Root and branch reform

Thursday, June 24, 2010

The old paternalistic, top-down approach to care services should give way to person-centred support and flexibility. And now – faced with both spiralling public debt and increasing levels of need – might be our moment to deliver radical change, says Martin Green, English Community Care Association chief executive

The government is faced with spiralling levels of debt and increasing levels of need. There is no longer the option of the current system going on without reform and what we need to see is not a rearrangement of deckchairs on the Titanic, but a recognition that the challenges we face are so enormous that they require radical structural change and a new approach to care.

At a time of economic difficulty and increasing need, we must move care services centre-stage and remind government of their economic, as well as social, benefits. The care sector not only provides care and support for people who need it, but it is hugely important as an employer and extremely economically active as a consumer.

In any debate with government about where care is positioned in the hierarchy of government priorities, our best approach is to play to our economic strengths because the focus of government will be on deficit and debt far more than it is on care and support.

This is a challenge for our sector because traditionally we have been values driven and support focused and I am certainly not advocating that we lose this, which is the essence and the very core of what we do. But I am, however, mindful of the need to play up other aspects of our work and to talk the language that government hears rather than that that it wants to turn away from.

Sadly, in order to meet the challenges we face, we cannot just rearrange the current system. We need a radical root and branch reform, which focuses on outcomes and service users, which acknowledges our economic contribution to society and which shifts resources from structures and transactional costs into direct services.

Over the past 10-15 years we heard much talk about public sector reform. The time has come for this to be delivered. It is not going to be easy or comfortable for the public sector because my reform agenda would be about minimising the input and the structure of the state, handing the power and the resources to service users and enabling people's needs to be met in new and creative ways, rather than following the old patterns of paternalistic service provision.

The state should confine itself to assessing need – how service users have their needs fulfilled should be opened to anyone who can deliver to a standard that ensures quality, safety and value for money.

I am in favour of a move away from the traditional notion of social work, which has tended to deliver a very rigid approach to the fulfilment of need, and I would like to see the development of independent advocacy/commissioners who work with service users to deliver on their needs assessment.

This would significantly reduce transaction costs, move away from the inherent conflicts of the statutory sector being both assessor and advocate, lead to more creative and lateral thinking, and place service users at the centre of the relationship that exists between assessment, commissioning and provision.

There is also a need to think more creatively about how we draw funding that is currently in the health part of the system and deliver it into social care services. Social care providers have the expertise and the track record of delivering care and support for people with long-term conditions.

If you examine both the unit cost and the user satisfaction of people with long-term conditions it is quite clear that health service provision is high cost and not delivering.

We have got to see a move towards not only this transfer of resources across the system, but eventually a move towards integrated budgets. Only when we have this and we monitor performance against outcome will we stop the turf wars between health and social care that have been so negative for users and so incredibly wasteful of resources.

We are in very uncharted waters as far as the level of deficit is concerned and this, combined with demographic change, will make a radical approach to care provision the only option in the future. Our financial position is a tremendous threat to traditional services, but I would argue that they have already had their day.

The 20th century paternalistic structured approach to the delivery of care services has to give way to person-centred support, enablement and flexibility – and now might be our moment to deliver it. For too long, decisions about care have been framed by the needs of staff and of structures – we need to change that and radically review how we engage in a citizenship approach to care and support.

Our current financial difficulties create an enormous challenge, but they are also an unrivalled opportunity because the challenge is so great and the resources so inadequate the debate about change can no longer be about maintaining the status quo versus changing it. It can only be about radical solutions, different approaches and better use of resources. This is not a discussion item. It is an imperative.