There’s a story about Aneurin Bevan, founder of the NHS, describing how, when he was a miner, he got himself elected to his town council, because he was told that was where the power lay. When he got there, power appeared to have slipped up to the county council. So he got on to the county council, only to discover that power seemed to have disappeared upwards to parliament. So he became a member of parliament (MP), only to discover that the power had been there, but that all he saw of it was its coat tails –‘slipping away around the corner’.1
Our search for leadership in adult social care and where it comes from was similarly elusive. We asked people who should know – including directors of adult social services, local providers and people who use social care – where leadership lies. But too often its coat tails seemed to be disappearing around the corner. In the words of one provider, ‘I struggle to come up with anybody in charge, to be honest.' Or as one directors of adult social services put it, 'Any leadership that does exist does so in the vacuum of a nationally defined vision and plan – meaning it’s a diffuse mess.'
At one level this should come as no surprise, modern social care is not so much a system as a disparate mishmash of responsibilities and functions scattered across central government, 151 local authorities and 18,000 organisations providing care. With an equally complicated mix of funding sources, the NHS is a paragon of organisational simplicity in comparison. The lack of clarity about leadership is an inevitable consequence of this Byzantine complexity, the consequence of successive policy choices over the years that have helped to shape the nature of what today we call adult social care.
Where we did find leadership was almost the opposite of Bevan’s quote. He was chasing power up to the centre. In contrast, the most inspiring leadership we heard about was local. Indeed, at times, the more local, the more powerful. Especially when directors of adult social services and councils had actively sought the engagement of people who use social care and of providers. We heard uplifting stories from those who had taken opportunities to be active participants in decisions about their care and support rather than passive recipients of services. The best organisations cherish such engagement, the poorer ones tend to hide from it.
In contrast, we found that leadership at the very top had gone missing – all of our interviewees were scathing about the role of the Department of Health and Social Care. 'There hasn’t been any evidence, for a long time, of what you might describe as leadership coming from there,’ said one interviewee. ‘There’s a really quite astounding lack of understanding of social care at the centre,’ said another. Much of this angst reflected not only the erosion of social care knowledge and capacity in the Department, but the absence of a senior voice, akin to the Chief Medical Officer, with credibility in the sector, to act as influential advocate for social care in government.
But it is not quite as simple as ‘local good, central bad’. The creation of a Chief Social Worker for Adults post in the Department in 2013, linked to a national network of locally based principal social workers, is an encouraging example of how national and local leadership can be complementary. Conversely, we heard of sharp differences in the quality of local leadership arising from individual personalities, organisational cultures and a history of poor relationships.
What can be done? Instead of specific recommendations, we float some ideas to stimulate discussion and debate, beginning from the premise that co-produced local leadership, not organisational integration of social care with the NHS, is the best way forward. Our suggestions include: restoring senior social care leadership, capacity and experience in the Department for Health and Social Care; a unified national voice for providers; a more national approach to fee-setting; a beefed-up role for the Association of Directors of Adult Social Services; new oversight of local authority performance and better data – reflected in the Department’s proposals for new legislation, Integration and innovation: working together to improve health and social care for all; and correcting the massive imbalance of investment in workforce development between the NHS and social care (just £14 per employee in the latter). But these steps alone will not be enough to resolve the longstanding inadequacies in the sector. Clear leadership from the government is needed to deliver on its promised plan for the long-term reform of delivery, workforce and funding of social care.
- 1. Bevan A (1943). Hansard (House of Commons Debates) 15 December 1943 vol 395 col 1616.
As ever a stimulating and challenging piece from Richard here prompting me to repeat what I say and re say about leadership over and over - credible (walking the walk people) real time leading coming from those that strive to embed values that simply reflect an ethos of kindness, enthusiasm, curiosity, team working and pride. If you don't spend time doing the doing on the frontline your insight, wisdom and judgement becomes distant and theoretical - I don't profess to be such a great leader myself but I do aspire to these principles but I also say this.... IN ORDER TO INSPIRE OTHERS YOU NEED TO BE INSPIRED YOURSELF. So inspiration is the ingredient that I am now speaking about most with others including my teams and colleagues across our sprawling perhaps struggling H&SC system.
Just to do some name dropping here if I may - In Devon we have some amazing people leading - our LA colleagues have been extraordinarily supportive throughout the pandemic - truly they have and I'm not playing disingenuous politics here, our ICS leader Dame Suzi Leather has given social care providers including care homes a voice at the top table with a parity of esteem with our NHS executives and clinical leaders, on the ground GPs like frailty lead GP Dr David Attwood (also honorary secretary of the British Geriatric Society), Dr Rachel Mann (lead GP responsible for enabling out residents to get the earliest vaccinations), Professor Adam Gordon, acute medicine huge advocate for care homes in his work with us using the national Whatsapp group for care homes, Drs Lucy Pollock (Somerset Geriatrician and author of the fabulous 'The Book About Getting Older'), Dr Trisha Elliot in Edinburgh and of course Andrea Sutcliffe ( now leading the NMC after her time as social care chief inspector at the CQC). Many many fellow vocal care provider leaders across the country using social media to elevate our previously much maligned care home voice and status - Raina Summerson, Karen Rogers, Vic Rayner, Christine Asbury, Louise Brady, Nicola Kendall, Geoffrey Cox, Mike Padgham, Adam Purnell to name but a few - people I look to and out for saying determined, courageous, confident things about what we do- 'working out loud' making positive noise in these difficult times.
If you have not heard of many of those I have listed please look them up - add them to your following list - this of course is the central aspect of leadership - without followers leading is simply a dysfunctional process of fine words from lone nuts (quoting the immortal words of Derek Sivers here - famous for the 'how to start a movement' 3 minute clip on you tube.
My plan after reading this is to share more, listen more, reflect better the need for a wider likeminded alliance of social care leaders and serve this up to the higher level influencers who I adamantly believe want and need leaders who can support optimistic futures for those that require care and those providing it.
Thanks for a great piece Richard - see you on the other side I hope.