Stories from social care leadershipProgress amid pestilence and penury

Richard Humphries Nicholas Timmins

February 2021

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ContentsForeword 3

Key messages 4

Introduction 6

Alittlebackground,andalittlehistory 10

Whatwefound 12

Themorelocal,themorepowerful 12

Wheredidourintervieweesthinkthatleadership morebroadlylies? 16

Soifleadershipisfragmentedanddispersedand ofdifferingquality,whatdoesthisleadto? 18

Socialcareinevitablyinteracts,foratleastsomeofthetime, withtheNationalHealthService.Doesitprovidesupport forsocialcareleadership? 19

Sohowdoessocialcarefeelaboutitself? 24

Astrongervoiceforsocialcare? 26

Whatelsedidwehear? 29

Itisnotjustlocalleadership,itisrelationshipsthatmatter 29

Lackofdata,lackofinfrastructure,lackofresearch 29

Lackoftraininganddevelopment 32

Lackofleadershipfromthetop 34

Contents 1

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2

3

Contents 2

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Whatdidweconclude? 38

Leadershipmattersateverylevelinsocialcare, butlocaliscritical 38

TheNHSshouldnot‘takeover’socialcare,nor localgovernmenttheNHS 38

Dataismissingandneedstobeassembled 40

Trainingforskills,trainingforleadership 40

Supportingusergroupsandassociationsofproviders paysdividends 40

Thereisacaseforamoreunifiedprovidervoice forsocialcare 41

AndforbeefingupthevoiceoftheAssociationof DirectorsofAdultSocialServices 41

Isthereacaseforanationalapproachtosettingfees? 42

Thereisalsoastrongcaseforassessinghowwell localauthoritiesaredischargingtheirduties 42

ThesocialcarefunctionintheDepartmentofHealth andSocialCareneedsrestoring 43

And finally… 45

Annex 47

References 49

Acknowledgements 52

Abouttheauthors 53

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Foreword 3

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ForewordSupportingleadersintheNHShasbeenalongstandingpriorityfor TheKing’sFund.Yetastheimportanceofgreaterintegrationbetweenhealthandsocialcarehasgrownithasbecomejustasimportanttounderstand,andsupport,leadershippracticebeyondtheNHS.Thisiswhywearepublishingthisreport nowandwilllaterintheyearalsoreportonworkwithDirectorsofPublicHealth.

Webelievethattheevidenceisclearthatcompassionateandinclusiveleadershipprovidesbenefitstostaffworkinginhealthandcareandthepeoplethatusetheirservices.Thisreporthighlightssomeofthestrengthsofsocialcareleaderswiththeirmoreinclusiveapproachestosharingpoweranddecision-makingwiththepeoplethatusetheirservices,aswellasthecommunitiestheycomefrom.Itunderlinesthepoweroflocalleadershipwhengiventhefreedomtoactandthereismuchherethatthewidersystemcanlearnfrom.

Thereare,ofcourse,alsorealchallengesforleadershipinthesector.Thisincludestherelativelackofdataandresearchandtheabsenceofanationalvisionandstrategyforthesectorasawholethatbuildsonandsupportsthesestrengthswhiletacklingtheobstacles.

Ifwearetointegratehealthandcaretoimprovepopulationhealthandwellbeing,weneedtobuildon,andsupport,theleadershipstrengthsofeachpartofthesystem,whetherNHS,socialcare,localgovernmentorthevoluntarysector.Thiswillincludetacklinglongstandingissuesthathavegotinthewayofmorecompassionateandinclusiveleadershipwherevertheymayhavecomefrom.ThisleadershipjourneyisonethatTheKing’sFundiscommittedtosupporting.

Richard Murray ChiefExecutive TheKing’sFund

Key messages 4

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KeymessagesAdultsocialcareisthetoooftenforgotten,tooofteninvisible,armoftheBritishwelfarestate.Ithas,foradecadenow,beenunderacutefinancialpressure.AspartofTheKing’sFund’sworkonleadershipinhealthandsocialcare,RichardHumphriesandNicholasTimminsinterviewedsome40peopleaboutthenature ofleadershipinthesector.Wheredoesitlie?Howeffectiveitis?Whatmightbedonetoimproveit?

Fromthoseinterviews,wehavedrawnsomeconclusions,andraisedsomeissuesfordiscussion.

• Localauthoritysupportforusergroups,andforlocalcarehomeassociationsandtheirequivalentsfordomiciliarycare,appearstopaydividends.Thebestlocalauthoritiesappeartovaluethatfeedback,theworsthidefromit.

• Leadershipmattersateverylevelinsocialcare,andthereisapowerfulcase forinvestingmoreintraininganddevelopment–ateverylevel.

• Longstandingpromisestoimprovethequalityofdataneedtobehonoured.

• Thereisacaseforfindingamechanismtotaketheheatoutoftheannualbattlebetweencommissionersandprovidersoverfees.

• Thesectormightwellbenefitfromamoreunifiedvoicethanthatprovidedbythecurrentmyriadofrepresentativebodies,andtheworkoftheAssociationofDirectorsofAdultSocialServicesinparticularcouldbestrengthened.

• Thereisalsoacaseforanannualassessment,probablybytheCareQualityCommission,ofthequalityofbothlocalauthorityandNHScommissioninginthissector–assessmentsthatshouldstrengthenthehandofthoseseeking toimproveserviceslocally.

• Leadershipfromthetopisjudgedtohavebeenmissingforsometime,andwhiletheDepartmentistakingstepstoaddressthat,thosestepsneedtobepursuedwithvigour.

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Themostdepressingquoteweheardinthecourseofthisworkwasnotfrom oneofourintervieweesbutfromLordBethell,thesocialcareministerinthe HouseofLords.Hetoldpeersthat‘Theresimplyisnotthemanagementorpoliticalcapacitytotakeonamajorgenerationalreformoftheentireindustryinthemidstofthismassiveepidemic.’Thatmaywellbetrueintheshortterm.ButaminimumrequirementisthattheDepartmentisputintoapositionwhereithasthemanagementandpolicy-makingcapacitytoundertakethatoncethepandemiciscontained.

Introduction 6

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1 Introduction

The ordinary man in Great Britain has been spending his life for the last couple of generations in this will-o’-the wisp pursuit of power, trying to get his hands on the levers of big policy and trying to find out where it is, and how it was that his life was shaped for him by somebody else.(AneurinBevan1943)

Socialcareistheoftenforgotten,tooofteninvisible,armoftheBritishwelfarestate.Itlacksthelandmarkbuildingsthatkeepschools,hospitalsanduniversitiesinthepubliceye.Itdoesn’tevenhavetheshopfrontsofthejobcentres.Muchofithappens,veryquietly,veryinvisibly,inpeople’sownhomes.

Yettoday,publiclyfundedadultsocialcareinEnglandsupportsalmostamillionpeopleatanyonetime,anditsmixedeconomyseeshundredsofthousandsmorepayforelementsofsocialcarethemselves.SocialcareemploysmorepeoplethantheNationalHealthService(NHS).Itisestimatedtocontributemorethan£40billiontotheeconomyand,atitsbest,enablespeoplewithawiderangeofneedstoleadindependentlives.Itprovidesessentialcareandsupporttoothers,anditprotectspeoplefromharm.Atitsworst,however,itcancauseanguishandevenleadtoabuse.

InthewordsoftheAssociationofDirectorsofAdultSocialServices(ADASS):

Social care at its best enables and transforms lives. It enables millions of us to live the lives we want to lead, where we want to live them. Whether we need support with our mental health, because of physical disabilities, learning disabilities, or because we are older and need additional support. It supports us to work; to socialise; to care and support family members; and to play an active role in our communities. (ADASS 2020,p4)

Thecoronaviruspandemichasforonce,thoughinunwelcomeways,thrownsocialcareintothespotlight.Toparaphrasetherecentwordsofonesocialcareleader,‘thepennyhasdropped’thatsocialcarematters,evenifthereisstillnofullpublic

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graspthatitsreachgoeswaybeyondtheissueofdischargesfromhospitalandthatitneedstobeseenasasectorinitsownright.Adultsocialcareisnotajuniorpartnerof,orhandmaidto,theNationalHealthService.

Socialcareis,nonetheless,inevitablyconjoinedtotheNHS,andthereisawidelyrecognisedneedtobetterintegratethetwoservices.ButunliketheNHS,whichisstillrecognisableasonesystem,adultsocialcareisanythingbut.Asalreadymentioned,itembracesnotjustthecareofolderpeople–thebitthatgetsmediaattentionontherelativelyrareoccasionsthatsocialcaredoesinfactgetmediaattention–butservicesforthoseofworkingage,onwhicharoundhalfthe publiclyfundedbudgetgoes,thoughonewouldnotknowitfrommostofthe publicanalysis.

Adultsocialcareismind-blowinglycomplex(seebox).ItisalmostashardtoexplainasthestructureofhealthcareintheUnitedStates.Ithasahugelytangledmixofpublicandprivatefunding,offeesandoftop-upcharges,andofwhatisknownas‘self-funding’inthejargon–thatis,moneyspentprivatelybyindividualsandfamiliesforcareintheirownhomesorincarehomes.ThatfundingcaninvolvetensionsbetweentheNHSandlocalauthoritiesoverwhopaysforwhat,withmuchheartacheandtraumafortherecipientsandrelativesinvolvedinthosedecisions.Itisanequallytangledmixofmainlyprivatebutalsosomepublicprovision.Andsocialcareworksacrossmanyotherboundaries,bothpublicandprivate.IthasaworkforcelargerthanthatoftheNHS,thoughagainmostpeoplewouldnotknowthat.Itslabyrinthinenaturemakesitextremelychallengingforthosechargedwithleadingit.

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Thelabyrinthineworldofsocialcare:simpleitisnot

ExpenditurePublicspendinginEnglandonadultsocialcareisaround£22billion,fundedthroughamixofcentralgovernmentgrantandcounciltax.Thereisnoreliableestimateofprivateexpenditurebutitisthoughttobearound£11billion.Andanarmyofunpaidfriendsandfamilycarerscontributeanestimated£100billionto£132billionworthofcare.Justoverhalfofthepublicspendinggoesonadultsofworkingage,asopposedtoolderpeople.Thedataonsocialcareissothinthatmanyofthenumbersareestimates.

Whocommissionsit?Onehundredandfifty-twolocalauthoritiesinEnglandcommissionthebulkofpubliclyfundedcare.TheNHSfundsaround10percentofnursinghomebedsthroughNHScontinuinghealthcare.ItalsopaysforthenursingforarelativelysmallnumberofpeoplethroughNHS-fundednursingcare.

Whoisitprovidedby?Some18,000organisations,whohavearound34,000establishments.ThereareasmallnumberoflocalauthorityandNHS-ownedbeds.Around95percentofresidentialandnursingbedsareintheindependentsector.Thefourorfivebiggestcorporatesownbetweenthemaround12percentofthatmarket.The30largestprovidershaveonly30percentofthebeds.Ownersofjustonehomesupplyaround29percent,andownersoffewerthanfivehave45percentofthemarket.Agenciesandthevoluntarysectorprovidecare-at-homeservices,alongsideNHScommunityprovisionthatincludesdistrictnursesandoccupationaltherapists.

Therearealsovariousformsofshelteredhousingandextracarehousingin boththepublicandprivatesectors,sometimessupportedbyincreasinglysophisticatedtechnology.

Whopays?Fortypercentofthoseincarehomespaytheirownfees.Localauthoritiespayforthebulkoftheremainder.Butinaquarterofcases,individualsandfamilieshavetotopupthefees.Adultsofworkingagecanreceivebothfreecareandcharges.Somepeoplealsopayforentirelyprivatecare.

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Thispictureofanessentialpublicserviceinamixedeconomythatishighlydiverse,fragmentedandfracturedledTheKing’sFund(whichhasdonemuchworkonleadershipintheNHSandsomeonleadershipinsocialcare)toaskRichardHumphriesandNicholasTimmins,twoofitsSeniorFellows,totakeafurtherlookatsocialcareleadership.Wheredoesitlie?Howeffectiveisit?Whatmightbedonetoimproveit?

Thisresearchwasonlypossiblebecausealmost40peopleinmorethan30interviews(afewofthemwerecollective)somehowfoundthetime,generously,inthemidstoftheCovid-19pandemic,totalktousabouttheseissues.Toencouragepeopletobehonest,alltheinterviewswerenon-attributable.

Thelabyrinthineworldofsocialcare:simpleitisnotcontinued

Whoworksinsocialcare,andwhere?Around1.5millionpeopleworkinsocialcare,slightlymorethantheNHSemploys.Justoverathirdworkindomiciliarycare–providingcareinpeople’sownhomes.Addinthosewhopayprivatelyforcareintheirownhomesandthefigureisthoughttobeover40percent.

Roughly280,000oftheworkforcearenotBritishcitizens,comingfromtheEuropeanUnion(EU)ortherestoftheworld.TheimpactofBrexitonthatworkforceisstillunknown.

Some145,000carersareemployeddirectlyaspersonalassistants,eitherthroughdirectpaymentsandpersonalbudgetssuppliedbylocalauthorities,oremployedprivatelybythosewhodonotqualifyforpublicfunding.

Whatiscentralgovernment’srole?Twogovernmentdepartmentsareinvolved.OneistheDepartmentofHealthandSocialCare,whichhasbeenresponsibleforpolicyandlegislationsince1974.Forthemostpart,itnegotiatesthecentralgovernmentgrantwiththeTreasury.Butthosemoniesflowthroughtheseconddepartment–theMinistryofHousing,CommunitiesandLocalGovernment–althoughthemoneyisnotring-fenced,andtherearedebatesbetweenbothdepartmentsandtheTreasuryastohowmuchshouldfalloncounciltax.

Sources:Bottery and Babalola 2020; Skills for Care 2020; Laing 2019; Competition & Markets Authority 2017.

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Wechosesevenreasonablydiversepartsofthecountry:threecountieswithawidegeographicalspread,oneLondonborough,twocities,andonetownthatisaunitaryauthorityandthusresponsibleforsocialcare.WesoughtineachtospeaktotheDirectorofAdultSocialServicesalongwithatleastoneproviderand/orusergroupineacharea,pluslocalauthorityCabinetmembersforsocialcare.Wealsospoketoalimitednumberofmorenationalfigures.Thiscannotclaimtobeafullyrepresentativesample;giventhetimeavailableandtheprevailingcircumstances,wedidnotsucceedintalkingtoalltheplayerswesought.Nonetheless,aclearpictureemerged.Noteveryoneheldthesameviews,buttherewasastrongconsensusonmanyoftheissues.

Whatfollowsiswhatwefound.Inanutshell:hugevariation,somerealhighlights,butasetofleadersatvariouslevelsstrugglingtogetthingstoworkwellinasystemthatissofragmentedthatitisscarcelyworthyofthename.

Alittlebackground,andalittlehistory

Socialcareis,ofcourse,aproductofitshistory.ItsmodernoriginslieintheNationalAssistanceActof1948–passedinthesameyearastheNationalHealthServicewaslaunched.TheActboldlyclaimedto‘abolishthepoorlaw’,althoughitdidn’t,quite.Socialcareremainsfirstneeds-tested–individualsneedacertainlevelofcaretoqualifyfortaxpayerassistance–andthenmeans-tested.Thosewithassetsofmorethan£23,500(afigurethathasnotbeenupratedsince2010)donotqualify.Thosethatdo,needtoruntheirsavingsdownto£14,250beforereceivingentirelyfreecare.Asaresult,individualsandfamilieswhoneedlong-termcarecan,atthefurthestextremes,find£250,000andmoreoftheirsavingsconsumed.Andindeed,forthosewhogointoaresidentialornursinghome,thevalueoftheirhousecanalsobeeatenup.AsSirAndrewDilnotpointedoutinhis2011report(Commission on Funding of Care and Support 2011),socialcareistheonebigriskinlifethatis,inpractice,uninsurable.Asidefromtheotherdifficultieswiththewaysocialcareoperates,thiscauseshugeresentmentwhen–oftenonlyatthepointatwhichitisneeded–individualsandfamiliesdiscoverthatthatishowthesystemworks.AfarcryfromtheNHS,whichaimstocoveralmostallkindsofneeds,largeandsmall,andismostlyfreeatthepointofuse.

Inaddition,itprettymuchgoeswithoutsaying–butneedstobesaid–thatsocialcareinEnglandhasbeenunderimmensepressureforatleastadecade.Inthewake

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ofthe2008globalfinancialcrisis,manylocalauthoritiesdidtheirbesttoprotectthesocialcarebudget(thoughwithmixedresults)inthefaceofcutstolocalgovernmentspending,which,attheirpeak,reducedtheirexpenditureby40percent.Evennow,spendingonsocialcareinrealtermsisnotbacktowhereitwasaheadofthefinancialcrisis,anddemandhasbeenrisingasthepopulationages(Bottery and Babalola 2020).

Finally,bywayofbackground,governmentsofdifferentpoliticalpersuasions havemadepromisestoreformadultsocialcareforatleast25years.Those includetherepeatedbutsofarunfulfilledpromisebythecurrentPrimeMinister,BorisJohnson–to‘fix’socialcare.Wereturntothisissuebelow.

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2 Whatwefound

Thereisanother,morefamous,AneurinBevanquote,describinghow,whenhewasaminer,hegothimselfelectedtothetowncouncil,becausethatiswherehewastoldthepowerlay.Whenhegotthere,itappearedtohaveslippeduptothecountycouncil.Sohegotontothecountycouncil,onlytodiscoverthatpowerseemedtohavedisappearedupwardstoparliament.SohebecameaMemberofParliament(MP),onlytodiscoverthatthepowerhadbeenthere,butthatallhesawofitwasitscoattails–‘slippingawayaroundthecorner’(Bevan1943).Bevan,ofcourse,becameacabinetministerandproved,inthewordsofthehistorianKennethMorgan,tobe‘anartistintheusesofpower’(Morgan1992,p205).

Bevan’squoteresonatedhugelyaswesoughttofindoutwherethetrueleadershipinsocialcarelies.Itscoattailstoooftenseemedtobedisappearingaroundthecorner,andcertainlywedidnotalwaysfinditwhereonemighthavethoughtthatitwouldnecessarilylie.Wherewedidfindit–byandlarge–wasalmosttheoppositeofBevan’squote.Hewaschasingpoweruptothecentre.Wefound,bycontrast,thatmuchofthemostinspiringleadershipweheardaboutwaslocal.Indeed,attimes,themorelocal,themorepowerful.

Themorelocal,themorepowerful

Thuswespoketoagroupofadultsofworkingageinonecountywheretheself-supportsystemstheyhadbuiltwereinspirational.Individuals–thanksinparttopersonalbudgets–weretakingcontroloftheirownsituation,supportingnotjustthemselvesbuteachother,althoughoperatinginanenvironmentwherethelocalpoliticiansandsocialservicesdirectorhaddeliberatelysharedpowerwiththem.Noteverysuggestiontheymadeforwaystoimproveserviceshadbeenadopted–andtheyrecognisedbudgetandotherlimitations–buttheywereclearthattheirvoicewasheardandmadeadifference.

Equally,weheardexampleswherecareworkershadchangedservicesforthebetter.Forexample,duringthefirstwaveofCovid-19,whenconfusedolderpeoplefoundthesuddenarrivalintheirhomeofcarershiddenbehindamaskdaunting,evenfrightening,onecameupwiththeidea(adoptedbyothers)ofprintingtheir

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picturetopintotheiruniform–atleastmakingitclearwhotheywere,andthattherewasafriendly,recognisablefacebehindthemask.Weheardaboutaformerpostmanwithdementiawhousedtodisappearfromhishomeandgowandering.Thecarerworkedoutthatallhewasdoingwasfollowinghisoldround.SoshecameupwiththeideaofasimpleGPStrackersothatwhenhediddisappear,hiswifecouldcheckthatwasallthathewasdoing…andbeabletofindhimifhedeviatedfromtheroute.Thecareralsoputamirrorontheexitdoor,toencouragehimtoaskhimselfwhyhewasgoingout.Thesearesmallbutpotentiallycrucialchangesthatdemonstrateleadershipat,sotospeak,thecoalface.

Inanotherexample,thedirectorofonehomecareagencypersuadedthelocalcounciltofundarapidresponseteam,linkedtoNHS111.Ifsomeonecallsanditisjudgedthatanambulancemaynotbenecessary,theresponseteamofcarersgoesin,equippedwithbloodpressuremonitorsandotherequipment.Theycanliftpeopleoffthefloor,undertakeanassessment,calltheambulanceifnecessary,andproviderelief,assuranceandcomfort.Theprojecthassavedresources–ambulancetime,accidentandemergency(A&E)attendancesandprecautionaryhospitaladmissions–andhasequallysavedtherecipientsfromthestressofallofthat,notleastwhenitisclearthatnoolderpersonwantstogotohospitalunlessthatisstrictlynecessary.(Unfortunately,asweexplainbelow,thisprojecthasnothadanentirelyhappyending.)

Equallytheownerofonedomiciliarycareservicewhostartedoutrunningone,thensoldtoalargercorporate,hassincebecomeanowneragain.Hermotivationforreturningtorunningherownbusinessinarelatively,butnotentirely,ruralareawas:

…that they had about 120 businesses dotted around the country, and their big mistake in my eyes was that they tried to standardise everything. So everywhere ran as it would in Birmingham or Manchester or London. They just did not understand that the communities in more rural towns and villages need different things to those people who are living in a city. You have to understand your community.

Andindeed,onthethemeofhowpowerfullocalleadershipcanbe,morethanoneofthedirectorsofadultsocialcarethatwetalkedto,whenaskedtheopening,framingquestionof‘Wheredoyouthinkleadershipinsocialcarelies?’,startedwiththerecipientsandtheirexperienceandworkedtheirwayup.Onelocalgovernmentcabinetmemberforsocialcaresays:‘Iseeleadershipintheamazingvoluntary

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sectorleaderswehavelocally,whoaresaying“Comeonyou,sortoutthequalityofcarelocally”.That’swhereItakemyleadershipfrom.’

Anotherpoliticalleadforsocialcareinacountysays:‘Co-productionisimportant–creatingservicestogether.Ithinkitisabouttheleadersunderstandingthecommunityandthepeoplewithinthecommunity,andaboutthatsocialpurpose.Thefurtherawayleadersgetfromunderstandingthepeoplethatlivewithinthecommunity,theweakertheleadershipis.’

Onenationalfiguresays:

It comes from the fantastic care home manager, the amazing community support worker, or the great outreach worker and, of course, from the experts by experience. And you can see that in the public sector, the voluntary sector and the private sector. It comes from hugely dedicated personal motivation, which is rarely accompanied by great pay and conditions.

Andwhenitcomestothequestionofwhetherverylocalleadership–indeed,userleadership–matters,itisworthrecallingthatthearrivalofpersonalbudgets,andwiththatotherpartsofthepersonalisationagenda,happenedbecauseagroupofdisabledpeopleinHampshirelaunchedthecampaigntogetthem.

Co-production

Co-productionisahorriblepieceofjargon.Butinonehyphenatedworditdoessumuponeofthemostpositivetrendsinsocialcare–givingpeoplewhousetheseservicesasayinhowtheyaredesigned,commissionedanddelivered.Amodelofleadershipthatisaboutdoingthings‘with’people,ratherthan‘for’them,orworse‘to’them.

Andwhileprovidingsomeminimalofficesupportforassociationsoflocalcarehomeprovidersandcareagenciesdoesnotfitquiteintothesamecategory,weheardaboutgainsfromthataswell–anabilitytodothings‘withthem’ratherthan‘tothem’,notleastbecauseitcanhelpgetboththeconversationandtheactionbeyondtheannualbattleoverfeesbetweenlocalauthoritiesandproviders.

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Co-productioncontinued

Co-productionisthereinpersonalbudgetsanddirectpaymentstousers.Currentlyaround240,000peoplereceiveadirectpayment,with75,000oftheseemployingtheirownstaff.Thisisonecomponentof‘self-directedsupport’thataffordstheopportunityofenhancingpeople’schoiceandcontrolovertheirlives.Althoughitisnotablethatthetake-upofpersonalbudgetsanddirectpayments,whichrosesharplyafterimplementationoftheCareAct2014,hasstalledataround4outof10workingageadultsand2outof10amongolderclients.

Examplesofco-productioncitedtousincludethepartnershipboardthatonecouncilhassetupthatgivespeoplewithlearningdisabilitiesaseatatthetable,andawebsitethatprovidesinformationrelatingtoevents,activitiesandgroupsbeingrunforpeoplewithlearningdisabilities.Onecouncilhasagatheringonthelinesofapeople’sparliament,awiderforumthatenablespeoplewithlearningdisabilitiestoengagedirectlywithcouncillors.

Anotherputsmoneyintoenablingservicesusersandtheircarerstoworkwiththe councilinshapingdecisionsaboutservices.Duringthepandemicthisprovedvaluableinbringingtogethercouncilandhealthstaffwithpeoplelivingincarehomes, theirrelativesandcarehomestafftodevisesafewaysofretainingsocialcontact withresidents.

Elsewhere,relativelysmall-scalelocalauthoritysupportforalocalcarehomeassociationhasbothhelpeditserveitsmembersbetterandwassaidbyitschair–asaresult–tohavesignificantlyimprovedrelationswiththecouncil,movingbothsidesonfromjustanannualbattleoverfees.

Whenweheardfrompeoplewhoareengagedinsimilarinitiativesitisclearboththattheywerehighlyvaluedandthatthoseinvolvedfelttheyhadagenuinevoiceoverthewayserviceswereprovided.Itmeanttheywereactiveparticipantsinshapingthedecisionsthataffectedtheirlivesinsteadofpassiverecipientsofcare.Itseemsclearthatthebestcouncilsvaluethefeedbackthatthesemechanismsprovideandusethatfeedbackeithertoimproveservicesasfarastheycanwithinthefinancialconstraintsorenableindividualstodothatforthemselves–althoughagainwithinthefinancialconstraintsthatwillalwaysbetherebuthavebeenparticularlyacuteinrecentyears.

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Wheredidourintervieweesthinkthatleadershipmorebroadlylies?

Allovertheplace,istheanswer.Fromministers,theDepartmentofHealthandSocialCare,councilleadersandchiefexecutives,tocabinetmembersforhealthandsocialcare,directorsofadultsocialservices,providers,theregulator,recipients,tradebodiesandpressuregroups.AlongwithperceptionsofincreasedinfluencefromNHSEnglandandNHSImprovement,whichisfarfromalwaysseenasconstructive.Inotherwordsitishugelyfragmented,widelydispersed,toooftenunco-ordinated–withmanyhavingwitheringcriticismsoftheleadershipfromhigherupthishierarchy,towhichwewillcome.

Onehighlyexperiencedownerofcarehomessays:

I struggle to find out who is actually leading us. Because I don’t see it as the Secretary of State, I don’t see it as the minister, I don’t see it as the CQC [Care Quality Commission], I don’t see it as ADASS, I don’t see it as the local authority cabinet members in that sheet you put to me of outline questions, and I don’t see it anywhere. It’s all fragmented. I struggle to come up with anybody in charge, to be honest. Ours comes from our care home managers, many of whom have been with us for years. But finding new ones is a challenge.

Aserviceuserputsitthisway:‘Itisbetweencountycouncillevelandnationalgovernmentthatitallbreaksdownmassively.Idon’tfeelthatIhaveanysortofinfluenceatthattypeoflevel,whereasIfeelIhavesomeinfluenceatthecountylevel.’

Oneortwoarguethathavinghighlydispersedleadershipisastrengthaswellasaweakness–‘thevibrancy,thechoiceandcolourfulness’.Directorsofadultsocialserviceswerewidelyseenaskey,buttheirquality–ajudgementmadebydirectorsthemselves,notjustbytheircritics–wasseenasveryvariable,throughamixtureofexperienceandpersonalities.Thisisanotherissuetowhichwewillreturn.

Theviewofmanywassummedupbyonedirectorwhosays:

Any leadership that does exist does so in the vacuum of a nationally defined vision and plan – meaning it’s a diffuse mess. Most things are reactive. What we are all trying to do is the best job that we can with the deck of cards that have been dealt, which this year includes pestilence on top of penury.

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There is some leadership in the provider sector. And there has been an increased role for people who use care and support. But I think that austerity has hampered co-production and has hampered the progress that was being made on personalisation.

Theheadofanationalpressuregroupinthisareasays:‘Thenotionofleadershipwithinsomethingthatisnotasystemisquiteahardonetothinkabout.’

TheLocalGovernmentAssociation(LGA)wasrecognisedashavingaroletoplay,butsomefeltithadbecomelesseffectiveinrecentyears.AndtherewerehighlymixedviewsabouttheCareQualityCommission(CQC),theindependentbodythatlicenses,regulatesandinspectshealthandsocialcareproviders.

Itshould,ofcourse,besaidthatnobodyisgoingtolovetheirregulator,andtherewasrecognitionthatinitsannual‘stateofthenation’report,theCQCtellsitlike itis.Buttomany,inthewordsoftwoofthecarehomeproviderswespoketo,it is,thesedays,‘justapoliceman’–andonethatseveralfeltwastheretocatchpeopleout,ratherthanactingasaforceforimprovement.Thereis,againofcourse,atensionhereinthattheCQCistheretoassessquality,whichincludesspottingandrootingoutbadpractice–evenclosinghomesandservicesifnecessary.Itcannotbetoofriendly,andlegallyitisnotanimprovementagency.Butwithinthatmanyfeltitcoulddoappreciablymoretohelp,bypointingindividualcarehomesandotherservicestoresourcesandgoodpracticeduringtheinspectionprocess,ratherthanjustdamningtheabsenceofstandards.Andagain,tobefair,inoneoftheareaswespoketo,bothprovidersandthelocaldirectorofadultsocialcaresaidthatrelationsweregoodandtheCQCwasapositiveforce.Soagain,thereappearstobeatleastsomevariationwithintheCQC’sapproach.ItsannualStateofCarereportwascitedasanexampleoftheregulatorspeakingtruthtopowerandgivingaleadershipvoicetotheevidencefromitsregulatorywork.

ADASSalsoattractedmixedviews.ThosewhowereawareofitsactivitiespraiseditscurrentPresident,JamesBullion.Itsannualbudgetsurveyiswidelyregardedasanauthoritativeandaccuratepictureofthefinancialstateofthecommissioningsideofadultsocialcare.Buttherewas,includingfromdirectors,afeelingthat itisunder-powered.OnedirectorstartedtolisttheorganisationsADASShastoliaisewithifitistohaveinfluence,andprettymuchgaveupafterthenumberpassed10–anotherindicationofthefragmentednatureofsocialcareleadership.

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‘Itstruggleswithcapacity,’onedirectorsaid.Directorspointedoutthatithasatiny,albeitindustrious,staff.Itspresident,whoisthepublicfaceofADASS,servesjustaone-yeartermbeforechanging,whichmeansthenewindividualhastobuildnewrelationshipswiththemanyotherindividualsandorganisationswithwhichADASShastointeract.‘Wegottothepointwherepeopleweren’tcomingforwardeventobevicepresident.Wewerehavingtorustlepeopleup.’

Anothersays:

It is tricky. A lot of councils, particularly in recent years when money has been so tight, are very iffy about giving up their director for a year for them to do this on top of their day job. I think there is a big question for ADASS. It does have some successes. But to make it more effective we’d need to pay more in and change its nature somewhat.

Soifleadershipisfragmentedanddispersedandofdifferingquality,whatdoesthisleadto?

Variation,istheone-wordanswer.That,ofcourse,shouldnotcomeasasurprisetoanyone.ItisthereintheresultsofCQCinspectionsanditsannual‘stateofthenation’report.Butitabsolutelyistheexperienceontheground.Oneserviceuserwhohaschairedvarioussupportgroupsthatcrosslocalauthorityboundaries,saystheonehelivesin‘doesagreatjob.Theyengage.Theylisten.Wehaveinfluence.’Butthetwoneighbouringauthoritiesare,hesays,‘dreadful’–aviewalmostentirelymirroredbyacarehomeproviderinthesamearea.Oneauthority,hesays,‘isreallygood.Weknowwherewestand.Notjustthesocialservicesdirectorbutthechiefexecutivecomestovisitus–comestoourhomes.’

When Covid-19 came, the first thing they did was to ring all the home owners and say ‘we are going to have a Zoom meeting with all our team, director of social services, deputy, all the commissioning team, and some social workers’. What a fantastic thing. We knew where we stood, right from the word go. So they are leaders. The neighbouring authority is not too bad. But the third is, in my opinion, the worst in the country. The lack of communication, the lack of empathy with the private sector – and they are the lowest payers. They are just awful.

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Anotherprovider,whodealswithbothacountyandacity,says‘therelationshipwiththecountyismuchbetterthanitiswiththecity.Thecountyconsults.Itlistens.Itadaptswhereitcan.Thecitymuchlessso.’

Onenationalfiguresays:

There is a lot of variation. It can depend on the financial situation of the local authority, some have been worse hit than others. But culture, attitudes, the quality of the formal leadership and its ethos all make the difference. Even within an area that has got some really good innovative stuff that is enabling people to live the life they want to lead, as much as they possibly can, with whatever support they need, it is a bit like in a hospital where you can have fantastic wards and services and right next door something dreadful is going on.

Socialcareinevitablyinteracts,foratleastsomeofthetime,withtheNationalHealthService.Doesitprovidesupportforsocialcareleadership?

TherewaswidespreadrecognitionofthefactthatSimonStevens,theChiefExecutiveofNHSEngland,hasrepeatedlyspokenoutontheneedforaproperfundingsettlementforsocialcare–asindeedhaveChrisHopson,theChiefExecutiveofNHSProviders,andNiallDickson,untilrecentlyChiefExecutiveoftheNHSConfederation.Suchsupportfromthehealthservicewaswelcomeforatleastkeepingtheissueinthepubliceye.ButthereweredifferingperceptionsofhowfartheNHS’sdriveforintegratedcaresystems(ICSs)1isimprovingmatters,whenICSs–theclueisintheirname–aremeanttoincludeintegrationwithsocialcare.Itisamixtureofgoodandnotsogoodnews.

Thegoodnewsisthatthemajorityofourinterviewees–wheretheyhadanopinion–saidthatrelationswiththeNHShaveimproved,particularlywithgeneralpractice.But,thatword‘variation’creepsinagain,withdifferingopinionsonhowfarthiswasduetoICSs.

1Foradescriptionofintegratedcaresystems,seeNHSEngland(2020).‘Integratedcare’.NHSEnglandwebsite.Availableat:www.england.nhs.uk/integratedcare(accessedon3December2020).

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Weheardoffineexamplesofjointworking.Onedirectorsays:

We’ve got some cracking integrated services here that provide a whole raft of support for people in the community with dementia. We’ve got a falls prevention service that’s targeted and reduced secondary falls hugely, again with multidisciplinary input. We’ve got 33 multidisciplinary teams linked to GP practices that have got GPs, district nurses, social workers, mental health experts, the voluntary sector all involved to look at connecting people into local communities and a kind of holistic view. So when you’ve got the right people with the right skill sets and the right mindset, which is ‘let’s just try and simplify this and focus and wrap around the individual’, it works great. It’s when the start point [in discussions with the NHS] is, well, let’s focus on the logo on the door, that’s when it all goes west.

Indeed,onelocalgovernmentpoliticalleaderwhohadbeenintheroleforeightyears,saysthatrelationswiththeNHSwere‘100timesbetter’thanwhenshestarted:

We have multidisciplinary teams working across health and social care. It has been a long time coming, and it is relatively recent, but yes. Far better. Though I chair a group of political leads of councils in the region and some of the reports I get are not so favourable.

Inanotherexample,onepoliticalleadsays:‘Wehaveexcellentrelationswithourclinicalcommissioninggroup’andindeedwiththehospitalandmentalhealthtrust,withanotherdescribinghownotjustgeneralpracticebutthehospitalareworkingwiththecounciltogethealthfacilitiesintoaleisurecentrethecouncilisplanning.Andallofthatisclearlybuiltonrelationships,sharedobjectives,systemleadershipandpersonalities–anotherpointtowhichwewillreturn.

AsforICSsthemselves,someintervieweessaytheyweremovingonfromtalkingtoimplementation–‘Verymuchso,yes.We’rescopingplansthatweintendtoputintoplaceforApril.’Anotherfigurewithamorenationalviewsays:

Certainly some of the ICS chairs are absolutely seeing the need for local government and NHS locally to work hand in glove and many of them are starting to do that at a system and place level, wherever place is – recognising that places are bigger in some places than others. So you see that. And there are people in NHS England and NHS Improvement who get this, and they can influence the Department. It is

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actually probably more likely that NHS England will be in a cross-government discussion about social care than anyone from local government will be, which is sad but true.

Anotherdirectorsays:‘ICSsarenotjusttalk.Thereisalotoftalk,butitisalsotranslatingintobetterservices.’

Othershavealessrosyview,feelingthattheNHS–ormoreparticularlythehospitalsector,whichtendstodominateinthesediscussions–stilldoesnotreally‘get’socialcare,seeingitlargelythroughthelensofseekingtodischarge,asswiftlyaspossible,patientswhonolongerhaveamedicalneedtobeinhospital.SomealsoworrythatasICSsbecome,notyetlegallyresponsible,butmoreresponsibleforperformance,thefocuswillmoveupthelineandawayfromtheverylocalarrangements,andtheveryclosepersonalrelationships,thatmakeintegratedcareworkinpractice.

Againstthat,somebelievethatCovid-19hasopenedtheeyesofsomeintheNHStosocialcare’srole.‘Ithinkthere’ssomepenniesdroppingaroundthesystemmorewidelythatsocialcareisimportant,’onecouncilleadsays.Thereappearstobemoreofanunderstandingthatitisnotjustcarehomesbutdomiciliaryservicesthatsupportpeopleofworkingage,andsupportolderpeople,intheirownhomes,helpingkeepbothgroupsashealthyandactiveandengagedaspossible–andoutofhospital.

Indeed,someofthosewetalkedtosaidthattheCovidemergencyhadbrokendownbarriersandledtopeoplemakinginstantdecisionstoworkbettertogether.Mostoftheseinterviewswereconductedafterthepeakofthefirstwaveandbeforethesecond,butalreadytherewereworriesamongsomethattheolder,slower,moreformalandbureaucraticwaysofworkingwillreassertthemselves.Onedomiciliarycareprovidersays:

Covid-19 brought about an amazing change for a very small period of time, which worked really well. What I saw was that peeling back of the layers around decision-making. People needed to just take action – really, really quickly. Just find a solution to the problem. There was that need for speed, and it worked really, really well.

I find that people are now, within the local authority, drifting back into a situation where they’re sort of saying ‘oh, we need to review that’. And the review will

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need three or four months to work through, and ‘we’ll need a proper proposal put forward’. It was really refreshing that people were able to break down those barriers, just do what needed to be done. But it’s all coming back in now and it’s a shame.

Anotheralsotooktheviewthatasmallsilverliningtothepandemicwasbetterunderstandingandcloserworking.‘OurrelationshipwithourCCG[clinicalcommissioninggroup]partnershadevolvedmassively[aheadofthepandemic],’ onedirectorsays,butduringit‘wesawNHScolleaguespilinginbehindusratherthanseekingtodetermineorcontrol’.

Foralltheprogressthatisbeingmade,andwasbeingmadeaheadofCovid,barriersremain.Afewstories.Thefirstaboutthehomecareagency’srapidresponseteam,mentionedearlier.

Itstartedoutasatwo-yeartrial,fundedbythelocalauthority.Allthegains,however,wereaccruingtothehealthserviceintermsoflesspressureontheambulanceservice,andreducedA&Eattendancesandshort-termadmissions.Accordingtotheagencyownerwhoseprojectthiswas,somesixmonthsagothelocalauthoritysaidthatbecauseallthegainsweregoingtothehealthservice,itnolongerwantedtofundit.SotheypasseditovertothelocalCCG,saying:‘We’renotgoingtofundthisanymore.Butit’savaluableservice.Willyoufundit?’TheNHStookitonforsixmonthswhileitranareview.Itdecidedtheservicewasnotbeingusedintensivelyenough.Itthencameupwithsomelessthanhelpfulproposals–suchastheemergencyresponseteamsonlybeingpaidwhentheywerecalledout,which,astheownersaid,wouldnotbeappliedtoanyotherhealthemergencyservice,andwouldnotbeviable.Itwouldbeimpossibletoretainthestaffwhoare‘justtwomembersondutyatanyonetime–12-hourdayshiftsand12-hournightshifts’.Toavoidtheservicebeingoverwhelmed,limitshad,fromthestart,beenplacedonwhocouldcallonitsservices.Spreadingthenetwider–alittlewiderintermsofgeography,somewhatwiderintermsofwhocouldaskforitsassistance–would,theownerargues,haveincreaseduptake.ButtheCCGwouldnotagreetothat.‘Theywantedtokeepthepathwaysmallandnarrow.’So,atthetimeofwriting,theserviceistoclose.‘Moneyhaswonoveroutcomes,’theagencyownersays.2

2ThisaccounthasnotbeencheckedbackwiththelocalauthorityortheCCGinvolved.Itistheprovider’sperception.

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Thenthereisthestoryofanelderlyclientwhoreceiveda30-minuteeveningvisittohelphertobedandprovideahotdrink.Shewasprescribedsurgicalstockingsandcreamsforherlegs,whichneedcleaningandcreamingbeforeretiring.Thecouncilrefusedtopayforaslightlylongervisitfromthecarertocoverthat,sayingitwasahealthneed.Buthealthdeclinedtopay,sayingtheydidnothaveadistrictnursetodoit.Theagencysaidtheydidnotneedadistrictnurseforasimple,ifcumbersome,task.

We said, as we had said before, we’d do the work. So we went back to social services who said again they would not pay for it, and health again said they would not pay. Which is a shame because, without this, her legs will break down, she’ll get ulcers and end up in hospital when the NHS will be paying more.

Thesolution?Thecarernowdoestheclient’slatenighthotdrinkaspartofteatime,notbedtime,providingthe5or10minutestodothelegsandthestockings.‘Butitisnotideal.Itisnotwhatthecustomerwants.Itshouldn’thappenlikethat.’

AcarehomeownerweinterviewedsaidtheyhadjustbeentoldbytheGPwholookedafterresidentsinoneoftheirhomesthathisservicewasgoingtocease.TheCCGinwhichthedoctorwasbasedhaddecidedongeographicallimits,andthehomewassituatedoutsideofthose.TheGPsaid,accordingtothisinterviewee:

‘I know we’ve looked after you for the last 30 years, but we can’t look after you as from 1 October. I’m ever so sorry, but it’s not my decision.’ Well, it would have been nice to have had a letter from the CCG, a phone call, or somebody from health to say, ‘I’m sorry, you’re losing your GP and you’ve got to register all of your residents now with a new GP, 50 of them – and we will help you find one’. Not good practice. That’s not leadership. It gives a bad reputation to the health authority in my opinion.

Andthenagainfromanotherpartofthecountry,apoliticalleadsays:

I was talking to a GP the other day who has a post-Covid patient with terrible lasting diarrhoea, and needs a shower, ideally a walk-in shower. But the GP can’t order a shower and the patient does not have the sort of sharp elbows to be able to sort it for himself. So the GP writes to the council, which replies saying ‘you can’t

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tell us to put a shower in, only an occupational therapist can tell us to do that’. So I’m trying to sort that out while the person affected is living in really miserable circumstances and probably acquiring more care needs.

Somepartsofthecountry,includingtheonereferredtohere,haveappointed‘carenavigators’tohelpthelessableclientsnavigatethesystem.Butbothofthosewhotoldusaboutthatseethemalmostasanadmissionofdefeat.Asoneputit:‘Wetalkaboutthisasaninnovation.ButIhavereallymixedfeelingsaboutit.Itisawfulthatwe’vegotsuchacomplicatedsystemthatindividualsneedsomuchadvocacytogettheservicesthattheyneed.’Anothersaidthatwhentheprimarycarenetworksuggestedappointingsome:

…my response was that the minute you employ somebody with the words ‘care navigator’ in it you’re basically admitting that your system is too complex for your citizens to sensibly be able to use, and therefore we have failed. And they’re going, ‘that’s a bit harsh’. So we are looking at other ways of getting the mainstream services to work better together.

Sohowdoessocialcarefeelaboutitself?

Inthreewords,fartooinvisible–atleasttothepubliceye,withdegreesofinvisibilitywithinthat.Inmostpublicdebate,itiscareofolderpeoplethatgetswhateverlimitedattentionisgoing,andwithinthat,carehomes.Adultsofworkingage,whoseneedsareoftenverydifferenttothoseofolderpeople,feelexcludedfromthatconversation,eventhough,asalreadynoted,aroundhalfthepublicbudgetisspentonthem.Andsomeworryaboutthetransitionfrombeingclassedasworkingage.Forexample,thosesupportedbypersonalbudgetsworryiftheirrelativefreedomswillbelostastheybecomedefinedasneedingolderpeople’scare.Onespeaksformanywhenshesays:‘Don’tlumpusallintogether.Weallhavedifferentneeds,whateverourage.’

Thesamesenseofinvisibilityappliesevenwithincarehomes.Theheadofonelocalcarehomeassociationcomprisedmainlyofsmall-andmedium-sizedproviders,says:

I do feel sometimes that we are a lost voice. The bigger corporates have their association and their access to DHSC [the Department of Health and Social

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Care]. But probably 75 or 80 per cent of the market is made up of smaller providers. We have created the Care Association Alliance for the smaller- and medium-sized homes to create some sort of voice and make a noise about the challenges that we face.

AnddespitetheUnitedKingdomHomecareAssociation(UKHCA)–therepresentativebodyfordomiciliaryservices,whichsomeseeashavingmadeagoodpubliccasearoundfearsomelytime-limitedvisits,lowpayandzerohourscontracts–someprovidersofcareinpeople’sownhomesfeelevenmoreinvisible.Theproprietorofonesuchagencysays:

You have seen it on the media during Covid. ‘We must look after the NHS. We must look after care homes, and making them priorities for PPE [personal protective equipment].’ And I am screaming at the telly, ‘What about domiciliary care?’ We need PPE, we need testing, and we are still not [at the time of writing] a priority for that, and our workers are going out there, taking the same risks, picking up people coming home from hospital and equally worried about infecting those we care for.

Addingtothesenseofinvisibilityisthepublic’sawesomeignoranceaboutsocialcare;aboutitscomponents–workingagesocialcare,olderpeople’scare,domiciliaryservicesandtheNHScontribution.Butalsoabouthowitworks–thewayitisbothneeds-testedandmeans-tested.

Tobefairtogovernmentsofallpersuasionsoverthepast25years,theyhavesoughttoaddressthat.Alonger-termreformofsocialcareisstillmissing.But therehavebeenmorethanadozenGreenPapersandWhitePaperssince1996, eachofwhichhassoughttoexplainhowthingswork.Severalinvolvedsignificantconsultationexercises.TherehasbeenaRoyalCommissionandtheDilnotCommission,asidefromtheeffortsofassortedthinktankswhich,inthecaseofTheKing’sFundalone,includedareviewofsocialcarebyDerekWanless(Wanless 2006)andtheBarkerCommissiononHealthandSocialCareinEngland(Commission on the Future of Health and Social Care in England 2014).Inthepasttwoyears,threecross-partyparliamentarycommitteeshaveachievedpoliticalconsensusincallingformajorreform.Still,asrecentworkbytheHealthFoundationandTheKing’sFundshows,‘Thepublichaslittleunderstandingofhowsocialcareoperates,andevenlessunderstandingofhowitisfunded’(Bottery et al 2018).

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Ononelevel,thepublic’sbyandlarge‘ostrich’viewisnotsosurprising.Asonesocialservicesdirectorputsit:

We are asking government to prioritise something that the vast majority of voters don’t understand and/or don’t want to think about. And it is not that surprising. Nobody wants to think about diminishing powers as you grow old, and for working age social care you assume it won’t happen to you: until it does.

Buttheseviewsdoraisethequestionofwhethersocialcare’svisibility,andwiththatpublicunderstanding,mightbehelpedbyastrongervoice?

Astrongervoiceforsocialcare?

OneofthemanycontrastsbetweentheNHSandsocialcareisthat,quiteasidefromNHSEnglandandNHSImprovementbeingresponsiblefortheservice,theNHShasastrongprovidersidevoice.Tobefair,therearetwovoices–thatofNHSProviders,whichessentiallyrepresentsNHStrusts;andtheNHSConfederation,whichincludesnotjusttrustsbutalsoCCGs,theemergingICSs,andtheIndependentHealthcareProvidersNetwork,whichrepresentsprivateandindependentprovidersofNHScare.Itisalsofairtosaythatboththepublicandprivateinfluenceofthesetwogroupingshaswaxedandwanedovertheyears.Butseparately,andattimestogether,theyprovideaclearvoiceforNHSorganisations.

Bycontrast,andreflectingthehighlyfragmentednatureofsocialcare,itslandscapeislitteredwithrepresentativetradebodies.AsidefromtheUKHCA(alreadymentioned),whichrepresentsdomiciliarycareproviders,andtheNationalCareAssociation,whichchieflyrepresentssmall-andmedium-sizedhomeownersbut alsosomedomiciliaryproviders,thereisthegrandlynamed–andmuchbetterresourced–CareEngland,althoughitischieflythebailiwickofthebiggercorporates.ThenthereistheNationalCareForum,whichrepresentsthenot-for-profits;theRegisteredNursingHomeAssociation,whosemembershipchieflyincludesnursinghomesasopposedtocarehomes;theAssociationofMentalHealthProviders;andtheAssociationofRetirementCommunityOperators.Anotherbody,theVoluntaryOrganisationsDisabilityGroup,speaksfornot-for-profitserviceprovidersforpeoplewithdisabilities.ThesegroupsandothersarebroughttogetherintheCareProviderAlliance,whichdescribesitselfasaninformalbody.

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Totheoutsideobserver,theircollectivevoiceappearstoadduptolessthanthe sumoftheparts.Andtensionscanrippleacrossthem.Locallyweheardfromonecareassociationforsmall-andmedium-sizedhomeswhicharguedthatbringingindomiciliarycaremembers–and,indeed,homesthatareprovidedbythecouncil–hadbroughtmuchbetterrelationshipswiththelocalauthority.Itschairsays:‘Wehavetoappreciatethatit’snot“themandus”withhomecareandcarehomes.Wehavetoworktogethertorepresentcare.’Oneofitsambitionsistobringsupportedlivinganddaycarecentresintomembership,‘evenifitmeanswesometimeshavetoswitchoffourpersonalintereststogettoonevoice’.Bycontrast,acarehomeassociationinanotherpartofthecountryrefusestoletlocalauthority-providedhomesintomembership,arguingthatthecouncilfavoursthemoverprivatelyprovidedones.

Therehaveinthepastbeenattemptsatmergers,andsomefeltthattheinterests ofthedifferentpartsofsocialcarecanbesodiversethatasinglevoiceisimpossible.Mostofourinterviewees,however,believedthathavingamoreunifiedvoicefortheprovidersidewouldbeastrength,providingaclearernarrativefor thepublicandaclearermessagetogovernment.

Thissectiondiscusses,sofar,onlytheproviderside.Thereis,ofcourse,asomewhatbewilderingarrayofotherplayers–includingnotjustcarestaffbutfamilyandfriendswhocareforthoseinneed,andwhoare,perhaps,themostinvisibleofallinthissomewhatinvisiblesector.AttemptstobringsomeofthemtogetherincludetheCareandSupportAlliance,whosemembersincludeindividualproviders,CareEngland,andcharitiesandadvocacygroupssuchasAgeUK,theAlzheimer’sSociety,theBritishHeartFoundation,CarersUKandDisabilityRightsUK.Formedtoarguethecaseforfundingreform,itremains,inthewordsofoneofitsinstigators,‘moreanopinionplacethanaleadershipplace’.

Atanotherlevel,aninformalforum–the‘socialcareleadersgroup’–hasrecentlybeenformed,bringingtogethertheLocalGovernmentAssociation,theCQC,ADASS,SkillsforCare,theSocialCareInstituteforExcellenceandotherstoshareinformationandseektoalignmessages.Moreamatterofinternalliaison,ithasnot,atleasttodate,soughtapublicprofile.

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Asidefromleavingthepublicsomewhatconfused,thismust,fromministers’pointsofview,feellikeacacophonyoftoooftencompetinginterestsratherthanthemoreunified,bullet-likemessagethatNHSProviders(forhealth)ortheNationalHousingFederationandtheCharteredInstituteofHousing(forhousing),orUniversitiesUK(universities)canoftendelivertogovernment.

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3 Whatelsedidwehear?

Itisnotjustlocalleadership,itisrelationshipsthatmatter

Therecanhardlyeverhavebeenapiecewrittenaboutleadershipthatdoesnotsaythatrelationshipsmatter.Butthefactthatithasbecomeaclichédoesnotmakeitanylesstrue.Therelationshipsbetweendirectorsandthe‘expertsbyexperience’usergroupsthatsomelocalauthoritiessupportmatter.Asdorelationshipswithstronglocalorganisationsforcarehomesandhomecareagenciesthattaketheconversationbeyondtheannualbattleoverfees.Asoneusersaidofonedirector,‘He’sagreatleader,agoodcolleagueaswell,withaclearaim,andhedefinitelyhasthehumantouchandthehumanelementinhisleadershipstyle’.

Personalities,styleandrelationshipsmatter,notjustwithinsocialcarebutinitsrelationshipwiththeNHS.Onedirectorsays:

We’ve got some very good NHS chief execs. We’ve reached the point where we can be really honest with each other but very respectful. We get things done. So there is a very happy coalescence of some great individuals. But it can be very different on a different patch. One talks to colleagues, and I know of one area where there are at times real battles with NHS colleagues. Some of it is scary, but it is down to personalities.

Anditalmostgoeswithoutsayingthatgoodrelationshipstaketimetobuild,andchurnoneitherside–insocialcareandintheNHS–caneasilysetthatback.

Lackofdata,lackofinfrastructure,lackofresearch

Accordingtoonehugelyexperienceddirectorofservices,‘Thereisarealshortageofdataaboutwhat’sactuallygoingoninsocialcare.CertainlycomparedtotheNHSbutevencomparedtothepolice,wejustdon’treallyknowwhat’sgoingon.’Indeed,thatwasbrieflyillustratedintheearlydaysoftheCovid-19pandemicwhen,amidcriticalshortagesofPPE,theDepartmentofHealthandSocialCareappearednottoknowhowmanycarehomestherewere,letalonedomiciliarycareagencies,orhowtogetPPEtothem.

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Localauthoritiesdo,ofcourse,knowwhattheyspend–withandwithoutusercharges–andthosefiguresareavailablenationally.Butquitewhattheprivatemarketisforcarehomes,homecareservices,shelteredaccommodationandextracarehousingisthesubjectofestimates.TheCompetition&MarketsAuthority(CMA),whichisnotshortofnumbercrunchers,hadtoestimatethesizeofthecarehomemarketin2017(CMA 2017),andin2020theOfficeforStatisticsRegulation(OSR)reportedthat:

…this important sector of public policy is very poorly served by data… a scarcity of funding has led to under investment in data and analysis, making it harder for individuals and organisations to make informed decisions. This needs to be addressed… Improved data matters in solving problems, supporting efficiency and maximising outcomes. It is also important to inform decisions made by individuals about the care they receive or provide for themselves and their families.(OSR 2020)

Localauthoritieshavealegal‘marketshaping’dutythatincludesforecastingdemandforsocialcare.Butinthishighlymixedeconomy–somecarehomestakealargeproportionoflocalauthority-fundedresidents,sometakemoreofabalance,othersarelargelyorentirelyfilledbyself-funders–theinabilitytofullyunderstandthatmixandhowitisevolvinghampersforecastingandplanning,forbothphysicalprovisionandworkforce.Andthatisjustforthecarehomesector.Thereisevenlessknowledgeoftheprivatedomiciliarycaremarketandindeedofnewtrendsinboththepublicandprivatesectors.Forexampleextracarehousingandother,oftentechnology-driveninnovations.Indeed,theCMAin2017recommendedthatanewindependentbodybesetuptogatherdatainordertohelpcouncilsplan(CMA 2017).

Onesocialservicesdirectorsays:‘Noonehastheoverviewofworkforce,ofmarketstability,ofothersortsofdata.It’salldispersedallovertheplace.’Totakejustoneexample,thereisnorequirementforprivateproviderstodiscloseworkforcenumbers,andonlyhalfofprovidersfillinasurveyrunbySkillsforCare.

AnotherdirectorsaysthatHelenWhately,thecurrentMinisterofStateforCare, andwhopreviouslyworkedinthehealthcaredivisionofthemanagementconsultancyMcKinsey:

…cannot understand why you can’t aggregate social care up nationally, as you can in the NHS, and understand how many people are being served and how

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many people are waiting and not getting services. It is a fair question. But we don’t do it that way because it’s distributed out in local government. So we lack a national infrastructure.

TheOSRpointedoutinearly2020thatnooneknowsthevalueofunpaidcare,otherthanthroughhugelyvariedestimatesofbetween£100billion(OSR 2020)and£132billion(Carers UK 2015)–farexceedingthe£25billionofpublicmoneyspentonallformsofpersonalsocialservices.TheCQC,itsaid,isseekingtodriveupthequalityofcarebut‘withoutcross-governmentworkingtoimprovethedatacollections,itwillbeunabletocomprehensivelymonitorandmeasureimprovementstocare’.

TheOfficeforStatisticsRegulationalsosaidthat,incontrasttohealthcare:

… where the effectiveness of interventions is a priority research area, in social care there is very little understanding of the most cost-effective interventions and what the impact of each intervention is. In order to ensure people are getting appropriate care, comparable linked data on spending on care packages, the needs being met and the individual outcomes is needed. (OSR 2020)

ItnotedthattheDepartmentofHealthandSocialCarehadplansbackin2014forasignificantimprovementindatacollection,butthatremains‘workstillinprogress’.

Mostrecently,andwellafterwestartedourinterviews,theSocialCareSectorCOVID-19SupportTaskforceitselfunderlinedtheneedformuchbetterdata(Social Care Sector COVID-19 Support Taskforce 2020,seerecommendations35and36).

Lackofdatameanslackofresearch.TheheadofoneofthelargerproviderssaysthattheSocialCareInstituteforExcellenceisprovidingsome‘concreteandpracticaltools’butthebroaderpicture,outsideofafewacademiccentressuchastheLondonSchoolofEconomicsandPoliticalScience(LSE)andtheeffortsofthinktanks,is‘theabsolutepaucityofresearchintosocialcare’.TheNationalInstituteforHealthResearchdoesnowhaveaSchoolforSocialCareResearch,andtheEconomicandSocialResearchCouncilandtheHealthFoundationaretofundanewevidencecentreforinnovationinadultsocialcare.Butthefactremainsthatnotenoughdatameansnotenoughfortheresearcherstogettheirteethinto.Itismorethanlikelythatquality,effectivenessandcost-effectivenesssufferasaresult.

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Lackoftraininganddevelopment

Thereisaseriousunderinvestmentintraininganddevelopmentinsocialcare–forleadership,butnotjustforleadership.

HealthEducationEngland,thebodyforeducationandtrainingintheNHS,hasabudgetofaround£4billion(Health Education England 2020).Theequivalentforsocialcare–thoughtocallitanequivalentisamisnomer–isSkillsforCare.HealthEducationEnglandisanon-departmentalbodyoftheDepartmentofHealthandSocialCare,oftenintheroomwithministers;SkillsforCareisanarmslengthcharitybasedinLeeds,theDepartment’s‘deliverypartneronleadershipandworkforcedevelopment’.Ithasabudgetofsome£30million,mostofwhichisagrantfromDHSC.3

Asalreadynoted,thesocialcareworkforceandtheNHSworkforceareofsimilarsizes,andthedisparitybetween£4billionand£30millionisstriking–a133-folddifferential.Thereisnothinglike‘parityofesteem’here.

Tobefair,thefiguresarefarfromdirectlycomparable.HealthEducationEnglandfundingincludessupportforthetrainingofdoctors(typicallyaseven-yearcourseincludingobligatorypost-graduationqualification),nurses(athree-yearcourse),andprofessionsalliedtomedicine,wherecourselengthvariesbutisnevershort.

Andagain,tobefair,thesocialcaresectordoesnotneedthesameleveloftraininginvestmentastheNHS.Careworkersareskilled,butclearlydonotrequirethehighlytechnicalandspecialisedtrainingofmedicsornurses.Nonetheless,likeNHSstaff,thoseworkinginsocialcareneedcontinuingprofessionaldevelopment.Andtheskillsneededtobeadirectorofadultsocialservices,whichincludebeingasystemsleader,areonaparwiththoseofachiefexecutiveintheNHS–withtherequirementgrowing,withintheNHS,tobeasystemsleader,notjustaleaderofanindividualorganisation.(see www.kingsfund.org.uk/topics/system-leadershipformoreonsystemleadership).

Allthatsaid,theSkillsforCarebudgetequatestojust£14perheadfortheadultsocialcaresector.Whatcanyoubuyforthat?

3EquivalentbodiestoSkillsforCareinScotland,WalesandNorthernIrelandarenon-departmentalbodies.Theirresponsibilitiesgowider,includingregisteringandregulatingthesocialcareworkforce,whichdoesnothappeninEngland.

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Anindependentauditoftheorganisation’swork–admittedlycommissionedbySkillsforCareitself(Skills for Care 2019)–concludedthatthosewhohavereceiveditstrainingprogrammes‘experiencedarangeofpositiveoutcomes.Thisincludesanimprovementintheskills,knowledgeandconfidenceoftheworkforce,fromentry-leveltoseniorleadership.’Buttheorganisation’slimitedbudgetleavesholeseverywhere,evenatthemostbasiclevel.

TheNationalAuditOffice(NAO)in2018reportedthat65percentofnewlyrecruitedcareworkerssince2015hadtakenorweretakingthe‘carecertificate’–theminimumstandardsforacareworker,whicharemeanttobepartofbasicinduction.Thismeansthat35percentwerenot.TheNAOreportedthatmostofSkillsforCare’swork‘issmall-scaleandconstrainedbytheamountoffunding’(NAO 2018,p30).

Italsounderlined,asdidourinterviewees,thatthereisnonationalworkforcestrategyforsocialcare.TheNHShasbeencriticisedforbeingslowtodrawupitsownworkforcestrategy.Butforsocialcare,itisquitesimplyabsent.HealthEducationEngland’sdraftworkforcestrategyforboththeNHSandsocialcare,publishedin2017,devotesjust4ofits130pagestosocialcare,chieflydescribingtheproblemandthelimitedsupportavailablewhileindicatingthattherewillbemoretocomeinthe(stillpromised)socialcareGreenPaper(Health Education England 2017).TheNAOin2018notedthattheDepartment‘hasnotfollowedthroughoncommitmentstotrainingmadeinthe2012WhitePaperCaring for our future: reforming care and support’(NAO 2018,p29).

Inthepast,traininghasbeenseenasprimarilyaresponsibilityforcareprovidersandforlocalauthorities.ButtheNAOreportedthatwhilelocalauthoritieshaveadutytoencouragetraininganddevelopmentunderthe2014CareAct:

…providers are not formally required to offer development opportunities to staff. Local authorities lack the strategic ability to require providers to support training programmes, so development opportunities for staff vary depending on the provider. Both providers and commissioners from local authorities told us that current funding constraints necessitate them prioritising the provision of care in the short-term, over offering extensive long-term support for learning and career development to their staff. They told us that providing better training would be a priority if extra funding was available.(NAO 2018,p29)

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Nothinghaschangedsincethen.Andifthatisthepicturefortraininggenerally,ourintervieweesalsoworriedaboutleadershiptrainingfordirectorsofadultsocialcareinparticular.Onemadethepointthatasfundingconstraintshavestrippedoutposts,individualshavebeenpromotedwithinlocalgovernmenttoassistantdirectorpostsandabovemorerapidlythaninthepast,andthuswithlessexperience.Althoughthereisashortdevelopmentprogrammefornewandaspiringdirectors,runbySkillsforCareandADASS,thismaynotgofarenough.Anotherintervieweesays:

We need a package of support for newly appointed directors. You need a range of skills and not everybody is the rounded creature. So there are very practical skills. But then there is managing the political landscape skills and being a systems thinker – not everybody’s a systems thinker. There is a real breadth of skills you need and not everyone will have picked them up on the way up.

Anotherintervieweefeltthereneededtobemuchmoreattentionpaidtoequalityanddiversityinleadershipdevelopment.

Lackofleadershipfromthetop

Here,ithastobesaid,painfulthoughitwillbetoreadforthoseinvolved,thatthevastmajorityofourintervieweeswerescathingabouttheDepartment–theoneplacewhereonemighthavethoughtleadershipatthetopwouldlie.Theonlyotherissueaboutwhichtheyweremoredistressed–indeedsomewhatclosetodespair–wasovertheendlessunfulfilledministerialpromisesaboutacomprehensivereformto‘fix’socialcare.

Oneshouldalwaysguardagainst‘abetteryesterday’.Memoryplaystricks,withmanypeopletendingtorecallthemoregoldenoftheagesinpreferencetothemorepainfulones.Butourintervieweeswereclearthattherewasindeedabetteryesterday.TheolderhandsrecalledBillUttingandHerbertLaming;youngeronesDenisePlatt,DavidBehanandJonRouse.Whiletheirtitlesvaried,eachwasthechiefadviser,ordirectorgeneral,forsocialcarewithintheDepartmentofHealthandbuiltstrongteamsaroundthem.Allwereofandfromthesector,withtheexceptionofJonRousewho,asaformerlocalauthoritychiefexecutive,hadastronggraspofsocialcare.

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Althoughtheyhaddifferingstyles,theywereregarded(bythoseofourintervieweeswhohadbeencloseenoughtoobservethemorknowthem)asnotjustindividualleaders,butasleadersofstrongteamstheyhadhelpedtobuild.Thesewereseenaspeoplewhowouldspeaktruthbacktothesector,aswellas toministers.Asonedirectorofadultsocialservicessays:

I do remember David Behan coming to an ADASS conference, where he gave us an absolute bollocking because we had all said fairly disparaging things about the NHS in a session the day before. He told us that the NHS ‘has got more clout than you governmentally, it has more clout than you with the public, it has more budget than you, and it has more power than you’. And that if we went to war with it, we would do nothing but lose. We had to work with it, and constructively.

Shouldthechargebethat,althoughthesepeoplewereseenasleaders,therehasstillbeenaquarter-centurylongfailureto‘fix’socialcare,theansweristhattherehavebeenrealandsignificantimprovementsoverthattime–personalbudgets,forexample,alongwithsharedlivesschemes,asset-basedapproaches,reablement,innovativemodelsofhousingwithcare,and‘homefirst’hospitaldischargeprogrammeswiththeNHS.Indeed,theircumulativeeffortsinlateryearseventuallyledtotheCareActof2014.Mostofthedirectorsofadultsocialserviceswespoketoregardthisasagoodpieceoflegislationthatwasgenuinelyputtogetherwiththesector–‘co-produced’,inthejargon.Itstwodrawbackshavebeenfirstthatausterityhaslimiteditsapplication,andsecondthatthegovernmentpostponed–indeed,maywellhavecancelledforgood–theclausesthatimplementedthefundingrecommendationsfromtheDilnotCommission:namely,thosethatsetacaponindividualliabilityforsocialcarecostsandsignificantlyraisedthemeanstestsothateventheleastwell-offwillretainappreciablymoreoftheirassetsthanunderthecurrentsystem.4

Thesedays,however,leadershipfromthetopfeelsverydifferenttoourinterviewees.‘Avacuum,’saysone.‘Diminished,’saysasecond.‘Thedayswhenwehadveryclearleadershipatthetoparesomewhatdistant,’saysathird.Afourthadds:‘Therehasn’tbeenanyevidence,foralongtime,ofwhatyoumightdescribe

4Asenacted,theDilnotCommissionledtothethresholdforthemeanstestbeingraisedfrom£23,500to£100,000,allowingthelesswell-offtokeepmoreoftheirassets.Inaddition,afterthefirst£75,000ofapprovedcarecosts,thetaxpayerwouldpickupthebill,ineffectprovidingthetailendinsuranceforthe mostcostlycases.

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asleadershipcomingfromthere[theDepartment]’.Afifthsays:‘It’sbeendireforalongtime.Therehasn’tbeenvisibleleadershipforalongtime.’Andasixthadded:‘There’sareallyquiteastoundinglackofunderstandingofsocialcareatthecentre.’Thelistofquotescouldgoon.

Ifthatistheviewofwhathashappenedinthelongerterm,thereisashorter-termversionovertheresponsetoCovid-19.Onesays:

All you get from the centre is eleventh-hour short-term requests for reams and reams of data to provide assurance to the minister. That’s not leadership, it is form filling. All of the things that worked about the response to Covid were about the local services and the local communities and what they did to keep the show on the road, and everything that has been a monumental fuck-up has come directly from Whitehall.

ThecoreissuehereisthatsincethedaysofJonRouse,wholefttorunManchester’scombinedhealthandcaresystemin2016,therehasnotbeen,foranylengthoftime,adirectorgeneralforsocialcarewhosebackgroundisfromthesector.SeveralcitedDavidBehan’stimeasthelasttimewhentheyfelttherewassomeoneintheDepartment‘whounderstoodwhatitwasliketoleadtheseservices,understoodthefinances,therights-basedagenda,personalisationandalltherest,’andwhowasseenashavingrealinfluencewithministersandNHScolleagues.ThenumberofcivilservantscoveringtheissuewithintheDepartmenthassincethendiminishedand,accordingtoourinterviewees,thosemovedintocoveritdonothaveasocialcarebackground.

Thereissomesympathyfortheofficialsinvolved.‘Thenatureofsocialcarebeingsoconfused,contested,fragmented,itactuallyprobablyisaprettydifficultintellectualchallengetosuddenlycomeinasanofficialtounderstandallofthat,unlessyouhadsomesortofbackgroundinit.’Asecond,moreconspiratorially,says:‘Youdoendupwonderingwhetheritislikethisbecauseministersdon’twantsomeonetherewhocanmakethemsitupandlisten.’Athird,morekindly,says:‘someoftheseniorcivilservantshavebeenverygood.Buttheymoveonallthetime.Soitisreallydifficult.Thekeymissingpersonisthedirectorgeneralrole.’AdirectorgeneralwasappointedinApril2020,onlytobereplacedbyatemporaryappointmentinSeptember2020.

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ItshouldbesaidthatthiswasnotjustacaseofpeopleinthefieldwantingoneoftheirownintheDepartmentasasortofcomfortblanket.Asalreadynoted,previouschiefadviserscouldbeastoughwiththesectorastheywereclearwithministersandtheirNHScolleaguesintheDepartment.Itistheexpertiseandtheadvocacythatismissing.

TherewassympathyalsofromsomeforHelenWhately,thecurrentMinisterforCare.Oneintervieweesays:

…watching the realisation on her face over the last six months that ‘I’ve got no bloody levers. I can’t make the CQC do anything, not very easily. I certainly cannot make local government do anything. The providers spend their life whinging at me and I can’t make it better for them, even though I have found them some money.’ I think it is a really horrible role.

Sympathyaside,however,therewasawidelyheldviewthat,foralltheconstraintsaroundit,leadershipatthetophasgonemissing–andthattheonethingthatsocialcaredesperatelyneedsrightnowisthelong-promisedbutundeliveredreformtoitsfundingandoperation.

Thereisonenotableexceptiontothistrend:thecreationofthepostofchiefsocialworkerintheDepartmentofHealthin2013iswidelyviewedashavingboostedtheprofessionalleadershipofsocialworkbyprovidinganexpertvoiceforsocialworkwithingovernment.Inthewordsofthefirstpost-holder:

One of the key messages I have heard from social workers over the last year, is that they really value having a chief social worker to give the profession a voice within government and particularly within the Department, and the recognition that social workers have a key contribution to make to improving outcomes in adult services.(Department of Health 2014,p22)

Thechiefsocialworkerworkscloselywiththenationalnetworkofprincipalsocialworkersineachlocalauthority,creatingastrongerlinkbetweenfrontlinepractitioners,seniormanagement,andnationallytotheDepartmentofHealthandSocialCare.‘It’sbeenverylimitedinresources,certainlyuptonow,’oneoutsidersays.‘Butithasbeenapositive.Ithasgotsocialworkclosertoministersandithassupportedthenetworkofprincipalsocialworkersinlocalauthorities.’

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4 Whatdidweconclude?

Givenoursmallsamplesize,wedonothavethetemeritytomakerecommendations.Butfromwhatwehaveheardthisiswhatwewouldconclude:

Leadershipmattersateverylevelinsocialcare,butlocaliscritical

Someofthemostinspirationalandeffectiveexamplesofchangethatweheardcamefromusersandprovidersandcarestaffwhohadtakenleadershipuponthemselves–inmanycasesbecausetheyhadbeenliberatedsotodobyrelativelyrecentchangesinthewaysocialcareoperates–changessupportedbytheCareActof2014.

Inthejargon,thisisknownas‘co-production’:theproductofpersonalbudgets,directpayments,andhowleadinglocalauthoritiesanddirectorsofadultsocialserviceshaveencouraged–and,inthebestexamples,supported–‘expertsbyexperience’andcareproviderstohelpshapethewayservicesaredelivered.Thesegroupingsdonotalwaysgetwhattheywant.Eveninbettertimesthanthese,resourceswillbelimited.Butinthelastanalysissocialcareisaboutenablingthosewhoneedsupporttoliveasindependentlyastheywish,andasindependentlyaspossible.IndividualdecisionsaboutthatcannotbedirectedfromWhitehall.Itseemsclearthattheverybestorganisationscherishuserfeedbackwhereasthepooronestendtohidefromit.Insocialcare,tobeeffective,powerhastofollowthemantrathatitneedstobedevolvedtowherethebestexpertiseandmotivationsits.Thatofferstheprospectforusinglimitedresourcestobesteffect,andisentirelyconsistentwithpreviousworkbyTheKing’sFundonsystemleadership(The King’s Fund 2020; Bailey 2018; Timmins 2015).

TheNHSshouldnot‘takeover’socialcare,norlocalgovernmenttheNHS

Thisissomethingofanon-and-offperennialdebate,anditcameupwithourinterviewees.Giventhattheycameessentiallyfromlocalgovernment,orfromservicesheavilyinfluencedbylocalgovernment,itisscarcelysurprisingthatmostobjectedvehementlytoanysuggestionthatitshouldbethehealthservicethatcommissionssocialcare.

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Theypointedtotheaccountabilitythatlocalgovernmenthas,butwhichtheNHSlacks,throughtheballotbox–andtothefactthatsocialcarestretcheswaybeyondtheissueofdelayeddischargesfromhospital.Oneintervieweesays:‘Thefactthatpeoplestillthinkthisisonlyaboutdelayeddischarges,“solet’sletthehealthservicefundthem”,showswestillhaven’tgotacrossourunderstandingofthis.’

Someofthedirectorstowhomwespokearguedlucidlythatsocialcareatitsbestistiedintoawiderangeofothercouncilservices,includinghousing,leisure,widercommunityfacilitiesand,indeed,economicregeneration–serviceswellbeyondthereachoftheNHS.Andasonecouncillorputit:‘Peopledoexitsocialcareandwewantthemto.Butthereisahugenumberofpeoplewhoareeffectivelycomingunderourwingtolivetherestoftheirlives.’

Oneortwo–whileacknowledgingthatitwasprobablyabitofafantasy–speculatedaboutlocalgovernmentcommissioningthemorecommunity-basedbitsoftheNHS.Butmostrecognisedthatwhatthatwaslikelytodowassimplymoveanexistingbarrierelsewhere.And,eitherway,therewouldbeahugeopportunitycost.Insocialcare,asintheNHS,thememoryofthedisruptioncausedbyAndrewLansley’sHealthandSocialCareAct2012lingerson,asdoes(forthosewithlongermemories)therepeatedrestructuringofprimarycaretrustsinthe2000s.

Oneofourmostexperiencedintervieweessays:‘Anyidiotcanputtwoorganisationstogetheranditdoesn’tchangeasinglethingontheground.IfyouspeaktoNHSchiefexecutivesaboutwhattheycangetsackedfor,noneofitincludesintegration.’Itwouldbebetter,heargues,tolookfor‘anincentiveframework,legal,financial,regulatoryandperformancethatisconsistentinrewardingcollaborativebehaviour.People[intheNHS]arenotrewardedtobecollaborativeattheminute.ThatiswhereIwouldgoratherthansomegreatupheavalwhichwouldjustsoakeverybody’senergyawayanditwouldn’tbealotdifferent.’

Or,asonedirectorputsitsuccinctly:‘Integration“yes”.Structuralchange“no”.’And–atleastonthebasisoftheseinterviews–thereisprogress,ifnotyetuniversal,onintegration.

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Dataismissingandneedstobeassembled

Thatwastheviewofanumberofourinterviewees–quiteapartfromitbeingtheviewofthecompetitionandstatisticsauthorities.Assemblingitwillincluderequiringmoreinformationfrompurelyprivateprovidersaswellasthosewhoarecommissionedbylocalauthorities.Betterinformationonworkforce,marketstability,andontheoutcomesofcareanditscost-effectivenesswouldresult.Leadershipwouldbeassisted.

Trainingforskills,trainingforleadership

Wesetoutearlierthelimitednatureoftrainingatalllevelsinsocialcare,anditsimpacts.Wewouldconcludethatwhileprovidersandlocalauthoritiesdoindeedneedtothemselvesinvestintraininganddevelopment–andthatcentralgovernmentshouldnottakeovertheentireresponsibility–asignificantinjectionoffundsisrequiredtohelpthemdothat.SkillsforCareneedsnotjustalargerbudgetbutmoreclout,perhapsbecominganon-departmentalbody.Wealsonote,forotherstoconsider,thatEnglandistheonlypartoftheUnitedKingdomwheresocialcarestaffarenotregisteredandregulated.

Supportingusergroupsandassociationsofproviderspaysdividends

Asalreadyrelated,someofthemostencouragingaccountsweheardwerefromusergroups–someoperatingthroughtheThinkLocalActPersonalpartnership–andfromassociationsofcarehomesand/orhomecareagenciescloselyengagedwiththeirlocalauthorities.

Inmostoftheexamplesweheard,councilshadsupportedthesewithinfrastructurecosts,thoughwealsoheardofexampleswherelocalauthoritieshadceasedtodothatasmoneyforsocialcarehastightened.Onecarehomeownerwhorunstheircounty-wideassociationsays:

They pay us to disagree with them, which is quite a brave thing. But it does produce better understanding. Both parties are going to be open and willing to accept the other side’s point of view. We challenge each other. And ultimately both parties want the same thing, which is to improve the quality of care.

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Orasonedirectorputsit:‘Itisabitofacrunchyrelationship.Butatleastyougettheadvocacycomingtoyoutellingyouwhatisworkingandwhatisnot,andstoppingyoufrommakingtheobviousmistakesthatyoumightmake.’

Thereisacaseforamoreunifiedprovidervoiceforsocialcare

Thereweremixedviewsonthis.ButmanydidfeelthatsocialcarelackedthecloutthatNHSProvidersortheNHSConfederationbringstothehealthscene(orinanothersector,thatofUniversitiesUK).Somefeltthattheinterestsinsocialcarearesodiversethatasinglevoicewillnotbepossible.However,amodelonthelinesthattheConfederationhasusedmighthelp–afederatedonewith,forexample,sectionsforcarehomes,homecareagencies,etc,whichcanthenproduceasinglevoiceontheissueswherethereiscommonground.

AndforbeefingupthevoiceoftheAssociationofDirectorsofAdultSocialServices

Asourintervieweesnoted,ADASSisunder-powered,reliesonvolunteersforitsleadership,andarguablysuffersfromrapidturnover.Itshouldbeoneofthemostinfluentialvoicesforsocialcarebecauseithasaprofessionalratherthanpoliticalstance,itsmembersarethecommissionersforalmostallpubliclyfundedservices,andthedirectorshaveawidersystemleadershiprole,includingwithpublichealthandrelationshipswiththeNHS.Inthepast,ithasbeenmoreinfluential.Perhapsbecause,whensocialcaredepartmentswerebetterstaffed,localauthoritiesweremorewillingtogiveuptheirdirectorforayeartobemoreofafull-timepresidentfortheorganisation.Itisacharity,whichforsomerestrictsitswillingnesstointerveneinwaysthatmightbeseenas‘political’(withasmall‘p’).Itisnotforustomakedetailedrecommendations.ButthereisacaseforitsmemberstorethinkhowADASScanstrengthenitscapacityandleadership–forexample,bymovingtoanorganisationalmodellikeNHSProviderswithapaidfull-timechiefexecutive.Anditneedstobecome,inthewordsofoneinterviewee,‘muchmoresavvyinpoliticalinfluencing’.

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Isthereacaseforanationalapproachtosettingfees?

Theannualbattleoverfees–forcarehomesandforhomecareagencies–bedevilsthesectorandcanpoisonrelationships.Someofourintervieweesfavouredamorenationallydeterminedapproach,arguingthatthiswouldprovideclarityandmakeclearwheretheultimateresponsibilityforthepublicfundingofsocialcarelies.Thiscouldtaketheform,forexample,ofamandatorymethodologyforestablishingandagreeingthelocalcostofcare;oropen-bookaccounting;oranationallysetpricewithadjustmentsfordifferentpartsofthecountrytoreflectdifferingcosts.TheCMAraisedthelatterasafallbackoptioninits2017report(Competition&MarketsAuthority).Suchapproachesshouldnotabsolvethegovernmentofitsresponsibilityforensuringthatcouncilsareableadequatelytofundtheactualcostofcare.Noteveryonefavouredsuchchanges.Butitisworthexaminingthecaseforoneormoreofthemtoreducetheheatoftheannualbattleoverfees,allowingbothcouncilsandproviderstoconcentratemoreonoutcomesandquality.

Thereisalsoastrongcaseforassessinghowwelllocalauthoritiesaredischargingtheirduties

Notmanyofourintervieweesraisedthis,butthosethatdidfeltitwouldstrengthenleadership,providingmorepowertotheelbowsofboththeleadcouncillorsforsocialcareanddirectors.TheCQCwouldbetheobviousbodytodothis,andindeed,intheearlierpartofthepreviousdecade,ithadbeguntodoannualreviewsofcouncils’performance.That,however,fellvictimtoagovernmentdecisionandthebudgetcutsthattheCQC,likeotherpartsofthepublicsector,underwent.TherearesignsthattheCQCitselfisconsideringthisagain,butwouldneeddepartmentalpermission.Onedirectorsays:‘There’sadesirenowfortheCQCtobemuchbetterjoinedupwithlocalauthoritiestohaveasharedqualityimprovementagendabutalsoanambitiontoinspectthecommissioningofcouncils.Ithinkcouncilsmightwelcomethatnow.’Itsabsence,theycontinue,‘hasalmostenabledgovernmenttoavoidlookingattheconsequencesoftheimpactoffundingreductionssince2010onwards’.

Anothersays:

Inspection is no substitute for leadership. But the fact that the CQC only inspects providers is a bit of an anomaly. Local authorities have been losing funding, and they have been in a position – not because they have wanted to – to keep cutting

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their cloth [to what is available] without any really strong oversight of the impact of that. And that puts local authority leaders – directors, chief executives, political leaders, social workers – in quite an invidious position. There is no inspection to say that this authority has cut things to the bone, and this group of people who would have got social care are no longer getting it. There is no national lens on that at all. Good scrutiny with benign accountability can help leaders deliver, because it gives them something to make their case with when things are not working well.

AnyassessmentofhowlocalauthoritiesareperformingwouldalsoneedtotakeintoaccounttheNHS’sroleincommissioningsocialcare.

ThesocialcarefunctionintheDepartmentofHealthandSocialCareneedsrestoring

Asalreadynoted,byfarthemostwitheringcriticismweheardwasaimedat theDepartment.

Thecreationofthechiefsocialworkerrole(referredtoearlierinthereport)hascreatedawelcomefocuswithintheDepartmentontheprofessionalleadershipofsocialwork.However,thisformsaverysmallfractionofthewider1.5millionstrongsocialcareworkforce,andthechiefsocialworkerisnotonitsownasubstituteforthedirectorgeneralpost.TheDepartmenthasalsorecentlyappointedachiefnurseforsocialwork.Butthefactthatthisisonlyasix-monthsecondment,notapermanentposition,intheeyesofmany,saysitall,unlessthesecondmentisapreludetoapermanentpost.

Aswewerecompletingtheseinterviews,theSocialCareSectorCOVID-19SupportTaskforcealsorecommendedinAugust2020that‘DHSCsignificantlyboostsitsownexpertiseandcapacity,inrelationtosocialcare,forthedurationofthepandemicandbeyond’(SocialCareSectorCOVID-19SupportTaskforce,see recommendation34).Itrecommendedbringinginfigureswithcurrentorrecentexperienceatseniorlevels,bothwithinsocialcareandpublichealth.

TheDirectorGeneralpostneedstobere-createdandfilledbysomeonewithrealexperienceofthefield,andwithsufficientstafftomakeanimpact–bothupwardstoministersandoutintothefield.Aninterimdirectorgeneralhasbeenappointed,inSeptember2020,thoughnotsomeonewithexperienceofthefield,

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andtheDepartmentisplanningtorecruitarevampedsocialcaregroup,whichwillapparentlyhaveastaffofmorethan300.

Thisrestoration–orre-creation–ofthedirectorgeneralrole,withsufficientstaff tohavearealimpact,wouldclearlybewelcomedbyourinterviewees–providingthisreinforcementoftheDepartment’sexpertiseisthere,asthetaskforcerecommended,forthelongterm,andnotjustforthecourseofthepandemic,andprovidingithastheskillswithinittocoverthefullspectrumoftheissuesinsocialcare.Tosaythatisnottodenythehugeeffortofthosecivilservantsbroughtintoaddressthepandemicand,indeed,thewidersocialcarereformagenda,pendingthesechanges.

Wehaverepeatedlystressedherethatmuchofthebestoftheleadershipinsocialcareislocal.Butitneedstobeabletofunctionwithhigh-qualityleadershipfromthetoparoundthosethingsthatonlycentralgovernmentcando.Andthathasclearlybeenabsent.

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5 And finally…

Webelievethatthechangesoutlinedherewould–fromwhatwehaveheard–strengthenleadershipinsocialcare.Butwewouldforcefullymakethepointthatmoreeffectiveleadershipisnotinitselfasolutiontothelongstandingproblemsinthesector.Notjustthegovernment,butallthepoliticalparties,haveforalongtimenowacknowledgedthatamuchbroaderreformofsocialcareinEnglandisneeded.Butithasnothappened.

Thefailuretofixsocialcare

2021seesthe25thanniversaryofStephenDorrell,theConservativeSecretaryofStateforHealthlaunchingaconsultationona‘partnership’approachtoreformingthefundingofsocialcare.SincethentherehavebeenGreenPapers,WhitePapers,plentyofindependentrecommendationsforreform,plustwogovernment-commissionedinquiries,butstillafailureto‘fixthecrisisinsocialcareonceandforall’.

In the past 25 years there have been…

Eight green papers and consultation exercises

Overseen by...

Four white papers

Many independent recommendations for reform5

5Includingrecentlyfromthreecross-partyselectcommitteesintheHouseofCommonsandtheHouseofLords.6The1999RoyalCommissiononLongTermCare,andthe2011DilnotCommissionontheFundingofCareandSupport.

Nine Secretaries of State for Health

Two government-commissioned inquiries6

Fourteen Ministers for Care Services

Formoreonthedevelopmentofsocialcarefunding,see‘AshorthistoryofsocialcarefundingreforminEngland:1997to2019’(www.kingsfund.org.uk/audio-video/short-history-social-care-funding)

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ThemostdepressingstatementweheardinthecourseofthisworkwasthatfromLordBethell,thesocialcareministerintheHouseofLords,whotoldpeers:‘Theresimplyisnotthemanagementorpoliticalcapacitytotakeonamajorgenerationalreformoftheentireindustryinthemidstofthismassiveepidemic’(Hansard 2020).

Thatmaywellbetrueintheshortterm.ButaminimumrequirementisthattheDepartmentisputintoapositionwhereithasthemanagementandpolicy-makingcapacitytoundertakethisreformoncethepandemiciscontained,andthatthepoliticalcapacity–thepoliticalwill–istheretodoit.

Annex 47

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AnnexWesentallintervieweesthefollowingverybroadoutlinesetofquestions,whilebeingclear,asinpoint3,thattheycould–assomedid–raiseissuesnotcoveredhere.

LEADINGADULTSOCIALCARE

ISSUESFORDISCUSSION

1. Where do you think leadership in social care lies?

• Andhowisitsharedacrossdirectorsofsocialservices,localauthoritychiefexecutiveofficers(CEOs),cabinet/electedmembers?(Whatroledoprincipalsocialworkersplayinofferingleadershiptosocialworkteams?)DoesthelocalNHSplayarole?

• Andontheproviderside–CEOs/ownersversuslocalmanagersofcarehomes,homecareservices,etc?Howdoesitdifferbetweenbignationalchainsversussmalllocalorganisations?

• Thevoluntarysectorandthevoiceofusersandcarers?

2. The national context of social care leadership – Department of Health and Social Care (DHSC)/Ministry of Housing, Communities and Local Government (MHCLG)/the Care Quality Commission (CQC), etc

• Theroleofnationalbodiesinleadershipversussettingtheframework– egtheCQCisbothregulator/standardsetterandinspector.Doesthatamounttoleadership?

• HowfardoesNHSEnglandinfluenceorcontributetosocialcareleadership?

• DoestheNHS’sshifttowardsintegratedcaresystems(ICSs)changeanyofyourviews?

Howfardoyouthinkyourperceptionistypical,oristherejusthugevariation?

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3. What aspects of leadership are we missing – in your personal experience/locally, and nationally?

4. What changes would help make things better? In terms of changes within the current system, or changes to the system itself?

References 49

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ReferencesAssociationofDirectorsofAdultSocialServices(2020).Adult social care – shaping a better future. Nine statements to help shape adult social care reform.London:ADASS.Availableat: www.adass.org.uk/media/8036/adult-social-care-shaping-a-better-future-nine-statements- 220720.pdf(accessedon3December2020).

BaileyS(2018).‘TalkingleadershipwithSuzieBailey’.Interview.TheKing’sFundwebsite.25September.Availableat:www.kingsfund.org.uk/publications/talking-leadership-suzie-bailey (accessedon7December2020).

BevanA(1943).Hansard (House of Commons Debates)15December1943vol395col1616.

BotteryS,BabalolaG(2020).Social care 360.London:TheKing’sFund.Availableat: www.kingsfund.org.uk/publications/social-care-360(accessedon3December2020).

BotteryS,VarrowM,ThorlbyR,WellingsD(2018).A fork in the road: next steps for social care funding reform.London:HealthFoundationandTheKing’sFund.Availableat:www.kingsfund.org.uk/publications/fork-road-social-care-funding-reform(accessedon4December2020).

CarersUK(2015).Valuing carers 2015. London:CarersUK.Availableat:www.carersuk.org/for-professionals/policy/policy-library/valuing-carers-2015(accessedon10December2020).

CommissiononFundingofCareandSupport(2011).Fairer care funding: the report of the Commission on Funding of Care and Support.London:CommissiononFundingofCareandSupport. Availableat:https://webarchive.nationalarchives.gov.uk/20120713201059/http://www.dilnot commission.dh.gov.uk/files/2011/07/Fairer-Care-Funding-Report.pdf(accessedon3December2020).

CommissionontheFutureofHealthandSocialCareinEngland(2014).A new settlement for health and social care. Final report.London:TheKing’sFund.Availableat:www.kingsfund.org.uk/publications/new-settlement-health-and-social-care(accessedon7December2020).

Competition&MarketsAuthority(2017).Care homes market study. Final report.London:Competition&MarketsAuthority.Availableat:www.gov.uk/cma-cases/care-homes-market-study (accessedon3December2020).

DepartmentofHealth(2014).Annual report by the Chief Social Worker for Adults – one year on.London:DepartmentofHealth.Availableat:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/368485/Annual_report_2014_web_final.pdf (accessedon7December2020).

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Hansard(HouseofLordsDebates)28October2020,vol807col226.Availableat:https://hansard.parliament.uk/Lords/2020-10-28/debates/D9B0BFA4-0C47-46D1-B9C8-CE92CFFEFB9D/SocialCare(accessedon7December2020).

HealthEducationEngland(2020).Annual report and accounts 2019/20.HC737.Leeds:HealthEducationEngland.Availableat:www.gov.uk/government/publications/health-education-england-annual-report-and-accounts-2019-to-2020(accessedon7December2020).

HealthEducationEngland(2017).Facing the facts, shaping the future: a draft health and care workforce strategy for England to 2027.Leeds:HealthEducationEngland.Availableat: www.hee.nhs.uk/our-work/workforce-strategy(accessedon7December2020).

LaingW(2019).Care homes for older people: UK market report 30thed.London:LaingBuisson.Availableat:www.laingbuisson.com/shop/care-homes-for-older-people-uk-market-report (accessedon10December2020).

MorganKO(1992).Labour people: leaders and lieutenants, Hardie to Kinnock.Oxford:OxfordUniversityPress.

NationalAuditOffice(2018).The adult social care workforce in England.HC714session (2017–2019).London:NationalAuditOffice.Availableat:www.nao.org.uk/wp-content/uploads/ 2018/02/The-adult-social-care-workforce-in-England.pdf(accessedon2December2020).

OfficeforStatisticsRegulation(2020).Adult social care statistics in England.OfficeforStatisticsRegulationwebsite.Availableat:https://osr.statisticsauthority.gov.uk/publication/report-on-adult-social-care-statistics-in-england(accessedon26January2021).

SkillsforCare(2020).The state of the adult social care sector and workforce in England. October 2020.Leeds:SkillsforCare.Availableat:www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx(accessedon3December2020).

SkillsforCare(2019).Impact evaluation of Skills for Care 2013/14 to 2017/18.Leeds:SkillsforCare.Availableat:www.skillsforcare.org.uk/Documents/About/Evaluating-our-impact/Impact-evaluation-of-Skills-for-Care-executive-summary.pdf(accessedon7December2020).

SocialCareSectorCOVID-19SupportTaskforce(2020).Final report, advice and recommendations [online].GOV.UKwebsite.Availableat:www.gov.uk/government/publications/social-care-sector-covid-19-support-taskforce-report-on-first-phase-of-covid-19-pandemic/social-care-sector-covid-19-support-taskforce-final-report-advice-and-recommendations(accessedon7December2020).

TheKing’sFund(2020).‘Systemleadership:ourworkonleadingacrossorganisationalboundaries’.TheKing’sFundwebsite.Availableat:www.kingsfund.org.uk/topics/system-leadership(accessedon7December2020).

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TimminsN(2015).The practice of system leadership: being comfortable with chaos.London:TheKing’sFund.Availableat:www.kingsfund.org.uk/publications/practice-system-leadership (accessedon7December2020).

WanlessD(2006).Securing good care for older people: taking a long-term view.London: TheKing’sFund.Availableat:www.kingsfund.org.uk/publications/securing-good-care-older-people(accessedon4December2020).

Acknowledgements 52

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AcknowledgementsToencouragehonestywepromisedourintervieweesanonymity.Theymightwellbequoted,buttheywouldnotbeattributed.Theyknowwhotheyare.Andweareimmenselygratefultothemforfindingthetimeandforbeingsofrank.Insofarastheyagreewithit,thisistheirreportratherthanours.Particularthanksmustgotothoseofourintervieweeswithdirectexperienceofsocialcare.Theirinsightswereespeciallyvaluableandperceptive.

Abouttheauthors 53

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AbouttheauthorsRichard HumphrieshasbeenaSeniorFellowatTheKing’sFundsince2009workingonsocialcareandworkacrosstheNHSandlocalgovernment.Heisarecognisednationalcommentatorandwriteronsocialcarereform,thefundingoflong-termcareandtheintegrationofhealthandsocialcare.HeledtheFund’sworkinsupportingtheBarkerCommissionontheFutureofHealthandSocialCareinEnglandandwasspecialistadvisertotheHouseofLordsEconomicAffairsCommitteeinquiryintosocialcarefunding.

AgraduateofLSE,hisprofessionalbackgroundissocialwork,andoverthepast35yearshehasworkedinavarietyofroles,includingasadirectorofsocialservicesandhealthauthoritychiefexecutive(thefirstcombinedpostinEngland)andinseniorrolesintheDepartmentofHealth.Richardisanon-executivedirectorofWyeValleyNHSTrustandalsoaVisitingProfessorattheUniversityofWorcester.

Nicholas TimminsisaSeniorFellowatTheKing’sFundandtheInstituteforGovernment.HeisaformerpublicpolicyeditorattheFinancial Times,andaVisitingProfessorinSocialPolicyatLSE.Heistheauthoroftheaward-winningThe five giants: a biography of the welfare state,whichcurrentlytakesitsstoryupto2017.

ForTheKing’sFund,hisworkonthenatureofleadershipincludesNo more heroes (2011),The practice of system leadership(2015)andThe chief executive’s tale(2016).HisotherworkincludesNever again?,anaccountofhowthe2012HealthandSocialCareActhappened,andThe world’s biggest quango,thetaleofthefirstfiveyearsofthosereforms.Hehasco-authoredA short history of NICE(theNationalInstituteforHealthandCareExcellence),andhasrecentlyupdatedGlaziers & window breakers: former health secretaries in their own words.HewasrapporteurtotheBarkerCommissionandisanHonoraryFellowoftheRoyalCollegeofPhysicians.

Declarationsofinterest

InOctober2020RichardHumphriesbecameatrusteeoftheAssociationofDirectorsofAdultSocialServices(ADASS).HeisalsoaseniorassociateoftheSocialCareInstituteforExcellence.NicholasTimminsisatrusteeofThinkAhead,thefast-trackschemeformentalhealthsocialworkers.

Stories from social care leadership

TheKing’sFundisanindependentcharityworkingtoimprovehealthandcareinEngland.Wehelptoshapepolicyandpracticethroughresearchandanalysis;developindividuals,teamsandorganisations;promoteunderstandingofthehealthandsocialcaresystem;andbringpeopletogethertolearn,shareknowledgeanddebate.Ourvisionisthatthebestpossiblehealthandcareisavailabletoall.

www.kingsfund.org.uk   @thekingsfund

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PublishedbyTheKing’sFund11–13CavendishSquareLondonW1G0ANTel:02073072568Fax:02073072801

Email: publications@kingsfund.org.uk

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©TheKing’sFund2021

Firstpublished2021byTheKing’sFund

Charityregistrationnumber:1126980

Allrightsreserved,includingtherightofreproductioninwholeorinpartinanyform

ISBN:9781909029989

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AdultsocialcareprovidesessentialsupporttopeoplewitharangeofneedsandprovidesmorejobsthantheNHS,yetitsinvaluableroleis oftennotproperlyunderstood.TheKing’sFundconductedinterviews witharangeofpeoplewhocommission,provideandusesocialcare tofindoutwhereleadershiplies,howeffectiveitisandwhatmightbe donetoimproveit.

Stories from social care leadership: progress amid pestilence and penury sharesinsightsontheroleofleadershipinthesectoratalllevels,fromlocalauthorities,localprovidersandpeoplewhousesocialcare,tonationalbodiesandcentralgovernment.

Keyfindingsemerged.

• Thereishugevariationinthequalityofbothservicesandleadership,withsomeofthemostinspirationalleadershipcomingfromplaceswheredirectorsofadultsocialservicesactivelyengagewithprovidersandpeopleusingsocialcare.

• LeadershipfromtheverytophasbeenmissingforsometimeandtheDepartmentofHealthandSocialCare’splanstostrengthencapacityandexpertiseshouldbepursuedwithvigour.

• SocialcarecouldbenefitfromamoreunifiednationalvoiceforprovidersandastrengthenedrolefortheAssociationofDirectorsofAdultSocialServices.

• Thereneedsbemoreinvestmentinworkforcetraininganddevelopmentandbetterdataandresearchtosupporteffectiveleadership.

• Localco-productionandpartnerships,notstructuralintegrationwiththeNHS,shouldbethewayforward.

Thereportconcludesthatbetterleadershipalonewillnotresolvethelongstandingproblemsofthesocialcaresectorwithoutfundamentalreformofhowitisorganised,deliveredandfunded.

TheKing’sFund11–13CavendishSquareLondonW1G0ANTel:02073072568

Charityregistrationnumber:1126980

www.kingsfund.org.uk