In the Director’s Chair

The ‘In the Director’s Chair’ programme is a new series of thought-provoking essays from members of the ADSS Cymru Leadership Group, examining a wide range of topics right across the spectrum of social care policy and practice in Wales. It is an opportunity for service directors to use their professional knowledge and experience to speak freely and passionately about issues of social care policy and practice.

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Director of Social Services in Flintshire, Neil Ayling, offers his perspective on the concept of a national care service which has lately come under discussion and proposes an alternative solution in this debate.

Introduction

We have all been humbled by the contribution made by so many keyworkers, including health, social care, street-scene and many other service areas during the Covid-19 crisis, and these colleagues have been rightly recognised by governments and society at large. It has been refreshing to see the public mood changing towards much greater appreciation of the role of public servants in providing essential services to their fellow citizens, including a much higher profile for social care.

Of course, a time of such flux is when major change can happen, as happened in the post-war welfare state plans in Britain, when the NHS was set up. In this context perhaps we should not be surprised by the views being put into the public sphere about the potential for a national care service. This essay deals with the reality of this proposal and argues that a national care service should not be supported by ADSS Cymru, nor local government as a whole.

What does it mean?

Discussion about a comprehensive national care service has once again begun to creep into the public discourse and it is understandable that it might be included in political manifestos, due to having an outwardly intuitive and broad appeal. We acknowledge that seamless care and support is in all citizens’ best interests and fully endorse the plan put forward in A Healthier Wales. Yet in all likelihood, with social care remaining the poorer relation to health on a number of levels, if a ‘national care service’ were to be created, it would result in social care becoming part of the NHS rather than the establishment of a new entity of equal partnership. This paper sets out why such a development would be a regressive step for services in Wales.

This essay addresses seven key points that incorporate the main arguments put forward for creating a national care service, the pitfalls for public sector policy and alternative ways of tackling these challenges that demonstrate why social services should be retained as a key part of local authority public services. The essay then sets out a realistic alternative proposal to a national care service that addresses the challenges for social care.

Main Issues

1. We have seen how care homes have been pushed to the edge in this crisis and it does beg the question of how can we make the care home sector stronger and more resilient for the future?  Relevant to this is the issue of the status of the profession and the social care sector. In terms of its influence and access to senior policy, academic and governmental opinion, it is on a much weaker footing than the NHS. Although part of the reason for this is actually a strength of the social care sector – its diversity, strong links to communities and being spread across statutory, third and independent sectors – this nonetheless means there is not always a strong, coherent view.
   
   
   To respond to these concerns, what is needed is a revision of public sector policy to support and encourage that diversity which responds to local needs. The notion of bringing the care sector into a large, complex and unwieldy organisation such as the NHS would further dilute, weaken and marginalise the care sector.  There is much talk about strengthening and respecting the wider care sector and Welsh Government has played a credible, full part in this over the years. However, it is difficult to conceive that care homes predominantly in the independent sector will be prioritised in any joint health and care system over hospital beds and medical advances.
   
   
   Conversely, local authority social services departments now have a good track record of working very positively with the wider care sector, and there is abundant evidence of co-production in each authority; as well as a respect for real time cost increases (where the NHS have not – for example in regard to Continuing Health Care fees). It stands to reason, therefore that local authorities should be supported to continue this work.

2. Funding is an undeniable issue, as many working in the sector have experienced both professionally and personally. The reality is that the financial support underpinning social care is precarious and inconsistent from one authority to another. Claims have been made that a national care service would resolve this. However, in my view, this is not the case. Government of whatever hue and scale (Central, Wales, Local) could solve the social care consistency of funding issue by providing direct instruction to local authorities and giving them the financial clout to do so. The financial costs of doing this would of course be considerable, but more cost effective than channelling money through the health service where costs are greater, where ‘free at the point of need’ is the approach, and where the financial efficiency track record is much poorer.
   
   
   However, what we need are agreed long-term, dependable, financing strategies for adults’ and children’s social care that can enable local authorities to plan, work with care partners and build long-term sustainable service models.  This would have a direct, positive impact on our social care providers who could plan incremental increases in fees from one year to another.

3. Local authority-delivered social care is infinitely more financially efficient than services provided by the NHS in Wales.  The significant overspends across the country for all health boards, when further emergency governmental funding is required despite ongoing increases in funding, is unmatched in any other public sector service.  
   
   
   At the same time social care departments’ budgets are finite, constrained, but yet delivered well in the local authority context, where of course legally balanced budgets are required. Do we think social care budgets would be given additional funding in the NHS, if this funding was previously allocated to hospital care? This clearly would be very unlikely to happen. Local authority social care services have needed to innovate in services, for example reablement, to survive financially and have succeeded in curtailing ever increasing budget pressures, when the health sector been unable to do so.  Finally, social care has a robust, authoritative regulator in Care Inspectorate Wales, who have driven and insisted on improvement in services, and this is unparalleled within the health sector.

4. Good social care services work well when they work withorganisations and people, and the Social Services and Wellbeing (Wales) Act 2014 has ensured that citizens are placed at the centre of decision-making in regard to their care and support. The NHS approach, conversely, is based on diagnoses and prescribed courses of action.  This approach has been a priceless asset particularly in the months of the coronavirus pandemic months, and functions well in situations where a diagnosable illness or injury is present. However, it is inappropriate to the delivery and management of ongoing tailored care and support where the individual has a voice and control. That the NHS does not allow Direct Payments in Wales, for example, is indicative of its inflexibility, and the lack of prominence given to the Social Service and Well-being (Wales) Act in NHS circles (despite being written partly with the health service in mind) also indicates a detachment from its principles.  Certainly, the standard approach of health is to diagnose, treat and cure. This has been so vital in the last nine months, but that episodic intervention is a far removed from the long-term lifeline support models that have also celebrated during the same timeframe and required for good social care.

5. There is an issue of localism versus national consistency. Local government is a key part of British government and Wales has strong local authorities where local people vote politicians to govern key local services. There is much evidence to say that this localism works.  It makes a huge difference when services have direct local accountability and we know the NHS does not work as effectively in that way.
   
   
   It is instructive to see how differently local authorities and health boards deal with sensitive local and regional issues, often concerning service closure or provision.  Local authorities know their communities well, and their officers and elected members need to know their communities in order to survive. Many senior colleagues in the NHS do not have the same local community connections. There is considerable advantage from social services being an essential part of local democracy, as the services are much more centred and grounded in communities, a grounding that would be lost in a national care service.

6. The national care service view of the world perhaps assumes that health and social care services are the most obvious partners.  This is not the case, as social care has a huge range of key service partners, even more notable in children’s social care, and has as much in common with education, police and housing, to name three. If we made a change to integrate one part of the public sector jigsaw, we would undoubtedly create a gap elsewhere. Good local authority services working together with all public, private and third sector partners are some of the most creative and successful in Wales. Pulling social care out of the local authority family would perhaps terminally weaken local government and social care.

7. There is an issue regarding the experience of the response to the pandemic. It has been motivating and empowering to hear about how individual staff colleagues have positively changed people’s lives. However, it has also been highly rewarding to the leadership of social care to witness our local services, be they health, local authority, third or independent sector working together to move things forward at pace in the region and the country. Social care and local authority services are now used to moving at pace, and health colleagues have been impressed at the speed of decision for the financing, procurement and building of key projects such as care centres and temporary community hospitals, for example, health colleagues have said they would have taken much longer to navigate heath boards’ governance arrangements. Social care, as part of the local authority, can currently respond in a fast moving and agile way and any move to a national care service would, we suspect, limit this responsiveness.

An Alternative Plan for change

These then are the seven reasons why we as the leadership of social care reject the notion of a national care service. The final issue of course, is the required investment of change capacity to take forward such a whole scale change with no evidenced reason. The required change capacity to create it would be at least five years and with no clear benefits identified. However, we can still take forward the lessons learned from the Covid-19 experience and respond to the agenda for a stronger, more robust social care service.  Before concluding this essay, we should consider other key services which may work better if placed within the local authority setting and which will improve our service offer.

There are a small number of services currently in the NHS which have much greater synergy with local authority social care services, than with the acute, focused health approach and there may be scope to consider whether these could be included within local authority services. Of course, the point about change capacity raised above would apply, but there is certainly a case for considering moving the services listed below to a local authority led approach. These are:

• Public Health (already in England of course)
• Learning Disability Services, (local authority-led already)  
• Community Mental Health Services, including CAMHS
• Community Primary Care and Therapy Services

In all these areas, there may be clear advantages in working within a local authority service, but it is accepted that there may be good reasons to be cautious with this, due to the change investment capacity required discussed. Nonetheless, the experience of the pandemic – with the need for public health to work closely with local authorities – has illustrated the case for this being at least worthy of consideration, and elements of public health could be transferred in the future.

So, if not institutional change, what are the changes needed in social care to address the shortcomings of the current system?  In this context, three UK Prime Ministers have initiated work in this area that has then ceased. What is going to take us forward in Wales to improve the social care situation?

The realistic solution for social care is a five-point plan of action:

1. Resources: A five-year funding strategy for social care, protected by legislation, with more generous funding for the public sector to be funded in full.
    
2. People: The social care workforce must be consistently championed, supported and paid increases to reflect their improved esteem, and as first stage, advance their salary over living wage. The Association of Directors of Adults’ Social Services (ADASS), our England counterpart, have recommended a minimum hourly rate of £10.90ph for care workers, which would be a good place to start.
    
3. Building programme: A public sector-led capital programme to invest in local authority social care services for the future, akin to the 21st Century Schools programme. This will enable the public sector to work alongside private sector partners. 
    
4. Governance: Social care must be given more prominence in Welsh Government.
    
5. Legislation: Extend the Social Services and Well-being (Wales) Act 2014 and the spirit of co-production to become the dominant theme for the Welsh health and social care service, rather than just social care as at present.

Conclusion

If we, as a nation, take forward these recommendations, we will have a stronger social care service with national standards, yet delivered in communities, by local government. It will be a service fully fit for the future which can hold up its head alongside the NHS. We all know the NHS is an institution that we as a nation can be proud of, but its scale is significant, and one could argue that rather than seek to increase its size further investing in strong partners to work alongside the health service may provide greater security. Local authority-controlled social care services are one of those strong partners and we should make sure the wider social care sector is allowed to grow and flourish.

In conclusion, I feel the proposal of a national care service is far from the ideal solution purported by some factions. What works in social care is home-grown services, crafted by the experience of citizens and grounded in their communities, through local government.