“Everywhere it seems to be the case that the absence of government does not lead to bewilderment and confusion and disorder, as might be imagined if all government’s claims for itself were true, but rather to a resurgence of locally based forms, most often democratically chosen and scrupulously responsive, that turn out to be quite capable of managing the complicated affairs of daily life for many months, occasionally years, until they are forcibly suppressed by some new centralist state less democratic and less responsive.”
Kirkpatrick Sale
If Kirkpatrick Sale is right, and I believe he is, we are wasting our time thinking that it is possible to plan any kind of decentralisation. It can only happen if a top-down system collapses, leaving bottom-up ways of doing things to emerge from the ashes. Which will last until some new top-down state controlled power-seeking system imposes control.
The most intransigent part of the top-down system includes the big companies owning and running care homes for those with learning disabilities who are unable to care for themselves. They are totally outside the control of governments, national and local. They claim to be looking after the interests of people unable to look after their own interests. But their vested interests are entirely commercial.
These care home companies have become big during the past 15 years or so. And they are getting bigger as they take over smaller companies without the financial clout to survive. Bigness seems to be all-important in this world, perhaps because it increases their ‘value’ to their owners, the private equity and investment management companies.
These big companies process care staff as if in a factory. Because of standards imposed by the Care Quality Commission (CQC), staff have to be highly disciplined. Disciplined in the sense that, if staff step out of line, they are instantly pushed out.
Inevitably, care staff in such an organisation do not know who owns their company and cannot be expected to have any loyalty to their care home. Most of them see their jobs as filling in between better jobs.
This kind of caring is imposed on staff from above, in a rules-based system designed to meet the CQC box ticking regime. It is not a nice environment in which to work, so staff turnover is high.
Those staff who stay do so because their employment options may be limited. Often because they are over-weight.
Staff spend much of their time filling in paperwork to enable CQC boxes to be ticked. They also do the cooking (which they are not trained to do), purchase the food (the cheapest possible) and do the cleaning. So there may not be much time for caring.
These care companies depend on revenue from contracts with local authorities and NHS organisations to care for the residents. Contracts which are likely to approach £100,000 per annum per person being cared for. Prices are based on the number of hours of care seen by the commissioning bodies to be required for the care of each resident.
Residents whose care is paid for by social service and NHS bodies have to pay for ‘extras’ which are not included in the contracts with the care companies, such as contributing to a minibus, massage, foot care, tickets to outside events, meals out and personal care products. Those on benefits – most are – receive about £25 per week to pay for these extras.
The care companies are in an unassailable position in setting their charges because they have to provide care to meet legal and CQC requirements, and the public bodies have no alternatives once individuals have been put in the homes.
There is little to be gained in suggesting that such large organisations should reorganise how they do things, because that is how things are in the private equity world. Ownership of the care home companies may change from one private equity firm to another, but the top-down system set by the law and the CQC prevails. It is a benign kind of private sector totalitarianism.
Assuming that Kirkpatrick Sale’s model of organisation development in times of crisis is correct, what might happen if non-viable care homes have to close and are not taken over by a big company as happens now? We don’t know yet, because the public sector and financial institutions seem happy to support these care home companies, even when they don’t make a profit.
The planned decentralisation of the care home industry is not an option in the present economic situation. Decentralisation can only happen as a result of a major national financial crisis. But not to worry: if that happens local systems of care will then arise.
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I have a lot of sympathy with much of the analysis. However, having spent much of my working like trying to improve the care system for older people, it does seem to miss the crucial issue of how to pay for care services. Communities can do a great deal to help people, whether defined as geographical local communities, families or groups of carers – and they do. There comes a point when care and support from external agencies is needed to enable that help to be provided without unacceptable personal and social costs and when a long-term care setting is required. That costs a lot of money which is the main reason that we are failing to offer even the minimal levels of support which people need and should be able to expect. Without that structure of financial support, any system will fail.
I agree, but the money is not available and seems unlikely to become so.
We have to think outside the box of “business as usual”, which must mean that a new model of care is needed. A model in which relatives of those in care homes can join in the caring. This doesn’t seem to be possible whilst the big home companies continue to be propped up by the commissioning bodies.
The concerns about care services expressed in Barry Cooper’s piece are serious. So serious that they are in the ‘too difficult’ tray of today’s policy makers. But, a serious financial crisis might indeed force a radical re-think where ‘needs must’ would take over from the professional approach and top-down bureaucracy. Trouble is, we can only guess what else might happen after a major financial shock and there is a fair chance that much of it we would not like.
Nevertheless, it is hard to disagree with Barry when he suggests that there is no point in proposing change to the care system when we know that there are two almost insurmountable obstacles – the shortage of cash and the vested interests of the bureaucrats and the care home owners. But, it is not just ‘care’ that faces problems of this kind. We have blithely handed over many things to government without thinking about how sustainable that transfer of responsibility might be. ‘Health’ is prominent among them. The NHS faces demand that is almost infinite, but, it will always have limited resources. That mis-match is a recipe for the anguish that we see today – for those that run the service and for their customers.
Dreaming up new and better ways of doing things can be fun, but, working out how we make the transition from what we do today, to a better way in the future, is seldom as enjoyable. It is more challenging and where public services are concerned, a government risks losing votes as a result of doing something ‘sensible’. So, should we simply reconcile ourselves to accepting increasingly expensive and deteriorating services? I would prefer not to sit and wait for a crash, but, what is the answer from the radical centre?
David is so right about the obstacles in thinking about the future of the care system. This is how the top down system is. Intractable.
There are so many strands in this issue. All are interconnected dynamically. Ownership and management – private, public, mutual, community and family. Who pays for what? Standards and their enforcement. Responsibility – self or State? The roles of families, court appointed deputies and advocates. And so on.
Complexity is impossible to deal with from the top down. As David says, it is ‘too difficult’. So we must start thinking from the bottom up. We don’t know the future, but surely we could start thinking about it. Lots of what-ifs maybe. Such as: What if there is no more public spending on care? How might those of us at grass-roots cope? Perhaps we should talk about it?
Could Radix should take this on board in a Forum?