System Structure and Integration
The Social Care system is complex. Unlike the NHS, its favoured relation, it has never been designed. Rather, it has grown haphazardly since its inception in the 1940’s. Currently, the system is structured into tiers, each with unique accountabilities and responsibilities.
The top tier sits centrally at Government level, where elected members and Whitehall departments (notably the DHSC and the Treasury) define the legislative framework, set policy, control funding and determine how the Social Care sector should be overseen by the state.
The second tier sits at Local Authority and NHS level, where accountability also rests for some aspects of funding and resourcing, and where the processes of market shaping, commissioning, procurement and care management take place. Some Local Authorities also deliver services.
In two-tier systems there is a third tier at District and Borough level, where accountability for housing sits.
The fourth tier is defined by the provision of care and support – the provider.
Current Issues & Problems
Tier 1 – Government
Tasked with the setting of policy, funding from general tax and regulatory framework assessments via quango’s (such as the CQC) the current government remit is vast and overarching, covering many departments. Social Care does not sit isolated in one department but is heavily affected by others such as Department for Work and Pensions, Department for Levelling Up, Housing and Communities and the Department for Work and Pensions. This level of fragmentation demands co-ordination to deliver on policy – surely a a recipe for disaster.
Whilst there may be some agreement that the ‘making’ of legislation (whether the content is agreed or not!) and its processes are satisfactory overall, the collaboration, communication and implementation of legislation is, at times, beyond comprehension. Legislative guidance is also unhelpful as it leaves ‘grey’ areas which are challenging to implement.
The legislative and regulatory frameworks which interface with Local Authorities simply do not work and there is a gap (and disconnect) here.
There is also concern around the way the government consults with stakeholders and the public. How is this embraced to capture the unification of voice – or is it closed to challenge?
Tier 2 – Local Authorities (LAs)
Nationally, the form of LAs varies – some being unitary and others having two tiers. A collective push-pull system at County Council level is common. Fragmentation is a big problem.
Tasked with a statutory responsibility of the delivery of social care, LAs are not inspected by CQC and are therefore never scrutinised or criticised.
Consultation with the delivery of the care is often lacking in external engagement and too often, the tendering and procurement processes are used to block the path to success.
There is often a reluctance to engage fully. To truly engage and understand the pressures of the people they serve invariably would lead to additional drains on already stretched budgets. The inability to raise funds to cover this leads to the conflict.
A cultural narrative from the outset prevails. Historically, LAs sought places only in residential settings. A lack of team culture prevails today which is mirroring this. A move away from intervention and prevention due to a lack of quantifiable measurements and austerity has led to increases in the eligibility criteria.
How can we reconcile the conflicted role of the Local Authority which has a statutory duty to serve its population but little freedom to raise taxes?
What happens between legislation and policy making processes? At Tier 1, Ministers and civil servants shape the policy making process. The way this works will vary depending upon the party, the Minister, the environment, the timing of events and so on. Policy constantly evolves, with each new administration keen to implement its policy objectives. This leads to a reinventing of the wheel and further disconnect with the other tiers (examples include the CCGs and ICSs).
Historically, LAs were tasked with inspection of providers. Whilst this process lacked a national framework and there were some quality issues, the connectivity between the LA and service providers was inevitably far greater than with CQC inspection today. LAs were able to understand locality and what was happening in the local sector to feed back to Tier 1. Today this is fragmented.
A great failing of the Social Care system is the lack of system-level decision-making. No-one has an holistic, overarching view. People make decisions in their box, or silo, without understanding the impact elsewhere.
Why does housing sit in a different place to management of care and support, when environment is central a holistic support solution? Why are key decisions about workers coming from overseas made in the Home Office in tier one without reference to the impact on service delivery and organisational viability in tier four?
It can be argued that providers are the most important element of the Social Care structure since it it here that the overall structure interfaces with the person accessing the service.
It can also be argued that it is her that the continuity and system knowledge sits. Whilst governments, councils, civil servants and officers come and go, providers remain, often for decades, sometimes for generations.
Yet providers are rarely treated as equals in the system. Their experience and knowledge is seldom sought or applied in change processes. They are often the first point of blame when something goes wrong. The provider’s lot is not a happy one.
People accessing services
We are describing the structure of Social Care in terms of tiers, but should we even be talking about tiers at all? This suggests a structure which places the recipient of the service is at the bottom of the food chain.
As with providers, the voice of people accessing services is often unheard. What people want and need form Social Care is often assumed without reference or consultation. And as we explore elsewhere, people are often disenfranchised and objectified by Social Care – it is something done to to people, not driven by them.
At its simplest, the structure of Social Care and the systems that operate within it should ensure that the interaction, care and support delivered moment by moment, is as good as it possibly can be.
But what does that mean? Well, it means the right person, with the right values and skills, trained well, remunerated in line with their value, working to a person-centred plan through person-led processes, managed by a outstanding manager. And so much more.
Thinking about the moment of interaction is helpful because it gives an insight into what the system should be doing. It provides us with a litmus test – anything which enhances the moment of interaction has a place within the structure and system, and we should build on it, but anything which doesn’t, we should stop.
In our vision, the structure, the systems and everything which happens within them link to and enhance the moment of interaction.
Maybe this is a good place to start the redesign…
We offer a forward-thinking collection of ideas, thoughts and new solutions, underpinned by provider experience. We believe that all will result in a better experience for people accessing care and support.
Turning the structure on its head. We wish to see the Social Care structure re-envisioned with the recipient of care and support at the top and the structures which exist to organise and deliver that support sitting beneath them.
People at the centre. We wish to see a new collaborative approach to policy-making in which all stakeholders, including recipients of care and support and providers, place a significant role. Allied to this we wish to see the system move from a prescriptive approach to choice-based outcomes approach which encompasses the ‘person-led ownership’ of care choices.
Cross-departmental structures and connectivity. If people are truly to sit at the centre of Social Care, then their wants and needs should be met holistically and seamlessly. We have seen some progress towards integration between health and social care with examples of joint commissioning and pooled budgets, and the development of Integrated Care Systems is seen as a positive development. However, cross-department working has so far to go. We need systems which ensure, for example, that:
- people accessing Social Care have appropriate housing
- the benefit system supports people accessing Social Care to live more independently
- businesses support people with disabilities to work
- Social Care can be resourced by people recruited from overseas
Equality with Health. Social Care must be given equal prominence to that of health. It has been the poor relation for too long.
Social Care Independence Board. We wish to see people sit at the very heart of the Social care structure. To secure this, we see a need for a body which gives people a voice – an independent advocate for people who access services. This body will be a counterpoint for the over-dominant LAs and emerging ICSs. It will, for example:
- Conduct independent assessments in line with a nationally agreed framework, and make recommendations for the package of care required.
- Gather and share market information.
- Support people to choose their services.
- Promote best practice models which promote independence.
- Arbitrate where people have disputes with LAs regarding eligibility or funding.
The Social Care Independence Board would sit in parallel, and with clear links to the, to the ICS and LA.
Market shaping and signposting. The Care Act 2014 made much of the importance of market shaping and signposting as pre-requisites for market efficiency, but implementation has been poor. LAs must maintain up-to-date Joint Strategic Needs Assessments and produce annual Market Position Statements by sector. Without these it is impossible for providers to plan their strategic development.
Collaboration should sit at the heart of market shaping to drive creativity in providing opportunities for the people we support.
Appreciative Inquiry. In addition to changes in the structure we wish to see a significant change in the way that the structure works. We wish to see Appreciative Enquiry become the norm. At its heart, Appreciative Enquiry is about the search for the best in people, their organisations, and the strengths-filled, opportunity-rich world around them. Adopting Appreciative Enquiry throughout Social Care would see a fundamental shift in the overall perspective taken throughout the entire change structure to explore possibilities and build on strengths and successes.
Commentary on ‘People At The Heart Of Care’: The Adult Social Care Reform White Paper (published 01/12/21)
Best Practice Share
To be added
Our Key Takeaways