Where is the customer in residential care services?

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Des Kelly OBE, Trustee of the Residential
Forum, reflects on a workshop that asked whether the residential care market
was a myth or reality.  He shares the
flavour of contributions and concludes that the customer can easily get
overlooked in the worlds of regulation, commissioning and procurement.

I
admit I wasn’t sure that ‘Residential care market – myth or reality?’ Would be
a theme to generate the sort of lively discussion we are used to at Residential
Forum workshops. But it turned out my doubts were completely unfounded and the
debate was a stimulating as ever!

The
event held on 4 and 5 May 2017 started with presentations from John Kennedy
(The Residential Forum), Margaret Flynn (NISB Wales) and Jonathan Stanley (NCERCC).
Their combined input proved to be more than sufficient to spark the engagement
of the attendees at the workshop.

There
was universal agreement that efforts to create a market for residential care
services – whether for older people, adults or children or young people – had
not been successful. Whilst splitting commissioning from providing had
introduced competition and stimulated new providers, especially in the
independent sector, the result has been something of an imperfect market which arguably
does not operate in the interests of consumers. The market for residential care
services has always been a monopsony as the local authorities have, and
continue to be, the main purchaser of services.

The
mechanisms that generally monitor and control the entry and exit from the
market don’t work in the same way in the care sector. Local authorities
effectively set and maintain the price paid for the service. In addition, there
is no financial regulator for the care sector either at local or national
level. There has been little consumer legislation to protect people receiving
residential care and the levers of control remain rather limited. If any
thought is given to the issue at all it is assumed that the inspection process
will pick up any shortfalls.

Margaret
Flynn argued in her presentation, drawing on a major review of provision and
challenges in Wales, that when safeguarding concerns are overlaid on
residential care it highlights the cracks in the system. She suggested that the
evidence required to close care homes is such that few are actually pursued to
closure with operators exiting the market by other means.

Jonathan
Stanley suggested that residential child care is a socially constructed sector
made up of a series of markets. He felt that there is no real commissioning
only procurement. As price is always the dominant factor and social value
rarely seems to feature. Furthermore, there is little sector development and
limited innovation. The introduction of competition per se was regarded as a
good thing for residential care according to John Kennedy. However, shaping and
managing the market had proved difficult for local authorities and consequently
the outcomes were uneven which has had an impact on supply, choice and quality.

Who
is the customer?

All presenters highlighted the
dominance of price and the lack of meaningful commissioning. The absence of
consumer power in residential care was considered an indication there is not a
true market. Neither choice nor control are sufficiently well-developed. In
fact, agreeing who is the customer in relation to residential care services is
not always straightforward. This compounds the power imbalance that exists.

An
effective market may depend on the user and the purchaser being the same
person. That would certainly make being an informed consumer more meaningful.
Without a system of consumer- directed influence over residential care, caused
by the dominance of local authorities as the major purchaser, market shaping
and market management has rarely been developed in an effective way. Issues of
consumer power and control are important. So too, the purpose of residential
care services and the availability of alternative forms of community support
services. A market model implies the ability to exercise choice together with a
knowledge of alternatives.

The
workshop groups explored a range of factors including the role of regulation,
workforce issues, finding, information and marketing. Two key themes emerged:
the need to drive consumer sovereignty and the need for greater leadership for
the residential care sector. Both aspects are vital to create a responsive and
flexible ‘market’ of provision. Some participants felt that licensing providers
and regulating commissioning would be beneficial. The need for citizen-led
approaches was advocated in which residential care facilities might be regarded
as community assets – now that would amount to innovation!

The
Residential Forum is keenly interested to hear from you – as customers, workers
and stakeholders – how care homes can be a positive choice within the social
care ‘market’. Any suggestions then do click on: submit a post

What is the best initiative to support your residential service?

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Tracy Wharvell is
the Development Director at the National Care Association and a Residential
Forum member.  Her career in social care began over thirty years ago
as a practitioner providing social care, but now she asks how well NHS
initiatives are meeting
the aim of
supporting care homes.

Have you been asked?

There are significant amounts of funding coming
from health to support residential care homes to support improvements, in order
that care homes can help the NHS to reduce admissions and improve discharges
from hospitals. For example, support from sustainable transformation
partnership (STP), NHS England’s Enhanced Support for Care Homes, and the
recent £2 billion announced by the government.

What they all have in common is they are using initiatives from the
highly acclaimed vanguards, which found improvements through several
initiatives in locations where funds and energy were focused.  Was it the
initiative, or the focus on cultural change, and development of partnerships
and relationships?

Red Bags

The Red Bag scheme from Sutton is one of these initiatives, which
appears to be rapidly spreading across the country.  The Red Bag approach
has been designed to keep the care home resident’s belongings (clothes,
glasses, medication and notes) with them as they transfer from the care home,
to the ambulance to the hospital and back again. Great I hear all managers
saying, this will save me time tracking down lost property.  Sounds good
doesn’t it, that is until your resident is on a ward with many other red bag
holders. When the personalised approach of having a distinguishable bag will be
easier to track down.  A thought at this point; How will it feel for the
resident being labelled as a care home resident by the red bag?

Will this service really help care homes to improve their service or is
it a visual gimmick, for the NHS that puts another complicated process into an
already complicated system. Given the cost of rolling out this initiative
across the country, as a Residential Care Home Manager would you have chosen
this initiative if you had the choice or would you chosen a commitment from
health to respect the residents belongs (at no cost), the money to be spent on
training, or better access to clinicians, or something else.  

What would be your choice? Let the Residential Forum know http://www.residentialforum.com/
and feel free to comment through this blog site.

Most of all make sure you engage with your Clinical Commissioning Group
about initiatives and ideas that would support both your care home service as
well as the NHS.

Just when is residential care not residential care?

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Nick
Johnson, former Chief Executive of the Social Care Association, social care
practitioner, manager and member of the Residential Forum considers some of the
challenges to the purpose and image of residential care home living.

Many years ago, when trying
to define whether a couple were cohabiting for benefit entitlement, the
criteria were, “common roof, common table and common bed” – simple and clear.

In the case of residential
care, the judgement we made at the Council placements panel was on the need for
care throughout the 24 hours of the day. Anyone who did not need night time
intervention, could be supported at home.

That criteria have become
highly sophisticated with the regulators describing in more detail the
specifics of care and support to begin to narrow further the need for regulated
support which might equate to the need for a residential solution. This has led
to the reduction in residential care bed numbers and the de-registration of
many previously registered care settings because they have been deemed to not
be providing ‘personal care’ – especially in the Disability and Mental Health
sector.

Fearful

In every case, the working
age residential placement is temporary, rehabilitative and anticipates a return
to a more ordinary and inclusive life. For most older people, the move into a
residential home is the last move they will make and carries with it the growing
shadow of death. It is this that might make it so fearful but in fact, the fear
is not that at all but rather the likely experience of being in a residential
setting as perceived from exposes that they and their family have watched on
TV.

Generally, we choose where
we live, driven by our income, the demands of our job and the locality of where
we grow up or work. Historically, residential homes would have fulfilled a
continuity to this process with the choice to give up one’s home (often nearly lifelong)
was a choice based on the desirability of being part of a community of people
with support needs but more importantly, social networking needs.

Ironically, all the social
networking needs that enhance our lives, now fall outside regulation. People
living in supported housing may receive a lot of support to shop, access the
community, manage their domestic chores and discuss their options on any
decision, may receive more direct one to one support than a person living in a
care home but the service is outside regulation because no ‘personal’ care is
delivered.

Most regulation has its
purpose founded principally on ‘protecting the public’ – not first on quality.
The idea that any business setting out to offer support to a group of people
needing their offer should first be tested on their risk of harm to their
customers. And yet, the danger of residential care is far better known to the
public than the excellent care that thousands of people receive in the last
place they live or the place they underwent a recovery package from a trauma or
illness, prior to moving to a new address.

Toxic brand?

It may be that ‘residential
care’ has become a toxic brand and we need to rename it and re-brand it, just
like city companies do when things have gone wrong and their reputation is
lost. It may be that supported living is a better description and less arduous.
In many of these places that already exist in extra care housing, for example
the amount of care and support received in these unregulated settings is more
than would be delivered in regulated care.

The removal of bureaucratic
boundaries, regulatory lines, and budgetary gates would all help the image and
purpose in choosing to live in community rather than alone at various moments
in our lives.

Any thoughts on steps that
would assist enhance the residential care brand then lets us know at the Residential
Forum http://www.residentialforum.com/
or through a response to this blog

Demand in the Residential Care Market – a personal perspective

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Brendan Johnston, the Retired
Chief Executive at Northern Ireland Social Care Council and Residential Forum
member asks some questions about the supply and demand for residential care.

At the Residential Forum in May 2017,
we were looking at how we get the best and most appropriate residential care
using the market.  Markets are shaped by
supply and demand, so let’s look at the demand side.

Who shapes demand?

If I buy anything on any type of
market, I am the person who decides on the detail, the quality and the price of
what I’m buying.  The person who uses the
product or service is the person who pays for it.

However, often, this is not the case
in the residential care market.  The vast
majority of residential care beds are paid for by local authorities or, in
Northern Ireland, HSC Trusts.  Deciding
the nature, quality and price of the service (the demand side of the equation),
is therefore split between a number of parties, each of whom may have very
different priorities and concerns.

Specifying the demand involves among
others:

·        
The
commissioner;

·        
The
services user and, to a greater or lesser extent, their family; and

·        
The
care manager or other professional negotiating the placement.

Of course, not all these players have
equal power.  But who should have
sovereignty in the relationship. Putting the user at the centre would certainly
imply that power should be tilted in that direction – that the service user
should be given the money and make the choice.
This, however, is very rarely the case and can produce its own
challenges.

Informed Demand

Effective markets depend on a well-informed
purchaser.  The service user and their family
may have clear ideas on what they want, but have limited information on the
range of suppliers, the alternatives and what to look for in terms of indicators
of real quality.  How do we ensure that
users are protected from making poor or even risky choices?  

There’s a real challenge here.  We can’t patronise people or treat people as
infants –  incapable of knowing what they
want – we all have the right to make poor choices.  But we need to acknowledge there are issues,
not easily dealt with by regulation.  Regulation may keep bad providers out of the
market, but it doesn’t deal well with the mediocre or ‘good enough.’  Additionally, it has proved very difficult to
provide easily accessible information on the quality of provision that can
prove really useful to users.

A perfect market requires informed
and discerning buyers.  We need to be
honest about this and that means acknowledging that the market mechanism is far
from perfect or straightforward.

How does demand
shape provision?

Market processes involve dialogue and
negotiation.  I may know broadly what I
want, but until I go out shopping, I don’t really know what’s available – and
what’s more, I may find something that I hadn’t been aware of that meets my
needs more effectively or economically.
It’s not the customer who designs the motor car, but that doesn’t mean
they don’t play a central role in shaping the product.  A successful provider will be close to
customer demand and will be able to innovate to get an edge on competitors.

But look at how we commission
residential care.  We develop a specification
and go through a procurement process, the major requirement of which is that it
must be scrupulously fair and transparent (it’s public money).  But the process is also bureaucratic – it
allows little, if any, room for negotiation.
A provider that has something better and cheaper, but not necessarily in
line with the specification, can’t really be considered even if it’s a
legitimate alternative way of meeting need.
At best the process inhibits collaborative service development.  At worst, it stymies innovation and diversity
in provision.

Even at its best, the procurement
process consumes a huge amount of organisational energy and can become a
diversion to the real issue of meeting services user needs.

Is the market
analogy the best way of getting the best services?

A market that effectively meets the
needs of consumers requires several elements.
Choice is at the centre of it, but there are a lot of things that can
inhibit the range of alternatives available.
There may be scope for a lot of choice in a heavily populated city, but
if you’re living in a remote area and you want to stay there, there may not be
a lot on offer.

Effective markets imply that
consumers are well informed and act rationally in negotiating and meeting their
needs.  I’m not convinced that this is
the case – the criteria driving a commissioner may not be the same as that
which drives the end user.  I am far from
convinced that players in the market work to a shared, rational approach.

Where does this take
us?

This is not a treatise – it’s just a
blog.  It’s not the purpose of this paper
to advocate a way forward.  Its purpose
is to raise questions and challenge thinking.

It’s a long time since we moved to a
mixed economy of care and I’m not advocating any return to the old status
quo.  However, in securing publicly
funded residential care, we find ourselves in a model which is dominated by a
market paradigm.  The market provides a
reasonable analogy, but its only an analogy.
It has driven a lot of improvement, but we need to consider its
limitation.  Does it facilitate planning,
leadership, collaboration, innovation, diversity?  These are issues we need to think about.

Further information

As I said, this is just a blog and
responses and comments are welcome.  For
further information, resources and thought-provoking material go to our
website: http://www.residentialforum.com
 

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