5. Creating a more diverse and responsive care market

People want choice and control over their care and support, so they can receive the services which best meet their needs. In the future, individuals will increasingly be purchasing their own services. Those funding their own care will continue to seek a range of services. Read more about a diverse and responsive care market…

What do you think?

a. How would you define the social care market? What are the different dimensions we need to consider when assessing the market (eg type of provision, client group, size of provider, market share)?
b. How could we make the market work more effectively including promoting growth, better information for commissioners (local authorities and individuals), improved quality and choice and innovation?
c. Does there need to be further oversight of the care market, including measures to address provider failure? If so, what elements should this approach include, and who should do it?
d. Looking to the future, what could be the impacts of wider reforms on the market? What possible effects would the following have on the market: the recommendations of the Dilnot Commission’s report, the roll out of personal budgets and direct payments, and the drive to improve quality and the workforce?

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24 Responses to 5. Creating a more diverse and responsive care market

  1. claire rhodes says:

    I have worked with older people for several years and, generally speaking, they do not want more choice in their care and support. They just want decent statutory services. They certainly don’t want to be bothered with purchasing their own services and are vulnerable to being ripped off by disreputable independent providers when they do. Giving people more choice and control sounds great in theory but essentially boils down to government passing over the complex business of commissioning and arranging care to individuals who have no training in health and social care.

    • Jeremy Labram says:

      Put this way, Claire, you are absolutely right, and many people see it as you do. I myself used to see it your way too having taken both my parents through end of life involving frailty and ultimately dementia. I experienced the helplessness of not knowing what to do and how to help my parents make the right decisons about their lives.

      I don’t now thanks to some very influential work being done in Wiltshire where it is easy to forget that 70% of older people are ‘self funders’ and are having to buy individually from the market. Council customers who take the offer of a direct payment will also be in the same boat. This could be daunting if they have to fend for themselves in the market. In the new Wiltshire world then both categories will fall very much into the same model of care and support.

      Everybody is entitled to an assessment. If this is a person centred assessment then how the resultant support plan is delivered and by whom can really make all the difference. This is where a council can be placed in a very good position to give ‘sound advice’, as Wiltshire call it, during the assessment. In my view there is always room for improvement in how someone is cared for and supported. I utterly loathe the notion of ‘maintenance care packages’ which just keep people ticking over and of least trouble to whoever is caring for them. Progress might be very slow for some people who have lost capacity and motivation and much quicker for others who really want to regain much of the lives they once had before their life crisis. In my professional work we have shown how one third of the social care cases on the books of one particular council needed a different support plan. On average this resulted in 40% less being spent on the customer directly which sounds very draconian, until you hear that nearly everyone was happier as a result – there we only 7 complaints out of 1000 cases. Much of the new help came from the family and friends really from a understanding how they could make a positive difference as well as from the wider community. All this helped the person to feel more in touch and less lonely, as well as giving them the opportunity to get more independent.

      The council neds to commission a small number of providers who must work in a person centred way, and who must also do most of the case management. Wherever a support plan is going wrong then they must manage this as an exception with the Council and get it reviewed quickly.

      There’s a lot more to say on this but primarily it gives the opportunity for the Council to be in charge of what they commission and continually make sure that it is meeting customers’ outcomes.

  2. Bridget says:

    In all the engagement and involvement activities we have facilitated with the public, patients, carers and service users (which is a lot) their priority is to be able to access good quality safe care near to home. They don’t want choice – they want to know that what is available locally is good.

    • Jeremy Labram says:

      I think I know what you mean by choice, and if so, I would agree. I think the choice you are criticising is where there are loads of confusing options and then being left somehow to choose.

      what is terrifically important is the person and their closest caring people around them understand that a process has to be be gone through which helps them make the right choices over what happens to them and their lives. Isn’t more about them understanding and agreeing to the choices being made. Put in other words ‘having access to trustowrthy ‘sound advice’ on matters, so that I can make the right choices.’

  3. Kaarina says:

    Well said Bridget. Summed up in your sentence “They don’t want choice – they want to know that what is available locally is good”.

    • Jeremy Labram says:

      I agreed with Bridget and with you too. My only proviso is working out what is ‘good’. This will be different for different people, so that’s where person centred planning nees to fit in, so that everyone gets what is appropriate and is essentially what they want, rather than what some other entity wants.

  4. Ken says:

    The activity of ‘shaping’ the social care market has to take account of the consumer. Social care ‘consumers’ have particular characteristics:
    - people with social care needs often feel vulnerable and powerless
    - many people don’t have the life experience or knowledge to make
    a judgement between good and bad social care services
    - people are often making decisions at times of personal/family
    crisis and huge uncertainty
    - social care decisions are often big life-changing decisions
    - people often have little choice other than to buy here and now ..
    social care services are often necessities like warmth and shelter
    - social care services are often scarce and difficult to access
    - people who rely on social care services are often the least adept
    at searching for and filtering market information.
    In this context it’s not just a question of increasing diversity and choice. We need to look at how we encourage market behaviours that support the confidence and authority of the consumer. For example, instead of consumers having to shop around for advertised goods and services we might look to suppliers to compete and shape their services to meet advertised needs.

    • Jeremy Labram says:

      Ken, your description of the circumstances for someone facing a ‘life crisis’ is absolutely right. For any other life issue – like getting married, or getting unmarried for that matter, or changing job, or deciding upon your child’s education – one would seek sound advice or wisdom from somewhere. This is no different but probably much more urgent and for that reason alone highly skilled.

      I’ve spent the last 18 month helping a council devise and commission a ‘total system’ that does just that.

  5. Jean says:

    Priorities 1. 3 & 4 seem the most important to me. We need more frontline staff and few layers of management. Listen to the clinicians.
    Priorities 2 & 5 are simply idealogical and quite meaningless. All I and anyone I have spoken with wants is a statutory good, effective, local service for whatever kind of care they need. Diversity and choice are sound bites – red herrings for passing the buck.

    • Jeremy Labram says:

      I agreed with Bridget and with you too. My only proviso is working out what is ‘good’. This will be different for different people, so that’s where person centred planning nees to fit in, so that everyone gets what is appropriate and is essentially what they want, rather than what some other entity wants.

      If you don’t, you will get instutionalised care because from a lot of current perspectives it is the most cost efficient way of helping people live out ther last few months and years. That surely is not good for the residents though? Having seen the effect upon my mother, my answer would always be no.

  6. michele poole says:

    All service providers should be non profit making and subject to the same kinds of controls that the gas, water electric providers have to work with. Not that that stops them from over charging!
    No one should be asked to pay upwards of £700 a week for social care.In my area patients with dementia are being pushed from pillar to post because the local authority has a cap on the weekly spend of residential care, and the family are unable to pay.The cost of care homes and care they provide is a scandal and one this Govt. is busily ignoring.

    • Jeremy Labram says:

      My mother got pushed around in the private sector as dementia set in. We put no cap on how much we were prepared to pay. I don’t think it’s got much to do with what type of organisation delivers the service (not for profit, commercial, social enterprise, council, charity, whatever).

      It has to do with what the provider is set up to achieve for customers. Is it maintenance, delivering a service, or making someone’s life better than it currently is. The latter takes imagination to work differently to much of current practice and an orgainsational environment that encourages working repsponsively and positively to older people.

    • Tom Cooper says:

      The suggestion that all service providers should be non profit making is absurd as only those who are already super rich as well as altruistic would contemplate investing millions of pounds in something that presents no return and there are not enough of them in this country to supply the growing demand for places. In any case there is nothing intrinsically wrong or immoral in running a care business for profit – the only question that is relevant is whether that provider operates a good, safe service. Furthermore, contrary to public perception, social care is already highly regulated by the Care Quality Commission and other agencies. Did you know that care homes get inspected by CQC, HSE, the local authority’s Social Services, Contracts, Fire and Environmental Health Departments, insurance companies and LINK organisations. You may think that care home fees are excessive but £700 per week equates to £4.16 per hour. In Suffolk the 2011-12 social services rate for residential care is capped at £348 or £2.07 per hour. Try finding a hotel that provides full board (with no personal care or specialist staff training) and activities for that rate. Frankly we need some reason in this debate rather than prejudice based on ignorance.

      • Nhiesha says:

        I read Liz`s article seyterday ,@ the similarities in the appaling level of care ,that my own Mother suffered for the last 6 weeks of her life .This was not in hospital ,although I could mention some awful examples over the years when my Mother was admitted . I am talking about the appaling care ,lack of basic nursing care @ lack of compassion at a Nursing home close to where I live.I complained to the Inspectorate @ the Health Board ,@ a POVA investigation ensued .The Inspectore side was adequate ,but the Health Board investigation I felt was poor. Certain changes have been implemated ,but the Manager ( who has no compassion is still in post ) .When will things change ? .There is no basic nursing care @ compassion these days ,@ I feel it is mostly as a result of the change in Nursing training.

  7. Jennie Morrison-Cowan says:

    3. As a small, independent, family provider we work hard to develop relationships with other services who support our clients. The reaction we receive moves between “we don’t want to know you – you are only social care” to ” we appreciate the feedback and information shared to support individuals”.
    Integrated services start with respect for one another, communication and perhaps looking at the combining of some of the care functions.

    Let me give an example: One of our clients returns home from respite in a Nursing Home where she has developed pressures sores having entered the Home with clear skin. The Health Care Assistant comes from the medical centre to clean the pressure sore and redress it – social care cannot do this however the HCA cannot administer medication but social care can up to controlled drug level. Should we be amalgamating some of these tasks and sharing responsibilities more?

  8. Jeremy Labram says:

    I think this a good point. From the customer’s perspective what they don’t want is to be caught in the middle of a row between two parties. They also want care to be simple to understand.

    Strange sort of respite which ends up with the person’s skin worse off than when they went it. Perhaps that’s a story for another day?

  9. Natasha Muirhead says:

    5) Integration
    How can we make sure the NHS, social care and other support services work more closely together to make things easier for people who use more than one service?
    See 3)

    • Jeremy Labram says:

      Health, Social Services, Providers and the 3rd sector all must be alligned to one way of working. In Wiltshire this vision is very clear now and has led to a totally different service bering commissioned from a small number of providers who have proved that they can work in a new way which aims to get customers better, or at least gets their lives better than they were. It does not really matter if Health use this service for CHC customers, or coucil funded customers use it, the service is the same and managed in the same way. I’m hoping by contributing to this consulation exercise, as I have been encouraged to do by the DH, we can make the Wiltshire way more widely available for others to consider.

  10. David Durston says:

    Having used Direct Payments, and agencies funded directly, there is an issue with continuity of provision. That is, should a carer be ill, or leave, on direct payments a person may struggle to find cover. I did suggest to Penderels Trust that they provide a list of carers working with other clients who are interested in other work if required. This extra cover would provide a safety net for people on direct payments, and then more people may prefer this route of care provision. Direct payments (employing staff directly) avoid agency costs, and this would significantly reduce care costs.

    • Jeremy Labram says:

      Lack of continuity is a real risk for someone relying upon one individual for their own support. The only way this can be managed is for there to be surplus capacity somewhere else which can be brought in. Surplus capacity has to be paid for by someone, normally a carer who is not fully maximised and therefore losing earnings. It is pretty logical that this ad hoc (sometimes called ‘spot’) support should cost more. The one way to reduce this on cost is to deal with organisations who have sufficient size to have the flexbility to divert carers accordingly. In my view, whether you call these larger organisations providers, consortia, social enterprises, or agencies, they have an important part to play. Quality and performance management across a geographical area, such as county, is much easier if there is a smaller group of providers to manage, all working to the same specification of service.

  11. Guildford Soroptimists says:

    Greater information on what is available locally is key. Without this clients don’t know what is available but also potential providers cannot identify niches which need to be met.

    By local however we mean in a geographic radius, not by local council. Care must extend across geographic and political boundaries to be fully effective.

  12. Varsha Dodhia says:

    I agree with Claire and Ken.

    “In this context it’s not just a question of increasing diversity and choice. We need to look at how we encourage market behaviours that support the confidence and authority of the consumer”.

    Having a diversity in provision is good because no one size fits all. The question is about a sustainable market provision and quality assurance. CQC is tasked with this but is under funded. HealthWatch who are proposed to be the new champions and also provide signposting look to be under funded.

    We all know what happens with light touch registration. I call for greater accountability from CQC that providers have regular inspection and at best whistle blowers are encouraged so that any inconsistencies between what providers say they deliver and what they actually deliver are highlighted.

    I agree there needs to be kitemarking. In the NHS they have come up with annual report for the Equality Delivery System with 4 kite marks Red, Amber, Green and Purple

    Providers will want to be green or purple!!

    • Jeremy Labram says:

      This is the text of a blog post I wrote on 23rd November.

      We are told today that the Equality and Human Rights Commission (EHRC) have discovered that some older people are not cared for in a dignified and respectful way and that as a result their human rights are not being met. To those close to the industry, this is no surprise at all. In fact the Care Quality Commission (CQC) in their last report 2010/11 stated that “One of the outcomes we look at covers ‘effective, safe and appropriate care’. For both NHS and adult social care providers, failure to meet the regulations on this outcome was one of the three most common reasons why we served compliance actions”.

      Why does it happen? Because important people in the process are not fulfilling their responsibilities and, because they are failing to do that, a watch dog is expected to oversee an operation serving 500,000 people. The watch dog has no buying power – just the power to sanction and, in extremis, to close a non-compliant operation.

      Let’s start at the beginning. By all means let’s take the Minister’s lead today and look at the front line and yes, there will always be rogue care workers who have, in the Minister’s words, switched off their basic compassion. With such a large number involved this is an inevitability which has to be carefully managed by the service provider. What many good people on the front line will tell you is that they are poorly trained and supported, poorly treated and asked to work with conflicting priorities – who are they serving the customer or their manager? This is also inevitable and also needs careful management.

      Beginning to spot a theme here? Now ask a Local Authority commissioner about how carefully their provider is managed and you will probably be passed on to the contract manager – this is someone who takes over the management of the provider from the commissioner once the service starts to be implemented. Now when you talk to the contract manager they will tell you that they have too many contracts to manage and so they are behind, but they probably have a conversation several times each year on any specific complaints and some discussions about trying to get day-rate prices down. Does this sound like a good basis for checking on this careful management the provider needs to have in place? – No.

      Maybe we need to look elsewhere? The Local Authority’s operations department deals with people approaching social services and, where necessary, assesses these people and decides upon a package of care to be delivered by one of the contracted providers. Each case will get logged on to the LA’s case management system and a purchase order sent to a service provider. In most instances the LA will get the care kicked off okay and then leave it to the service provider to look after. Anything up to a year later the case will be formally reviewed, but unless there is a complaint of some sort there will be no further checking. Have we now found a good basis for checking on the careful management the provider needs to have in place? – still no, but there is nowhere else to go, or is there?

      Yes, there is a third party monitoring organisation, the CQC with a stretched team of inspectors who go round checking on the performance of registered social care providers. The only data I could find for my local care home was a self-assessment done by the provider when they first opened two years before. Does this sound like a good basis for checking on the careful management the provider needs to have in place? Regrettably no, and I think this the end of the story.

      So to recap: the vast army of care workers out there needs careful management to ensure that sadists are rooted out and the good members of staff are properly trained, motivated and organised to excel at the job each commissioner has asked them to do. The council’s contract manager has to carefully manage the service provider (the contractor) but is not close enough to the provider to do that. The council’s operations manager has too many cases to look after so relies upon the provider and CQC. But in practice the provider is not carefully managed and the CQC, by their own admission is presiding over ineffective, unsafe and inappropriate care’.

      What is the answer? Surely it is not to spend more money overlaying more third party checking and quality control. This seems to be the Department of Health’s first response. Any process engineer will tell you that quality control is wasted effort – it might be necessary but its need has to be routinely challenged.

      I therefore strongly challenge the need for the CQC to be given more resources to check the front line services being provided by Local Authorities and their providers. The correct place to maintain quality is within the setting up and running of the contractual arrangement between commissioner and service provider. Notice I talk about two things: setting up as well as managing. As the EHRC correctly point out the commissioner must write a specification for the service which explicitly requires the provider to work in a way that protects human rights and they may well define particular measures the providers must adopt. Once the contract is signed, binding in the provider to deliver according to the specification, then the commissioning authority must guarantee that their chosen providers deliver what they have signed up to do. They pay for the service – they have a duty of care, no less, to ensure they get what they pay for from their nominated providers. This is what CQC should check first.

      There are just over 150 local authorities with responsibility for adult social care and many hundreds of thousands of front line workers – where would you start?

  13. Jane Ferguson says:

    Speaking as a parent of a disabled son I welcomed the chance to obtain direct payments, arrange my own after-school care and provide more independence for my son in ways that suited him. I am irritated by education and social care professionals who make all kinds of assumptions about what parents can and can’t manage. I am a highly educated education professional myself and know that I am best placed to arrange my son’s care, activities and lifestyle, knowing him far better than social workers who only see him once in a blue moon. I wish I had more control. I certainly have never been able to rely on our local authority to provide for his needs in any way.

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