A lot has happened in care since the launch of Care Talk in April 2011. We look back at the big issues featured in the magazine in its first two years, and ask some regular contributors which ones refuse to go away.
The new magazine coincided with announcements of Government spending cuts that, as Mike Padgham warned in his April 2011 opinion piece for Care Talk, would have a serious knock-on effect on providers. And so it has seemed, as local authorities tighten their purse strings and demand more care for less money.
And early Care Talk stories on the demise of Southern Cross only highlighted the challenges for care providers in a tough financial climate.
Health and social care lawyer Jonny Landau of Ridouts LLP believes: “Public sector cuts will undoubtedly have greater impact than any other policy change. We are already seeing the consequences – tightening eligibility and service users being kept at home for as long as possible. The older people residential market will contract if not disappear and all older people services will be higher dependence nursing and dementia units.”
The push towards person-centred care, especially in people’s homes, has faced a constant battle against the need to trim costs in order to win council contracts.
This is an issue that won’t go away any time soon, says health and care commissioning consultant Janet Crampton. “The financial pressure on local authorities is not abating, and they have still not bitten the bullet about what non-essential services to cut in favour of education and social care. “
But providers aren’t taking things lying down, as Jonny points out: “The successful judicial reviews against fee freezes and decreases were not something I initially expected. Courts tend to steer clear of micro-managing local authority finances. However, court rulings that local authorities must have due regard to the cost of care when setting fees was hugely welcome and undoubtedly led to modest fee rises in some where there may have been reductions otherwise. Regrettably, local authorities saved money by tightening eligibility criteria instead.”
Professor Martin Green
" I predict eventually there will be a resurgence of residential care"
The sector is moving in the right direction with its increased focus on personalisation and quality, which Professor Martin Green, chief executive of the English Community Care Association, describes as “the drivers that will deliver on the expectations of 21st-century citizens”. But he points out they also require enormous investment in terms of personnel and funding. “Given demographic change and the enormous pressures on the system, I predict eventually there will be a resurgence of residential care because the numbers of people required to deliver high-quality flexible care in the community will not be available, and people with resources will make informed choices about where to live and the level of service they want to receive.”
Health and care reforms
The launch of Care Talk coincided with the publication of the NHS White Paper setting out a shift to clinically-led commissioning and greater integration of health and social care.
Two years on, and this month saw a number of new bodies assume healthcare commissioning and delivery responsibilities.
The impact is likely to be long term, particularly relating to organisational culture within the changed health landscape, says Martin. “There is enormous potential for these new structures to deliver a much more integrated health and social care system, but the challenge, as always, is not the structures within which services are delivered, rather the attitudes and prejudices of the people who work within the system.”
Janet has concerns about the pressure on commissioning budgets in health, “not least because of the costly infrastructures around the new commissioning arrangements. Where will more person-centred services and individual choice and control sit when economies of scale are constantly being sought?”
Reforms in the care sector were also part of the Government’s plans, but continuing delays to the publication of the draft Social Care Bill and the White Paper Caring for our future: Reforming care and support were frustrating, and when they actually appeared in July 2012 proved something of a disappointment in not addressing funding more emphatically.
How people pay for care was very much in the spotlight in autumn 2011 with the original publication of the Dilnot Commission’s report, and ever since, as the sector awaited details of how the recommendations would be put into practice.
Has Dilnot been a bit of a non-event, more vision than substance? Janet is disappointed in the Government’s “late and mealy-mouthed” response. “It makes no real sense and benefits relatively few people. I was hoping to see the asset threshold rise to at least £25,000 in an attempt to edge towards the cap the Government is going to put on people’s contribution to the cost of their care, but it hasn’t happened.”
Even so, Martin believes that implementation of the Dilnot proposals will be one of the biggest impacts on the sector over the next two years. “The proposals themselves do not offer a solution for the underfunding of social care, but they do set some long-term objectives on how the split between individual responsibility and state funding will work.”
New Social Care Institute for Excellence chair Lord Michael Bichard’s view is that the complexity of conditions and personal circumstances experienced by growing numbers of people requiring social care and support will prove an even greater challenge in future. “We have not seen the necessary transfer of resources from acute hospital care to social care, nor have we seen enough progress towards integrated care and prevention. We also need to do more to avoid the sector being low skilled and low paid. In such a challenging context Dilnot and the Government’s response is only a small part of the answer.”
Care Talk has carried many stories on specific forms of funding like self-directed support, as well as constantly banging the drum for people to be able to make their own decisions regarding their care, including how it’s paid for.
Jonny reckons things are moving in the right direction in some respects. “The Mental Capacity Act was like a springboard that launched the importance of individual service users being at the centre of the services they receive. ‘Personalisation’, ‘person-centred’ and ‘individual’ are quite rightly key words for all working in social care. The concepts in turn have led to personalised budgets allowing
service users to spend their money as they choose. All of this is a welcome advance from the paternalistic past where the social worker knew best.”
Janet is more pessimistic about the overall picture: “I expected to see far more on personal budgets than has been delivered. The problem with personalisation in a climate of financial hardship is that it’s not the most defensible in terms of cost per case or cost per outcome. Commissioners are chasing economies of scale and personalisation doesn’t fit.”
Systemic ageism is part of the problem, says Martin. “Currently older people are seriously underfunded compared to other sections of the community. In the next two years, with the full implementation of the Equality and Human Rights Act, I believe we will see a challenge to the inequality of funding between older and younger people. This could completely change the balance of funding and force local authorities to equalise their funding across client groups. This will be an enormous challenge because there will be significant losers, as well as winners in this process.”
Discussion of a new vetting and barring scheme, intended to root out potential abuse (and introduced late last year), in the May 2011 issue, was sadly swiftly followed by a Panorama exposé of horrific abuse of vulnerable residents of the now infamous Winterbourne View.
Care Talk was not the only one to ask ‘how was this allowed to happen?’ and look at ways to encourage whistle-blowing.
High-profile cases during the past two years will have a lasting impact, says Janet. “After Winterbourne and Mid Staffs, everyone is much more safety conscious and risk-unwilling. The legacy is improvement in the position of people who want to whistle-blow, a fairer regime for staff, patients and end users, but it is increasingly in a climate of concern at scrutiny and the unreliability of inspection, regulation and compliance.”
The newly-launched Care Talk paid special attention to the needs of people with dementia in light of worrying estimates of the numbers expected to suffer from the disease in future. But our coverage has often been positive, with case studies showing what it is possible to do to help people live well with dementia.
Dementia has steadily become a priority, not just for the sector but the Government and the wider public sector, voluntary organisations and communities, and Care Talk has been happy to report on initiatives such as Dementia Friends, and the Prime Minister’s own Dementia Challenge.
This has come as something as a surprise. Martin says: “I think the most remarkable thing that has happened and which I never expected to see, was the Prime Minister making a speech and a personal commitment to improve services to people with dementia. For so long dementia had been in the shadows and not recognised. Of course speeches are easy, but the challenge now is to rise to the aspiration and commit the necessary resources.”
Staff development was in the spotlight in the first issue of Care Talk, with the introduction of the Qualifications and Credit Framework, while Enabling Excellence recommended regulation of healthcare and social workers.
Upskilling generally and for specific roles, such as registered care home managers, have been recurring topics for discussion. Care Talk has been able to report on a range of initiatives, such as the new framework for leadership qualifications featured last month.
Underlying these individual efforts to improve the workforce is the need to embed core principles. “Quality standards can only be delivered and maintained if staff are appropriately skilled and caring. I’d like to see some radical reinforcement of that,” says Janet. “We are protected when we buy goods and services to ensure that they are provided with reasonable skill and care, yet in the very arena where it matters most, there is little protection and few sanctions. This needs to start with recruitment, induction and continuous in-service training.”
The image of the sector
The lead article in our launch issue asked why a magazine like Care Talk was necessary. The answer was, because the sector needs to recognise its achievements and progress, especially to combat the negative image the media often presents.
Of course, the media has an important part to play, but the balance needs to be right, says Jonny. “Both television and print media have campaigned vigorously against poor standards and worse in care homes in recent years and this is bound to have impacted on public perception. However, often the media vilify care providers without getting to the root causes of poor standards including falling real cost fees and poorly led regulation.”
It’s a constant battle to change perceptions. “Care Talk, the Great British Care Awards and so on all contribute to raising the profile but it only takes one Panorama programme to blow the whole thing apart again,” says Janet.
Care Talk has never ignored what ‘others’ say about the sector or how they see it – through regular features like Caught on Camera, and news stories on damning reports from organisations like Age UK – but tries to focus on all the good work being done. This has extended into spin-off events like the Great British Care Shows and, this month, the first ever Good Care Week, originally mooted in summer 2012.
“I think the profile of the care sector has changed significantly in the past two years and some of these changes have been positive and some negative. There is undoubtedly a greater national focus on care, partly driven by negative stories of abuse and the business failure of Southern Cross,” concludes Martin. “A significant improvement in the perceptions of care staff in the past two years is due in part to the Great British Care Awards and Care Talk, which have championed good practice and the work of outstanding and committed individuals.”