led to confusion amongst managers. Practices were forced to adapt; for example, adhering to stricter infection control measures and taking on extra care duties such as virtual GP consultations. External stakeholders also spoke about how these circumstances encouraged some level of collaboration within the community and a desire to assist local care organisations; for instance, a parish council was enabled to collaborate with the local chemicals firm and local school to source PPE such as goggles and hand sanitizer which could then be distributed to care providers.

Despite this opportunity to establish a resource network, collaboration between the two care homes and their surrounding communities was not evidenced as Marshall et al. had found previously. This was attributed to two main reasons. Firstly, resource dependency was less prevalent because effective internal management within both care homes meant they already had a sufficient supply of PPE. As one of the deputy managers recalled, the manager for her home made the decision to stock up on PPE and to lockdown early, therefore minimising the spread of the virus. The second reason was down to external circumstances that aided both care homes. Since both operate within rural areas of West England, they occupy less densely populated regions than care homes within inner city locations and therefore surrounding transmission rates remained relatively low. The implication is that locality largely eliminated the need to establish support networks with external stakeholders because they were not experiencing the same level of devastation seen in many other care homes. This was corroborated by staff who felt ‘fortunate’ compared to what they were seeing on the news.

These findings indicate the importance of effective management but also the extent to which contextual circumstances may or may not have necessitated collaborative networking between care homes and their surrounding communities during the early months of the pandemic. Whilst collaboration was less necessary here, the background coordination of parish council and local actors to produce a ‘safety net’ of resources did highlight the potential of localised collaboration and intervention in times of crisis. Perhaps, had such coordinated localised governance been enabled within the surrounding communities of less fortunate care homes, they may have been spared some of the devastations of the pandemic. Regardless, there is certainly a strong call for greater support towards the care sector for government and policymakers to consider – particularly in terms of clearer guidance, increased funding, and enabling localised governance to support care organisations.

Luke Bradbury graduated from the MSc Public Management in September 2021.

After austerity, comes the reckoning

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Jason Lowther

The publication last month of the Institute for Government’s report on the impact of cuts in local services during the decade of austerity has revealed to the public what has been obvious in the sector for years – austerity was hugely unfair and hit the poorest hardest. 

Neighbourhood services under strain is written in IfG’s usual forensic style, and its conclusion is all the more brutal because of it: the most deprived areas received the biggest grant cuts, resulting in bigger reductions in local services such as libraries and recycling.  Central government grants were cut more in deprived areas because of the way cuts to grant funding were distributed ignoring councils’ different degree of dependency on this income source.  Because of the central cuts and pressures such as the increasing demand for social services, councils have been forced to cut preventative and universal services like children’s centres and housing programmes to help vulnerable people to live independently.

The report’s detailed analysis of changes in spending reported to DHCLG concludes that most councils chose to protect similar services.  ‘Relatively protected’ services included environment and regulatory services, homelessness and public transport.  At the other extreme, most councils applied higher than average spending cuts in housing, cultural, and planning services (figure 1 below).  This mirrors earlier analysis by the National Audit Office (which also highlighted the protection of social care services).

Figure 1: Local authorities that disproportionately cut, relatively protected, or increased neighbourhood services spending between 2009/10 and 2019/20, by category

Source: Institute for Government analysis of DLUHC, Local authority revenue expenditure and financing in England: individual local authority data – revenue outturn 2009/10 and 2019/20.

The IfG report hints at the innovative ways different councils responded to these pressures, from contract renegotiation and the use of new technology, to service redesign and rationalisation.  For a more detailed exploration of this, I recommend Alison Gardner’s excellent thesis on how local councils responded to austerity – including strategic asset management, shared services, commercialisation, co-production and demand management.  Whatever methods were used, however, it’s clear that by the second half of the decade of austerity the cuts were no longer into ‘fat’ but into ‘flesh’.

These new findings add to a growing library of research on the effects of the UK government choice to pursue austerity policies, including a BMJ study in October 2021 which suggested that the constraints on health and social care spend during this period of ‘austerity’ have been associated with 57,550 more deaths than would have been expected had the growth in spend followed trends before 2010.  Considering cuts to local government funding specifically, a July 2021 study in The Lancet estimated that cuts in funding were associated with an increase in the gap in life expectancy between the most and least deprived quintiles by 3% for men and 4% for women between 2013 and 2017. Overall reductions in local government funding during this period were associated with an additional 9,600 deaths in people younger than 75 years in England. Well before the pandemic, the UK was seeing a rapid slowdown in life expectancy gains in the 2010s and, although a number of other high income countries also saw such slowdowns, of large populations only the USA experienced a more severe slowdown/reversal and the magnitude of the slowdown in the UK was more severe than other large European populations.

Perhaps the most damning finding of the IfG report is that central government lacks the information to know what the impact of its spending cuts are on local services.  This echoes the assessment of the Nuffield Trust and Health Foundation back in 2014 which warned government was making decisions with ‘no comprehensive way to quantify the impact that social care cuts are having on their health and wellbeing’ and were therefore effectively ‘flying blind’.  Having abolished the Audit Commission in 2010, the government was left with no comparable performance statistics for two-thirds of local services.  Some may believe that this was quite convenient, given what we are now learning about the effects of that government’s spending policies.

Transitional safeguarding – putting children first

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Cllr Ketan Sheth

Picture credit: https://drugpolicy.org/issues/protecting-youth

Most of us can remember as teenagers those exciting moments of independence, of achieving the landmarks of adulthood; perhaps learning to drive; our first relationship; our first job. These landmarks all signify moments of increasing maturity, of independence, but each of these landmarks remind us that there is no one moment of independence. We don’t flip a switch to become a grown-up – one day a child, one day an adult. Maturity is a gradual process, a high wire that we walk where most of us benefit from a safety net of parents, family, friends. 

For our most vulnerable children and young people too, there isn’t a switch and sadly too often they don’t have the safety net they need. There is now much more emphasis on the transitional period so that services extend from aged 16 to around 25. There should not be abrupt changes to a service just because someone reaches the age of 18, with its attendant risk of falling between the gap where services don’t always join up!

In recent years, safeguarding children and adults has become increasingly complex, with risks such as sexual exploitation, gang and group offending and violent crime challenging the children’s and adults’ safeguarding workforce to identify opportunities for innovation. The notion of transitional safeguarding is an emerging one, not currently widely applied in policy or practice. Its implementation requires changes in policy and practice and across systems involving all agencies. 

However, some local authority areas, like Brent, are already innovating and creating opportunities for more flexible and bespoke support, and providing valuable experiences for young people at a key point in their lives. This makes sense in most circumstances, but keeping vulnerable young people safe as they transition from adolescence to adulthood challenges us all to remember that becoming an adult is a process of transition, of many moments. 

Transitional safeguarding is an emerging area of practice where we challenge ourselves in public service to make sure we keep that safety net in place; that we help keep safe and promote the well-being of our young people when they need it most, regardless of the artificial barriers of age, and including during those important times of transition to adulthood. 

Supporting young people’s safety and well-being during the transition to adulthood is not only morally and ethically important, but it is also important for the future health of society and future generations. Young people may experience a range of risks and harms which may require a distinct multi-agency safeguarding response, and safeguarding support should not end simply because a young person reaches the age of 18. Investing in support to address harm and its impacts at this life stage can help to reduce for the need for specialist and statutory intervention and criminal justice involvement later on in life.

In Brent, my scrutiny committee recognises the importance of taking this holistic, broad view for our Brent young people. We believe we are well placed to be at the vanguard of these developments, with promising pilot work, in collaboration with partner organisations, already completed to change and enhance services; and my scrutiny committee are recommending that Brent develops a council-wide approach to transitional safeguarding by working with those young people who need us most.

And most importantly, I think that everybody has a valuable contribution to make to the transitional safeguarding agenda to help improve our practice for the better outcomes of all our most vulnerable young people; and indeed, the service is there when they need to use it.

Cllr Ketan Sheth is Brent Council’s Chair of Community and Wellbeing Scrutiny Committee 

Help council commissioning to ‘build back better’

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Jason Lowther

Local government is digging deep into its financial reserves and hiking council tax bills by double inflation, but still anticipates making further service cuts in 2021–22. The Public Accounts Committee report earlier this month shows how central government support hasn’t matched Covid-related budget reductions. More positively, at the same time, councils and partners are eyeing the improvements made to commissioning and procurement during the pandemic and asking whether these could help balance the budget. Can adding value to local government’s annual procurement spend of £100bn help improve outcomes for citizens, sustain local councils, and build a better recovery?

As NESTA’s recent report, A Catalyst for Change, evidenced, councils’ collaboration with other public sector bodies, citizens and the voluntary and private sectors was at the centre of the response to COVID-19. Local authorities ‘stepped into their role as conveners, leveraged their existing relationships and partnerships, and forged new ones to dynamically address key issues. This allowed organisations to link up volunteers with vulnerable people, support businesses, deliver food parcels or find temporary accommodation for rough sleepers’.

I’ve heard from some of the council managers on INLOGOV’s teaching programmes of the amazing agility and flexibility councils have been able to develop with partners in areas such as social care and housing. Commissioning and procurement processes that in the past were seen as inflexible, slow, risk-averse, price-obsessed and lacking innovation were transformed rapidly in response to the immediate threats of the pandemic. Data was shared in more depth and quickly, enabling better targeting of services. More flexible financial and performance management arrangements opened the door to flexible service delivery.

Now, a major research programme led by Dr. Richard Simmons at Stirling University, called Optimising Outcomes, is looking at the impact of Covid on partnering and procurement. The programme is working with key sector bodies such as CIPFA and SOLACE as well as universities and research councils, to answer key questions such as:

  • How, and how effectively, are local authorities deploying their commissioning and procurement functions to address the challenges posed by Covid-19? What are the successes to be celebrated? Where are the tensions that need to be managed? Where is the system at risk of breaking down?
  • What are the opportunities for improved procurement performance? How do local authorities optimise every aspect of procurement spend?
  • Can local authorities adopt more innovative, strategic, entrepreneurial and relational approaches to strengthen local resilience and avoid a weak and incapacitated system?
  • What role can greater data-analytic capacity play in supporting a more agile and effective response?

As part of this research, council managers have been invited to take part in a survey to capture learning from the many challenges and achievements of the sector during the last year.  The survey is aimed at all UK council managers (there is a separate survey for procurement teams) and takes around 10 minutes to complete.  The closing date for responses is 21st June.

If you are a UK council manager and haven’t yet taken part, please would you complete the survey here.    

This is a great opportunity to ‘build back better’ by applying the lessons and innovations councils and partners have developed over the last 18 months. I’ll report back on the results later this year.

Source: DHSC website

Jason Lowther is Director of the Institute for Local Government Studies (INLOGOV)

Social care reform – comprehensive is good, but comprehensible vital

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Chris Game

Cllr Ketan Sheth’s recent blog on ‘Local Government and the NHS Integrated Care System’ was, as he explained, timely for him personally – as an elected London borough councillor about to take on a novel scrutiny role in a new ICS.

For us Midlands readers it was timely too, for reasons most easily conveyed by the King’s Fund’s recent highly colourful Map 1 of ICSs so far established – highly colourful, that is, for some parts of England, including Cllr Sheth’s London, but bleak grey for others, like the whole of the Midlands, with merely our at least slightly more localised Sustainability and Transformation Partnerships (STPs).

This blog is not directly about either STPs or ICSs, which have only a late walk-on role. It is, though, about the future of social care and local government’s involvement in, or marginalisation from, that future, and it opens with one of Boris Johnson’s first Prime Ministerial broken pledges, in his very first speech as PM, to “fix the crisis in social care once and for all with a clear plan we have prepared”.

The ‘clear prepared plan’ bit was obvious fiction, and confirmed as such in the Conservatives’ December election manifesto.  60 pages, nearly 1,000 days working on a promised but still undelivered Green Paper, and no sniff of a plan.  One un-costed pre-condition (p.23) – that nobody should have to sell their home to pay for care – and a slightly desperate hope to build cross-party consensus on reform.

But last week, just eight months on, jostling with daily lockdown bulletins and courtesy mainly of The Guardian newspaper, saw a sudden small flurry of tantalising leaks. First came Ministers’ “radical plans for everyone over 40 to contribute towards the cost of social care in later life” – paying more in tax or national insurance, or insuring themselves against “hefty care bills when they are older”.

Broadly resembling the German and Japanese funding systems, it is variously labelled a ‘comprehensive’ and ‘compulsory’ insurance model, both of which, to be effective, it surely has to be.

But an even bigger question, I suggest in the blog’s title, is surely whether it can become a comprehensible and comprehended model, and pretty quickly – because the evidence is that our collective understanding of even the existing system is worryingly low.

With coincidental but near-perfect timing, the New Statesman magazine recently commissioned a poll by Redfield & Wilton Strategies asking a sample of 2,000 GB adults about their awareness of how social care is currently funded and organised. Its findings, for a topic dominating news headlines for several months now, were concerning.

Fewer than one in eight felt they were “significantly aware”, under half even “moderately aware”, and nearly a quarter “not aware at all”. They were then asked which of (1) the NHS, (2) private operators, and (3) my local council, they thought were currently providing community care in their locality.  Being a GB-wide sample, there are no precisely right or wrong answers, and ‘providing’ makes it almost a trick question – which personally I’d have opposed phrasing in this way. Still, there are better and worse guesses.

“My local council”, chosen by 55%, is a decent pick – if, by providing, you mean paying for.  But not, for decades now, if you mean actual care home beds.  As Covid has tragically demonstrated, funding is nowadays effectively separated from extremely fragmented provision, with only some 3% of beds directly provided by councils and at least 80% in over 11,000 homes by for-profit private companies, local organisations and charities.

As for payment – roughly £600 per week here in the West Midlands – just over one-third of residents have their fees met by their local authority; one in eight pay top-up fees, but the biggest fraction must find the full fees themselves.  Which, given our apparently limited understanding of the present-day system, must frequently come as a serious shock.

Exactly half the poll respondents ticked the “private operators” option. However, virtually as many (48%) nominated the NHS, which, note the authors, is nowadays “a very small player” indeed in providing social care.  It’s not totally wrong, but close – and that, in the proverbial nutshell, is Ministers’ social care problem.

The public generally have low understanding of how even the present care home system works, of how literally dis-integrated it has become, with home care provision twice as fragmented and considerably more expensive. But they love, clap for, and think they know ‘their’ NHS.

It was even more starkly highlighted in the crunch question: “Which of three options for the future of social care comes closest to your own view?”  Exactly half the respondents selected the ‘NHS model’ that many had just demonstrated they seriously misperceived: “Social care should be free at the point of use, regardless of whether individuals contributed taxation into the system during their working lives”.

Just over one-third preferred the ‘pension’ or ‘compulsory insurance’ model referenced in the Guardian story – or, rather, first story.  For, the following day, it reported Government plans to in effect merge health and social care services, taking the latter away from local councils altogether and handing them and their £22.5 billion annual funding over to the NHS.

The Department of Health and Social Care issued a routine denial, but the PM’s long awaited ‘plan’ appears, currently, to be that care services would be commissioned by, and funded through, the new NHS regional Integrated Care Systems (ICSs) gradually unrolling across England – although not, as yet, the Midlands, where we’re still in the Sustainability and Transformation Partnership phase.

I conclude with what seems a bit of a personal dilemma. Having worked for over half my life for an ‘Institute of Local Government Studies’, I instinctively deprecate both the fact and implications of elected and accountable local authorities losing a major function for so long integral to their existence.

On the other hand, if that’s what most people reckon they want, and the Government fundamentally misunderstands, distrusts, and already wants to diminish and/or abolish local councils ….   The question is: would the public be prepared to pay the cost of NHS-style “social care, free at the point of use”, largely unaddressed in the New Statesman questionnaire?  But that’s for another blog.

 

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Chris Game is an INLOGOV Associate, and Visiting Professor at Kwansei Gakuin University, Osaka, Japan.  He is joint-author (with Professor David Wilson) of the successive editions of Local Government in the United Kingdom, and a regular columnist for The Birmingham Post.