What Relevance Do Regulatory Frameworks Have To Choice in Social Care?
By Dame Denise Platt, DBE
Reproduced by permission of the Public Management and Policy Association.
The Commission for Social Care Inspection, of which I am chair, came into existence on 1 April 2004 and brings together the social care aspects of the National Care Standards, The Social Services Inspectorate and the SSI/Audit Commission Joint Review team into a single organization. Our scope is wider than the transferring organizations because we cover the entire social care industry: public, private and charitable.
We have been created to give a single overall picture of the quality of social care services and the performance of local councils in meeting the social care needs of their populations.
The legislation, which created us, has given us a prime function to promote positive improvement in the service. The Government intends that investment in public services be linked to reform and improvement. Over £12.5b of public money is invested in the service. In addition, 30% of the people who use social care services fully fund their care and may not approach the public authorities for assistance. This is a lot of money. People – and Government – need to know whether they are getting good value for money.
The Commission is charged with providing an authoritative and independent assessment of the quality and efficiency of social care in England. We will report annually to Parliament on the ‘state of social care services’, including how new resources are deployed and public funds are being spent. We will, therefore, be charting the progress in modernising social care in all sectors.
More than 50,000 inspections take place each year of services that have to be registered with the Commission. In addition, we inspect local council social services – including how they commission and assess services – and later this year we will assign their star ratings. We also have the function to carry out value for money and other special studies, and can cast early light on the implementation and effectiveness of current policy issues.
Working closely with other inspectorates, we will be able to track people’s experience as they move between services. For example, using our powers to carry out special studies, we can track a person going into hospital from home, through A&E and, after a period of treatment, returning home with a package of care arranged by the local council.
Who are ‘the vulnerable’?
More than 1.6 million people every year receive social services in the UK. Many people might describe them as ‘vulnerable’ – this is a word often used lightly. But what do we really mean by it? Who are we talking about?
- Disabled children wanting to join in like other children, to realise their potential or to go to school.
- Young people in care whose aspirations are limited by the services they are offered.
- Older people, perhaps disabled or living alone, wanting to change the quality of their lives, wanting peace of mind and independence.
- People with severe sensory impairments living at home, often cared for by others – usually a parent or a spouse.
- Carers who want to support their relatives at home – but need support to do so.
These are people with their own identity and rights, their own history, needing to be recognised as individuals. The word ‘vulnerable’ can disguise the real strengths, qualities and personality of people who rely on social care services. And it can result in people ‘being done to’, rather than being included and consulted.
But many people who rely on social care services can be very vulnerable because of other circumstances in their lives.
- Those who are isolated and have few friends or contacts can be vulnerable – to ill health and to neglect.
- People who cannot speak for themselves, who have no speech, or who speak a different language can be vulnerable – to deception or exploitation.
- People who rely totally on others can be vulnerable – to abuse and exploitation.
- People are also made vulnerable by the attitudes of others, who see their inabilities rather than their abilities. People with ill health or disability do not want their life to be defined by their illness, even though their life is often dominated by it.
- People are vulnerable to the actions of others when they are not involved in solutions about their care and support. They want to know what’s going on, what their rights are or what services, what choices, might be available. And they want to be listened to. They want decisions made about them made with them.
There are other factors, too, which can make people vulnerable.
Poor quality care. For example, I met one person with physical disabilities who experienced 26 home carers in one week, some perhaps poorly qualified, failing to introduce themselves and then carrying out the most intimate of tasks. We would not hesitate to challenge a residential care home that provided such fragmented care.
Inadequate commissioning. Commissioning that is so risk averse, so focused on what people can’t do, that it neglects to see what they can be supported to do. Commissioning that even when offering a choice offers only either “spuds or potatoes”. Commissioning that results in services that are geared to the organisation’s goals, not the individual’s.
Poor partnership. People do not want to be shunted around different systems. They want consistency and continuity, especially when they are in transition, for example from childhood to adulthood. They want to know that professionals are working together in their interests.
Unclear responsibilities for care. Our inspectors still find many services that are fragmented or delivered in ways that people find unsympathetic. The only person who knows what services are supposed to come when is the person receiving the care.
These, then, are the myriad factors, which can – and do – make people vulnerable when they do not have to be.
What people want from their services
The Commission is committed to taking the experiences of people who use social care as our starting point, and we are already exploring how we will do this.
For our launch, we commissioned a MORI poll to see what the public wanted when they got older and might need social care. Our first publication, When I Get Older, reported the findings. The overwhelming majority said they wanted independence and choice in older age; choice to decide where, how and with whom they live their lives. And 75% thought that people should be given the resources to choose and arrange their own care through direct payments.
People who use social care services now are clearly no different. Whether at home, at work or in their local communities, they want the same choice, control and freedom as other citizens. Whether they are seven years old or seventy, they tell us they want to be empowered to live their life as independently as possible, with practical and emotional assistance based on their choices and aspirations.
They want these choices to enhance their dignity and self-esteem and offer them respect as people. They want services, which are flexible enough to fit, round them as individuals. They want services to be consistent – in the quality of the care and the staff they provide. They want stability on their services: for example young people do not want to be always on the move from one foster placement to another. And they want staff who are competent, courteous and who make them feel safe.
The Commission will judge the services we inspect and regulate by how they reflect these qualities. We will comment on whether services are appropriate for, and meet the needs of, the people who rely on them, and on how they are progressing independent living. And we will also look at the choices and support people were offered when they had to make decisions about their care.
People who use social care services should not simply have a menu of choices but should be involved in the very compilation of the menu and all the ingredients that go into it too.
User focused regulation
It is vital to develop choice within which regulation fits, rather than see regulation as a constraint on choice.
The Commission will modernize social care regulatory framework and the way in which we approach it. Government policy emphasises the importance of inspection activity being proportional to risk, efficient in terms of the demands that it places on regulated bodies and primarily focused on the experience of the people who rely on the service.
We will question whether the services offered to people are appropriate. We will ask, for example, whether it is right for so many people with disabilities to be in residential care – however good the establishment. It is possible that a direct payment would suit many such people better? We will deliver user-focused regulation by including:
User experience: We will provide our inspectors with a range of tools that will help them to focus on the people’s experience of the service. We have already started developing the use of case tracking, which allows us to look in detail at the experience of a small number of residents or other people who rely on social care services, viewing the quality of the service from their perspective.
Proportionality: We will be transparent in identifying those services, which are good quality and need little external support to improve; and those, which are poor quality and are struggling to improve. We also want to be able to recognise those that operate above the minimum standards, and this means achieving better outcomes.
Efficiency: We will make our inspection more efficient – directing more of our own resources to doing fieldwork and reducing the amount of our paperwork that the service has to deal with. This is a common theme in our joint work with the Healthcare Commission and the integrated inspection framework for children led by Ofsted.
Better information for the public: Our reports will be written in a way that better tells people what it is like receiving a given service. Better information should enable potential users of the service, their carers and other interested people to make informed choices.
Of course, it’s easier to draw the big brush-strokes than to fill in the details of the picture. We are working internally on our business processes and hope that people will soon start to notice improvements in our performance. We have also drawn up a corporate programme structure and will work with our different stakeholders as we roll it out. And we are organising events, which allow us to meet and listen to what the people who use services say.
Our modernising process also includes discussing with the sector how we could develop self-assessments, so that the responsibility for appraising the quality of services also falls on the service provider.
This is a hugely important and exciting project. It will give those responsible for the delivery and the commissioning of services the opportunity to be innovative, to concentrate on improving services and to provide choices. We have already started to work with the Rowntree Foundation on evaluating a new approach to providing nursing within the nursing home sector.
User-focused regulation means keeping the individual, or resident, at the forefront of our attention and using the regulatory framework and national minimum standards in order to ensure effective outcomes for that person, outcomes which derive from their choices and aspirations. Achieving user focused regulation means:
- Assessing risks in terms of the probability of events and the impact on the people who use the services.
- Assessing services basing judgements on contemporary best practice and experience, including the experience of those reliant on the service.
- Making judgments in the context of the local environment and the needs of people who rely on services, being clear how and why these judgments are made.
I want to develop our discussion with the sector to how the service best meets the needs of people, not the semantics of the regulations and standards. We should be debating achieving excellent outcomes for people, wherever they live – what sort of ambition is it that aims to be mediocre?
A modern regulatory regime therefore requires all the partners in it to work together, respecting each other’s different perspectives and drawing on the valuable lessons that each derive from their own particular angle.
In developing real choice for people who use social care services, there are some risks that will need to be understood and addressed.
First, I can hear some people say there are national priorities that require a standardised approach. I can’t agree with this.
There are few people who would disagree with the national priorities:
- That looked after children should gain a good education.
- That care leavers, once they have left care, should be in education, training or employment at the same rate as the general population in their area.
- That people should be looked after at home rather than in institutions.
- That people should not be kept in hospital when they do not need to be there.
Lets take the first point – the evidence is that looked after children value education more highly than the average child – but they are more likely to be excluded. Think back to the qualities people value in their service – stability and continuity featured highly. Research shows that looked after children achieve more highly where there is stability of placement. Stability of placement is a national indicator. Children tell us that they should be consulted about the choice of placement – where they are not it often does not work out.
Local priorities mean working at the things that matter in your local population. National priorities can very effectively be taken forward to fit local circumstances.
Secondly, I can hear people ask whether the people who use social care services truly can make a real choice when often they are not fit to make such choices, or legal action deprives them of choice. For most of the people who use social care this is far from the case. And even for those where it may be true there are choices of ‘how’ even if not about ‘what’.
This article has shown that the regulatory framework we have started to build is based on choice and on the qualities that people expect and want from their social care services.
What is important is not what relevance regulatory frameworks have to choice, but ‘how should regulatory frameworks enhance the capacity of people to make better choices that support them to realise their aspirations and ambitions?’