Stories from social care leadership: Progress amid pestilence and penury

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Overview

  • Adult social care is the often forgotten and invisible part of the welfare state. For the past decade the sector has been under acute financial pressure.
  • Funding is both public and private, and there is a bewildering array of providers, commissioners, representative bodies and voices involved.
  • The King’s Fund conducted unattributable interviews with people from a range of organisations, from a small number of more national voices to directors of adult social services and service users. We asked where they believe that the leadership in social care lies. How effective is it? What could be done to improve it?
  • We heard that there is huge variation in the quality of both services and leadership, with some of the best leadership being very local indeed. There was a widespread complaint about a lack of leadership from the Department of Health and Social Care, on top of the longstanding failure to ‘fix’ social care.
  • We heard that key issues included a lack of data, of infrastructure and research, and of training and development.
  • A more unified voice might well benefit the sector, while the changes to national leadership that the Department of Health and Social Care has under way need to be seen through and made permanent.
     

Background

Adult social care is the too often forgotten, too often invisible, arm of the welfare state. It has, for a decade now, been under acute financial pressure. And the arrangements for it are complex in the extreme.

It is a tangled mix of public and private funding with a somewhat bewildering array of providers of various forms of care, of representative bodies and of voices with an interest in it, while even at the level of central government it involves two different departments – the Department of Health and Social Care and the Ministry of Housing, Communities and Local Government.

Leading this diverse and highly fragmented sector is plainly a challenge. The King’s Fund carried out interviews with people working within social care and those accessing its services: we asked three essential questions. Where do those interviewed think leadership in social care lies? How effective is it? And what might be done to improve it?

What we heard

A number of themes emerged.

  • An acknowledgement that there is huge variation in the quality of both services and leadership.
  • Some of the most inspirational leadership comes from care staff themselves, and from adults of working age who have been empowered by personal budgets and direct payments to shape their own, and others’, lives. The more local the leadership, the more powerful it could be, was the message that came back.
  • There is a lack of good data, a lack of infrastructure and a lack of research in adult social care. Funds for training and continuing personal development at all levels of social care are in short supply.
  • Relationships with the National Health Service can be strained. But, in the view of most of our interviewees, the drive to better integrate health and care services is making progress, although not everywhere.
  • There has been a desperate lack of leadership from the top – from the department and from politicians. As one director of adult social services put it: ‘Any leadership that does exist does so in the vacuum of a nationally defined vision and plan.’ While we acknowledge that the Department of Health and Social Care is taking steps to address that, there is clearly a large hole to be filled.
The failure to fix social care: In the past 25 years there have been 8 green papers, 4 white papers, many independent recommendations for reform, 2 government-commissioned inquiries, 9 secretaries of state for health and 14 ministers for care services. Despite all of that, no one has managed to 'fix the crisis in social care once and for all.'

1 Including recently from three cross-party select committees in the House of Commons and the House of Lords.
2 The 1999 Royal Commission on Long Term Care, and the 2011 Dilnot Commission on the Funding of Care and Support.

What we drew from what we heard

Almost 40 people generously found time, mainly during the Covid-19 pandemic, to talk to us. But we are aware that our sample size is too small for us to make recommendations.

We do, however, raise a number of issues for consideration.

  • Leadership matters at every level in social care, and there is a powerful case for investing more in training and development – at every level.
  • Local authority support for user groups, and for local care home associations and their equivalents for domiciliary care, appears to pay dividends. The best local authorities appear to value feedback, the worst hide from it.
  • Longstanding promises to improve the quality of data need to be honoured.
  • There is a case for finding a mechanism to take the heat out of the annual battle between commissioners and providers over fees.
  • The sector might well benefit from a more unified voice than that provided by the current myriad of representative bodies, and the work of the Association of Directors of Adult Social Services in particular could be strengthened.
  • There is also a case for an annual assessment, probably by the Care Quality Commission, of the quality of both local authority and NHS commissioning in this sector – assessments that should strengthen the hand of those seeking to improve services locally.
  • Leadership from the top is judged to have been missing for some time, and while the Department of Health and Social Care is taking steps to address that, those steps need to be pursued with vigour.

Final thoughts

The interviews, of course, took place against the longstanding failure by successive government to honour their promises to ‘fix’ the way social care is funded.

The most depressing quote we heard in the course of this work was not from one of our interviewees but from Lord Bethell, the Social Care Minister in the House of Lords. He told peers that ‘there simply is not the management or political capacity to take on a major generational reform of the entire industry in the midst of this massive epidemic’. That may well be true in the short term. But a minimum requirement is that the department is put into a position where it has the management and policy-making capacity to undertake that once the pandemic is contained.

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