Monthly Archives: January 2018

Why it is hard to deliver compassionate care in a compassionless system….

Michael Sandel argues the free market is not just a mere mechanism designed to deliver goods, it also embodies certain values, and the problem is these values ‘crowd’ out non market values which are really worth caring about and preserving, such as compassion’.

Increasingly ‘neo-liberalism’ is up for debate. Whilst well known to economists, politicians, Guardian readers and academics (like me!) it is rarely thought about in wider society. Yet its impact on our society over the last 40 years is immense, many would say for the good, others are not so sure.

For example a report published by Lancaster University  entitled ‘A Trade in People’ clearly expresses the failure of  a neoliberal care system. The report states

‘it is clear to us that the way in which the healthcare economy has been encouraged to develop by recent governments turns people into commodities and liabilities. For local authorities and CCGs they are liabilities that they have often sought to export to other areas and for independent hospitals they are a commodity and source of millions of pounds of income and profit.’

Whilst this report is referring to learning disability services from my experience I think it could also easily apply to a  broad range individuals who require care;  older people, those with mental health difficulties, substance misuse, physical and cognitive disabilities, child care, indeed just about any care need you can think of has been turned into a commodity to be traded and profited from.

This is why I think it is important to be aware of the influence neoliberalism has in shaping our daily lives because it has provided successive governments with a framework to deliver its ideas, ideals, values and beliefs about the world and provides a guide on how life should be lived, how society should be structured and our role in society , along with that of government and the free market. Most controversially for me has been its wholesale export into the realm of health and social care, where ‘care’ has become a commodity to be profited from.

In short it determines the nature and limits of that state, what matters and whom.

There are a number of strands to neoliberalism. In recent years, from a political perspective, successive  governments have used this ideology as a vehicle  firstly, to stigmatising those who require support, just look at the reforms to welfare,  and then to disinvest in the public sector that provides their support, instead promoting open unregulated markets and the transfer public services into the free market.

This has resulted not only in the deregulation and privatisation of publicly owned assets, such as housing, but also the transfer of responsibility for those requiring public services away from government, so when there is a failure in the system, i.e. Grenfell Tower; Winterbourne View; Mid-Staffs, holding someone to account is almost impossible due to a diffused chain of responsibility government has put between it, and the individual, by creating a host of intermediary layers of officials and organisations , such as management companies, contractors and sub-contractors.

A key tenet of neoliberalism is the role of free market in delivering everything from baked beans to iPhones’ and cancer care. The free market is highly valued in neoliberal ideology because it is viewed as a more efficient system in providing goods and services, and promotes individual liberty by empowering society through consumer choice.

Whilst neoliberal ideology has indeed empowered us to upgrade our iPhone at will and purchase cheap clothing and chemically enhanced food, what has this meant for those most vulnerable in society who might require quality  care rather than consumerism?

Whilst an economic and political system premised on the commodification of people and neoliberal theory maybe a reliable form of wealth generation for some, it is also associated with little compassion for those who require support, as well as structural inequality and poverty for many.

Nobel prize winning economist Joseph Stiglitz is clear, we are now engaged in a battle which is ideological, describing free market neo-liberalism as  a stifling economic ideology which has run it course.

Neoliberalism has an insidious presence in our lives, much like the air that we breathe, everywhere, yet unseen. George Monbiot  provides a compelling argument against this ideology, which values the free market as the place in which citizens can exercise their democratic choices through consumer choice and the private provision of goods and services.    Supporters of neoliberalism maintain  “the market” delivers benefits that could never be achieved by government, and that the more unregulated the market, the better the efficiency. Within this framework everything we do, and every person is a potential commodity that can bought, sold and traded for profit.

However, for me,  the free market  is associated with a loss of compassion, dignity and respect for one another as an inactive state projects structural failure onto the individual, along with an outdated mantra of ‘private sector good, public sector bad’.

One need not dig too deep to see the flaws within the current system. The research by Lancaster University adds to a plethora of  reports, all stating the same thing. This system is broken!

Just consider  housing and the care of older people to establish the limits of the free market.

Shelter’s report on the barriers low-income households face in private renting exposes the private housing  market’s limitations,  clearly arguing significant government intervention is needed if it is to play an expanded role in preventing homelessness and housing people on low incomes.

The same issues arises in the care of older people, where significant market failure is a continuing problem.

Over two years ago the King’s Fund  highlighted what many in the sector already know, the free market is failing stating

‘Social Care is now a complex and sprawling sector – more than 12,000 independent organisations, ranging from big corporate chains to small family-run businesses, charities and social enterprises, which makes the NHS provider landscape look like a sea of organisational tranquillity. Less than 10 per cent of social care is actually provided by councils or the NHS – their retreat from long term care provision is virtually complete. But unlike the NHS, when a social care provider hits the financial rocks, bankruptcy not bail-out is the more likely scenario.  But a deeper problem is the failure to think through the consequences of shifting the bulk of our care provision to a private business model’.

This is supported by  Andrew Dilnot , former drector of the Institute of Fiscal Studies, who suggests social care is is a classic example of a market failure where the private sector cannot do what’s needed.

However, the effect of the failure of the free market and neoliberal ideology extends beyond money,   the real effect of failing markets rests upon the poorest and most marginalised in society, like the  residents of Grenfell Tower and those with social care needs in private institutions, the frail and vulnerable who require support.

The problem in government today is that many of those who govern this country are woefully out of touch and too quick to blame individuals for their descent into a commodified system of care, and those who provide care, rather than look at their own role in creating a a system of care that has no space for compassion, whilst those on the frontline still fight to demonstrate, and deliver, care with compassion, dignity and respect in an increasingly brutal system .

Michael Sandel argues the free market is not just a mere mechanism designed to deliver goods, it also embodies certain values, and the problem is these values ‘crowd’ out non market values which are really worth caring about and preserving, such as compassion’.

Where values and ethics are weak in any system which seeks to support those in need, we need a strong and active state to intervene, where both are weak those most vulnerable in society will continue to be denigrated and exploited.


Going dutch – lets put ‘care’ back into our health and social care system ….

I first wrote about Buurtzorg 4 years ago, at last Buurtzorg is now developing in the UK.

The Dutch model of Buurtzorg Care provides an alternative model of care across health and social care,   could we learn from this tried and tested model?

The provision of care for older people is a case in point. The organisational culture of some providers in our current system leave some older people neglected and without support where surviving the ‘system’ takes precedence over ‘thriving’, and often leads to unnecessary hospital admissions through poor levels of support at home. This is not about lack of resources but the poor allocation of resources.

As a social work practitioner I saw at first hand how good quality home care could reduce admissions to hospital. Good quality care at home can reduce, or even prevent, carer breakdown. It can support good nutrition which is essential to optimise both physical and mental health, for example by reducing UTI’s (urinary track infections) one of the core reasons I found for many avoidable admissions to hospital.

Avoidable and unnecessary admissions are incredibly detrimental to older people, and especially for those whose lives are touched by dementia, not to mention extremely costly. Decisions re admissions are not taken lightly, however, GP’s are often faced with the dilemma of admitting someone with dementia to hospital because that is the only option, not the best option. Any savings made on reducing the cost of unnecessary admissions to hospital would, I’m pretty sure, more than cover any cost incurred in reconfiguring care services provided at home.

We know care provision in the future is going to have to cope with growing numbers, so we need a system that is sustainable. The notion of sustainability in this context could draw on the ecology movement, where sustainability is defined as “development that meets the needs of current generations without compromising the ability of future generations to meet their needs”. This captures two important issues facing care today, the need to support those currently requiring care without compromising the future of the care system to accommodate a growing number of users within budgetary constraints. At first glance the two may appear irreconcilable, however, by building on the drive for personalisation and person-centred dementia care, alongside reshaping organisational ‘cultures’ new concepts and models are able to evolve which can contribute to developing relationship based complete care.

Complete Care: a model in practice – Buurtzorg Nederland

Providing a new form of service provision able to incorporate the principles of relationship based care and capability, along with notions of ethical practice and sustainability will require a re-organisation of the way in which we currently use resources to deliver care at home. Research from KMPG International (2012) highlights how Buurtzorg Nederland might provide a blue print for such a model.

The founder of Buurtzorg Nederland, Jos de Blok a district nurse, became frustrated with the way traditional services were focused on policy, targets and administration rather than on care and compassion. So he decided to develop his own model where his role as a nurse regained its explicit social value to the community he worked with. Buurtzorg was founded 10 years ago and started with an initial team of four. The system that evolved deploys teams of up to 12 nurses, who are responsible for between 40 and 60 people within a particular area. There are now around 900 teams in the Netherlands, supported by no more than 50 administrators and 20 trainers.

In the Netherlands, the financing and delivery of care in the community is highly fragmented with various tasks – such as washing the patient, serving meals and putting on elastic compressions – paid through different reimbursement schemes and, more often than not, executed by different professionals. As a result, patient care tends to lack coordination, making it difficult for the care providers to respond appropriately to changing patient conditions, which in turn leads to compromised continuity of care and low patient satisfaction.

At the same time, many home care service providers have cut costs by fine-tuning the minimum skill level required to accomplish each task. Dutch home care also tends to be focused on responding to patients’ current problems rather than preventing deterioration, meaning that interventions are generally added on only once the patient’s condition has already worsened.

To respond to these challenges, the home care organization Buurtzorg (meaning neighbourhood care) was created to focus on increasing patient value. Essentially, the program empowers nurses to deliver all the care that patients need. And while this has meant higher costs per hour, the result has been fewer hours in total. Indeed, by changing the model of care, Buurtzorg has accomplished a 50 percent reduction in hours of care, improved quality of care and raised work satisfaction for their employees.

How it led to productivity improvement

One of the keys to the program’s success is that Buurtzorg’s home care nurses organize their work themselves. Moreover, rather than executing fixed tasks and leaving, they use their professional expertise to solve the patient’s problem by making the most of their clients’ existing capabilities, resources and environment to help the patient become more self-sufficient, visits focus on the person not the task. Simply put, even though Buurtzorg professionals’ visits are not time limited the aim is to make themselves superfluous as soon as possible, versus other providers who tend to execute tasks without truly focusing on the patient’s overall capability.

Buurtzorg uses small self-steering teams (with a maximum of 12 nurses) who attend to an area of approximately 15,000 inhabitants and work together to ensure continuity of care. As a result, the professionals build durable relationships with their community, which further strengthens their ability to find local solutions for patients’ problems. Although the teams are independent and self-steering, they are supported by a centralized service organization which provides management information to both the team and the organizations’ leadership in order to minimize local overhead and maximize the professional’s face-to-face time with patients. Every team is responsible for its own clientele and is in close contact with those who use services, their families and doctors. Teams are also responsible for their own financial results.

Key results

In just two years, more than 2,000 nurses have joined the program despite the increasingly tight labour market for nurses in the Netherlands. Indeed, by 2011 Buurtzorg employed 4,000 nurses and nurse assistants working in over 380 autonomous teams.

Preliminary results show that Buurtzorg‘s patients consume just 40 percent of the care that they are entitled to and half of the patients receive care for less than three months. As a result, patient satisfaction scores are 30 percent above the national average and the number of costly episodes requiring unplanned interventions has dropped.

I spoke with Jos de Blok a couple years ago, and in the years since it’s inception he is as enthusiastic as ever and rightly proud of the difference his teams are making to the lives of those who require support in the community, as well as the professionals delivering care. Surely these would be good outcomes for us all?

One issue is funding: the Dutch model is tailored to payments by health insurance companies, not a state healthcare system like the NHS or means-tested social care. I’m no advocate of privatisation, I believe models such as this could be utilised within a National Health and Social Care Service, which is publicly funded, to provide sustainability for the future by reinvesting profit into the system, rather than giving it to shareholders and bonuses for CEO’s and the like.

It is suggested another potential issue is the scrapping of hierarchies and specialisms within the nursing teams: a Buurtzorg nurse might administer wound care, but may also help someone to wash or get dressed. I feel the segmentation of care needs  is dehumanising as individuals become defined by a series of tasks, rather than the person they are. If I undertook wound care, would I really mind also washing and dressing that person, no I would not, I would see it as part of caring for that person. So I do not see a problem with this.

Some might see a third challenge, in that the model requires management to back off and allow their teams considerable latitude, with much less performance monitoring than has become the norm in, for instance, the UK. Bureaucracy is reduced to a minimum.

Many professionals in the current system would see this as a positive!

Government has to change its focus on the continued privatisation and marketisation of care as a commodity to be bought, sold and traded.

How we design and deliver  ‘Care’ tells us something about us as a society, the constant focus on profit disfigures us all.

Why the Social Work accreditation scheme is a waste of money , £8.5 million to be precise…….

Community Care recently publicised that £8.5 million was given to private companies to develop the social worker accreditation scheme. This information was released by government over the christmas period. I am sure the timing of the release of this information was designed to ensure it disappears without trace so as not to attract the attention of those, such as myself, who are disillusioned by governments failure, and those who represent social work to government, to do nothing but tinker around the edges and not address the real issues which face both those who receive and deliver social work services.

I am perturbed by this news for two reasons. The proposed accreditation system is a costly red herring which detracts attention away from the real issues impacting social work practice today. Secondly the future of social work in the UK appears to be being shaped by a few powerful and well connected individuals and multi-national corporations rather than the voice of those in practice and those who require social work support.

Firstly, lets consider how the new proposed accreditation process might have improved the practice of the manager who was recently made subject to a 12-month conditions of practice order by the HCPC for ‘supervision failure’, despite the fitness to practice panel saying he worked with “a heavy caseload, poor working conditions, inadequate management support of him in his role as a manager and significant personal health issues”. At one stage, the social work manager was responsible for managing about 120 cases, whereas 65 cases was deemed an optimum caseload.

How many people reading this are now thinking, this could be me I wonder ?

I do not believe the proposed accreditation process would make a difference to those in a similar position because it will not address the failure by government, and those who represent the profession, to get to grips with the real issues that significantly impact on professional practice and individuals lives.

Factors such as high case loads, diminishing resources, bureaucratic systems; organisational culture, burnout, limited opportunity to give or receive high quality supervision, lack of a coherent and funded CPD programme, political failure to address issues such poverty in income, food poverty, fuel poverty, poor housing, job insecurity, inequality and a pervading sense of hopelessness as both those who require services and deliver services see little authenticity in governments approach to effect genuine improvement.

My second concern is the continued involvement of private companies, such as  Morning Lane Associates, in shaping the future of social work. Morning Lane is a consultancy company  co-founded by the current chief social worker Isabelle Trowler. A previous investigation  into the chief social workers role in the development of the accreditation scheme found the chief social worker had been consulted on the bid, worth an initial £2.6m..

This is not a one off in successfully attaining funding either, in addition Morning Lane has received millions as professional advisor and training partner to Frontline, alongwith £4m in Innovation Fund money to roll out its Reclaiming Social Work model to five authorities.

We will see more involvement of Morning Lane in 2018 when Frontline receives more funding via additional funding for fast track social work training schemes in 2018. In respect of this funding the DfE says £35m was invested in Step Up and Frontline between 2010 and 2015 and £100m will be invested over the next four years.

However, the Department has refused to provide a breakdown of how the funding was split between the two programmes.

While there is no suggestion of legal wrongdoing, fears continue that children’s social work is being pushed in a particular direction by the agenda of a small number of powerful well connected people with a large amount of influence, and a large amount of resources at their disposal.

For example it is reported Frontline’s support comes from across the globe,  receiving ‘pro bono’ support from several powerful, and influential private multi-national companies, for example;

  • The Boston Consulting Group, an American worldwide management consulting firm with 90 offices in 50 countries. The firm advises clients in the private, public, and not-for-profit sectors around the world, including more than two-thirds of the Fortune 500 and is one of the ‘Big Three’ strategy consulting firms.
  • The Alexander Partnership which is Europe’s leading provider of executive coaching, leadership and culture development.
  • Abbott Mead Vickers BBDO (AMV BBDO) is an advertising agency that works with over 85 brands, including BT, Sainsbury’s, Diageo, Walkers and Mars. AMV is part of the BBDO network, the third largest agency network in the world and part of the Omnicom Group.
  • Baker McKenzie, founded as Baker & McKenzie in 1949, is a multinational law firm. As of August 2017, it is ranked as the second-largest international law firm in the world . It is also ranked as the second largest law firm in the world in terms of revenue with US$2.67 billion in annual revenue

One wonders why social work in the UK requires steerage from multi-national corporate influences and this begs the question just how does the current approach align with social work values as defined within a global perspective?

The rise and rise of Frontline is a good example of the changing world in which social work education is emerging. Ark is a charity which co-founded Frontline. However, it is also a profit making company and was set up as an alternative investment industry focusing on global education. The power of such organisations are changing the educational landscape and is increasingly highly influential in shaping public policy and redefining the role of government and businesses in the production, management and  delivery of public services embracing neoliberal ideology. (see World Yearbook of Education 2016: The Global Education Industry)

It’s all a very long way away from the social worker on the real frontline who enters the complex lives of those they work with on a daily basis. Neither can imagine what it must feel like to enjoy the resources, power and influence of those shaping both their futures.