After 50 years working in social care John Burton is used to talk of crisis and reorganisation, and government promises to stamp out poor care. Among many other jobs, I’ve managed care homes and been an inspector. I know from both sides that regulation rarely improves care and can destroy the relationships at the heart of social care.
In the 1960s the local welfare departments ran day care centres, old people’s homes, and the home help service. Some worked well and some didn’t, but social care was not regulated. In those days home helps were employed for domestic tasks and were often wonderful social care workers who largely organised themselves. My grandparents’ home help, Lily, was a neighbour on their small council estate, and remained a friend until they died.
In the 1980s I managed a 120-place local authority home for adults of all ages. It was opened in 1964 by Mary Wilson (wife of prime minister Harold Wilson) and Mervyn Stockwood, the bishop of Southwark. By 1982, although visited by department managers, councillors, and, of course, by the mayor each Christmas, it had declined into an abusive and neglectful institution. In the face of the inertia and downright opposition of the local authority, it took us about three years to turn it into a thriving, caring community, very much part of its neighbourhood. We set our own standards and the residents, relatives, neighbours and staff took control.
Today this wouldn’t have been possible because before it could get better, it would have been shut by the CQC (Care Quality Commission). Nowadays a good manager can’t afford to take on a seriously failing service and lead the deep and long-lasting changes that are required. Change takes too long, and the manager’s reputation will be marred by poor ratings. Instead, faced with an inadequate rating from the regulator, providers call in consultants and quality experts who give the home a makeover. Policies and procedures are rewritten, care plans updated, records put in order, staff are trained, and the service is prepared for inspection. If the inspector is suitably impressed, the home may now be deemed to require further improvement. So, the consultants are retained and outstanding non-compliance issues are tidied up, and within a year a previously inadequate service (be it a care home or domiciliary care agency) can get a good rating.
But small providers, struggling to survive on local authority fees, faced with an inadequate rating they often can’t afford the makeover and may have to close. Now some of the major national providers, who have been benefiting from the closure of the small homes, are facing the same financial squeeze, and another Southern Cross collapse is threatening.
The assumption is that this process of regulation and inspection is steadily improving social care, as poor providers are weeded out. Indeed, that’s the story that the CQC must tell.
Haunted by past failures, the CQC are themselves on trial, so they’ve designed social care regulation and inspection to prove their own effectiveness. They tell providers what inspectors must see to award a good or outstanding rating, and providers produce the right evidence, most of it written. Providers that fail to comply will close.
Not only does the current system of regulation encourage a superficial and standardised approach to care, but it distracts providers from long-lasting change and innovation. The whole social care sector is forced to prioritise the regulator’s demands over the needs of its clients, and they really aren’t the same.
The costs of regulation are enormous. The CQC itself costs over a hundred million pounds, and that’s dwarfed by the costs of meeting the regulator’s demands. But the biggest cost is not financial: it is the loss of initiative, leadership, and professionalism, and the devaluation of personal caring relationships such as Lily’s with my grandparents. Such friendship is neither compliant nor measurable, but it is the essence of good care.
See John's new book http://www.jkp.com/uk/leading-good-care.html