REBALANCING SOCIAL CARE IN WALES — Response to Welsh Government White Paper on Social Care.

Through the decade of austerity, the Welsh Government is to be commended for its efforts to maintain the sustainability of our social services, in contrast to other parts of the UK. Socialist Health Association – Cymru (SHAC-C) welcomes the initiatives to promote greater joint working with other key agencies such as the NHS, housing, and education. The cap on the costs of domiciliary care and the increased thresholds for residential care provides Welsh residents with a more generous provision than elsewhere.

We also welcome the proposals to improve the status of the social care workforce through its increased professionalisation and to seek remuneration solutions through the Social Care Forum. The initiatives to reduce the prevalence of zero hours contracts and to enhance the choice of the care workforce should help to bring some stability to the sector.

Innovative initiatives such as the Children’s Commissioning Consortium Cymru has provided a strategic response of humanely addressing some of the most difficult challenges in Children’s Services provision.

During the Covid-19 pandemic the Welsh Government recognised the vital role of its public sector partners as being pivotal in its response rather that embark on a wasteful and incompetent embracing of the private sector. It acted quickly to learn important early lessons by intervening to provide care home providers with personal protective equipment and to institute a regular programme of staff testing.

In this period of crisis, partnership working across organisational boundaries happened to an unprecedented extent. It showed what is possible – with proper leadership and the political will to make things happen. These achievements were on a par with those inspired by the “Spirit of 45” which followed WW 2.

SHA Cymru fully supports the Welsh Government’s £500 bonus payment to our frontline social care staff. It is a pity that the UK Government did not have the generosity of spirit to reciprocate.

Despite these commendable policy initiatives, SHA Cymru feels the consultation underestimates the scale of the challenges that the social care sector faces. The present substantially privatised provider model is in crisis at all levels from children’s services to services for older people. It is not at all clear what are the continuing advantages of this model. There is an underlying premise that it is possible to achieve the necessary improvements in quality through commissioners purchasing and procuring services from non-public services bodies.

Social care should not be a market. The approach of ‘switching suppliers’ may work for consumers of electricity, but it doesn’t work for social care. It does not matter who provides your electricity, the product is the same and it is just a matter of price. It does matter who provides your social care. Who delivers the care can determine what care is given.

The NHS was conceived as a national service, designed to meet the health needs of both individuals and communities. Provision was rationally planned and provided. Individuals accessed it when needed. Their needs were not assessed and then the market searched for the product. This is very much the “for profit” and insurance model where you justify your claim in line with means testing and eligibility criteria.

In the past a combination of pro-market ideology and determination to drive down costs was the rationale for the current model. As time has gone on it is becoming increasingly obvious that there is a price to be paid for this dogma – in terms of quality of care, workforce retention and training as well overall sector stability. SHA Cymru welcomes the view arising from the two-year review of A Healthier Wales that further work will be done to…” rebalance social care and address the barriers which have made it difficult for the public sector and not-for-profit organisations to be major providers of care.”

We accept that there will be an element of disruption if there was a precipitate switch to a public service model of care. However, we believe that this can be done in stages e.g., i) establishing national terms of service for care staff ii) national fee structures iii) taking domiciliary care services in-house and remodelling others into mutual/social enterprises iv) provision of new all-life housing as an alternative to residential care in advance of any wholescale transfer of residential care provision.

This consultation document recognises that the market is not working. Its responses are substantially proposals to re-shape the market. SHA Cymru asks if it is time to consider alternatives to the market itself. We believe this, in line with a substantial investment, is the only way to address all key problems that this consultation is trying to address. The inherent tension between the use of the for-profit sector to deliver public services is threatening the quality of care for service users and is undermining the attainment of the employment environment which the consultation wishes to achieve. In the event of market failure, it is the public sector that must pick up the pieces.

SHA Cymru supports the establishment of a National Care Service. This is the first step in addressing many of the consequences of the present fragmented provision model. This national model would have many of the features of the NHS which are so valued by people in Wales, but we do not support the “take over” of social care by NHS.

Social care is a service which not only interfaces with health care, but it also interfaces with many other sectors including education, housing, the world of work and training, the welfare system as well as culture and recreation. Social care and its workforce have a different range of values and professional standards which do not readily fit with the mainstream medical model.

A National Care Service must promote a more uniform set of standards of across Wales while recognising the diversity of our population and the diversity of its needs. These standards would include what citizens can expect from social care as well promoting a working environment that values the staff which will deliver the service.

Such a service must be free at the point of use. The present means testing system is long out of date as it catches more and more people on relatively modest means into its clutches following the growth in home ownership since the 1980s. There is a strong view that those who pay for care also contribute a premium to make up for the inadequate levels of public funding and the consequences of a decade of brutal austerity.

A reformed social care sector must be about more than structures and organisational boundaries. This is where the consultation document is weakest. The present market model of provision, linked to a decade of austerity, shapes what type of care is provided. Fewer people are being deemed eligible for more complex packages of care. Those who do not reach the threshold are obliged to fall back on their own resources and the resilience of their families, friends, and their communities where the root of the problem often lies in the first place. This is often falsely described as reducing unnecessary dependency and promoting the resilience of the care seeker.

As social care is only fully accessed by people with increased complexities of care this place greater demands on service providers who are invariably operating on stand-still levels of resources.

The service needs to be more citizen and user directed where co-production of provision is the heart of the assessment and delivery process. However, SHA Cymru has serious concerns about initiatives such as “direct payments” which have their own add-on costs, and which often operate on the fringes of poorly or self-regulated market.

SHA Cymru strongly believes that obtaining any advantages and benefits of user directed care are entirely consistent with a public sector or mutual/social enterprise model of care. However, it will require resources and a culture in which the service user is the key architect of the service provided. In this new approach the work of social workers and other Allied Health Care professionals will be to facilitate and empower citizens rather than being constrained by eligibility and financial barriers on what can be provided. We need to move beyond a service in which the citizen receives what is defined by a range of eligibility criteria and means testing to one that is based on a holistic assessment of their needs.

Response to individual Questions.

Summary of the consultation questions The Welsh Government welcome comments on all aspects of the proposals. We are particularly interested in responses to the questions. A summary of the questions is provided below.

Question 1: Do you agree that complexity in the social care sector inhibits service improvement?

The complexity and inefficiencies of the market exists at many levels.

Service users.
1. Services users are subject to a needs assessment which is often predicated on seeking ways to delegate caring duties to the applicant, their family, or friends.
2. Financial constraints may curtail the delivery of a fully holistic care package.
3. Applicants are subject to a financial assessment which can be difficult and obtrusive.
4. The lack of staff continuity means that service users must deal with a series of different carers.

Commissioning Process.
1. There is a multiplicity of providers of social care, usually in the for-profit sector. This involves additional and unnecessary transactional costs. This is further complicated by additional costs when a “self-funder” must be reassessed having dropped below the various capital thresholds.
2. There is continuing confusion between paying for “social care” and “continuing NHS care (which is free).

Cross Organisation Boundaries.
1. We welcome efforts to promote integrated joint working via Regional Partnership Boards and through funding streams such the Integrated Care and Transformation Funds. However, all these arrangements are not without their problems though they have made an important contribution to joint working.

The lack of clear mechanisms to identify, allocate and share budgets is a significant obstacle to joint working.

Joint working on the front line is facilitated by putting a “face to a name” and building trust. The relationships built during the present Covid-19 crisis bears this out. In “normal times” it unusual for front line workers in social care, housing, education, and the NHS to build up a relationship based on joint working – they do not know each other, they work for different organisations with different priorities, and they do not share a common workspace.

Question 2: Do you agree that commissioning practices are disproportionately focussed on procurement?

Yes. Except that the extremes, price will always trump quality.

SHA Cymru strongly believes that the number of people who obtain services and what services are provided are curtailed by financial constraints rather than by full needs assessments. This also applies to unpaid carers.

We accept that austerity is a major obstacle to commissioning for quality when resources are extremely limited, and need is increasing.

Also, it is difficult to measure quality as opposed to measuring a failure of compliance which is set out in rules, standards, and regulations. There needs to be better ways of capturing the lived experience of the service-user, their carers, their parents, and their advocates.

Question 3: Do you agree that the ability of RPBs to deliver on their responsibilities is limited by their design and structure?

Regional Partnership Boards are a step in the right direction. The Welsh Government must do more to promote their importance and profile.

However, most of the organisations that are involved still have a limited commitment and retain a strong territorial loyalty to their parent bodies. Competition for funding and resources is a major obstacle to joint working.

The governance arrangements for the RPBs are totally opaque and SHA Cymru suspects that their existence is only known to a small number of people in the NHS, local government, Third Sector, and public bodies such as NRW.

The RPB needs assessments and the strategic responses that they generate are not major priorities for most of the constituent bodies. They are more exercises in compliance that an engine for change and delivery.

We believe that RPBs could enhance their role and effectiveness by being a catalyst and conduit of best practice within their region and elsewhere.

Question 4: Do you agree a national framework that includes fee methodologies and standardised commissioning practices will reduce complexity and enable a greater focus on service quality?

Question 4a: – What parts of the commissioning cycle should be reflected in the national framework?

SHA Cymru supports a National Care Service in Wales in which citizens have a reasonable understanding of what they can expect from their social care service. However, this national service must reflect the diversity of need and culture in the various parts of the country.

We support the creation of a national social care workforce for Wales rather than the infinite variety of current employment practices and standards. This will ensure a uniformly trained workforce with national terms of service. As staff pay is the single biggest cost in the sector this will remove a lot of the fog that surrounds fee setting now. This will simplify the commissioning process and reduce its inefficiencies.

We also welcome the Welsh Government’s proposals for regular sector viability assessments. This will be an important mechanism to align capacity with need. However, we are disappointed that these proposals are not linked with policies to promote direct public sector provision where local needs are not being met.

The commissioning process must seek to identify unmet and unfunded need. This will provide important information for future planning cycles.

Question 5: Do you agree that all commissioned services provided or arranged through a care and support plan, or support plan for carers, should be based on the national framework?

Yes. However, this does not mean a one size fits all provision delivered in any colour providing it is a bland white!

In health and education people have a reasonable understanding of what to expect across Wales. There is no reason why the same should not apply in social care. Indeed, the co-payment element in social care makes this more important. We welcome the Welsh Government cap on the cost of domiciliary care and the increased thresholds for residential care.

Care plans must be co-produced with the service user and their carers rather than provided within constraints and obfuscations of means testing and eligibility barriers.

Question 5a- Proposals include NHS provision of funded nursing care, but do not include continuing health care; do you agree with this?

Without understanding the historical context, the present system is totally incomprehensible to the average citizen. There is no sense that one person gets a “free NHS bath” while someone else has to pay for a “social care bath”. Equally there is no logic that a person with a chronic illness such as cancer gets a free service on the NHS while those with dementia must pay for most of their care via social services.

These arrangements fly in the face of the Welsh Government’s commitment to user centred and integrated care.

Question 5b- Are there other services which should be included in the national framework?

As mentioned in our introduction we believe that in a National Care Service there should be national standards of care, national eligibility criteria for services, national means to promote co-production and citizen led services and national terms of service for staff.
Question 6: Do you agree that the activities of some existing national groups should be consolidated through a national office?

A National Care Service needs a strong sense of national purpose for social care. The concept of a “national office” fails to capture this vision. SHA Cymru believes that we need a national executive or directorate to drive forward many of the objectives outlined in the consultation document. The executive / directorate should have a clear mission to develop a quality, coherent service across all of Wales.

In a National Care Service in Wales many of the present “bolt-ons” should be integrated into a single cohesive organisation. However, the specific specialisms of the individual services need to be recognised and provided for.

Question 6a- If so, which ones?

While we support an overall National Care Service, the regulatory and inspection roles should be independent and seen to be independent. We welcome the integration of NHS and Social Care complaints processes on an independent basis from the NHS and local government.

Question 7: Do you agree that establishing RPBs as corporate legal entities capable of directly employing staff and holding budgets would strengthen their ability to fulfil their responsibilities?

Yes. SHA Cymru would welcome the establishment of the RPBs as corporate legal entities. Now they exist as a gift provision by their component bodies. This deprives them of the status or capacity to plan the delivery of integrated services across organisation boundaries.

There must be mechanisms to allocate resources to the RPBs for both their own administrative / management purposes and to have the means to fund integrated cross boundary services. We note the references in the consultation document to experiences in the other parts of the UK in relation to integrated working.

We believe that there are valuable positive lessons from the Scottish experiences. On the other hand, we would advise caution about replicating the main English direction of travel – which is deeply contaminated by serious under-funding and commercialisation of services.

Question 8: Do you agree that real-time population, outcome measures and market information should be used more frequently to analyse needs and service provision?

Question 8a- Within the 5-year cycle, how can this best be achieved?

The Financial Crisis of 2008, Brexit and the Covid Pandemic of 2020 show how vulnerable long-term planning is to unforeseen events. Any planning cycle must be flexible enough to adjust to such shocks.

However, we also realise that strategic change cannot be delivered on short time scales. The NHS process of in-built short- and medium-term reviews within a long planning cycle has a lot to commend it.

Question 9: Do you consider that further change is needed to address the challenges highlighted in the case for change?
Question 9a- what should these be?

The consultation document has presented itself with a range of almost irreconcilable ambitions.

For the immediate future we are likely to face continuing austerity. We welcome the Welsh Government’s commitment to continue to lobby and use its good offices to urge the UK Government to deliver on its decade old, and much delayed, pledge of addressing the challenges of social care. If these efforts are not successful, many of the consultation paper’s objectives will not be achievable.

A shift toward “commissioning for quality” is highly commendable, but the road to achieving this is littered with obstacles and potholes. The sector itself is in a highly fragile state bordering on unsustainably. At a very minimum, a quality service requires a valued, stable, and well-trained workforce. All these requisites are at the mercy of the variability that is inherent in a multi-provider for-profit model for care delivery.

Unless there is a way of addressing current financial pressures then the present trend of ever higher eligibility criteria will mean fewer and fewer people will be in receipt of care. As need is inevitably going to increase it will mean that more and more of people will be left to live deal with their problems by whatever means they can muster.

Question 10: What do you consider are the costs, and cost savings, of the proposals to introduce a national office and establish RPBs as corporate entities?

See the answers to Q6 and Q7 above.

Question 10a- Are there any particular or additional costs associated with the proposals you wish to raise?

We accept that a quality social care service will cost money.

We note the work that is being done on a social care levy and we wait to see its outcome. However, any market-based funding system will be subject to major shocks – we have seen three since 2008 – and we wonder how resilient they will be in the long run. Very few insurance based public services have been sufficiently resilient to survive without state interventions and guarantees.

Welsh language

Question 11: We would like to know your views on the effects that a national framework for commissioning social care with regionally organised services, delivered locally would have on the Welsh language, specifically on opportunities for people to use Welsh and on treating the Welsh language no less favourably than English. What effects do you think there would be? How could positive effects be increased, or negative effects be mitigated?

It is essential that social care services should be delivered bi-lingually. This is crucial across all age groups from children’s services to services for vulnerable older adults. Equally the right for people with learning and physical disability to live their lives thought either Welsh or English must be fully recognised.

The local needs assessments must take full account of the cultural values and diversity of the population it is assessing. Service providers must not regard responding to this diversity as an optional extra.
Welsh and English have a particular standing in Wales. However, many other vulnerable people e.g., asylum seekers, refugees, migrant workers, and minority ethnic groups will have needs which a holistic service must strive to address.

Question 12: Please also explain how you believe the proposed policy to develop a national framework for commissioning social care with regionally organised services, delivered locally could be formulated or changed so as to have positive effects or increased positive effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language, and no adverse effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language.

If “quality” is to be the key barometer of performance, then a citizen focused service that is planned and delivered in line with local needs can only promote Wales as a bi-lingual country. Most social care providers are heavily dependent on local people for service provision. This workforce will be familiar with local cultural values and norms. A secure, valued, and well-trained workforce can only enhance the quality of life of the citizens under their care.