Lessons from the Care Sector


One of the flagship policies of this new coalition government and one mentioned in the Spending Review is about outsourcing services from directly provided in-house type provision to a tendering out type market led style of outsourcing services.

This is not new in adult social care. It was an attempt of the 1990 NHS and Community Care Act. We (social workers) were going to be buying in services from many different sources. We were to be care managers rather than care providers. It was a seismic shift in social care provision driven by the ideology of Thatcherism which equated private sector as good versus the clunky inefficiency of the public sector.

Indeed, a part of the ‘Big Society’ ethos is ‘shifting power away from central government to the local level, – to citizens, communities and INDEPENDENT PROVIDERS’.

All sounds nice and fluffy but – we have local authorities in London at least (possibly throughout the country  but honestly, London is what I know best) merging services to create a potential democratic deficit – for the record, I don’t in general have an issue with joint service provision across boroughs but it doesn’t seem to fit 100% into the localism agenda. It is the ethos behind a move towards independent providers that I fear.

I  have seen the future and it is shaky and dangerous without exceptional and firm regulation and honestly if one thing is going in the cuts, it is exactly that.

Let me explain further taking the lessons learnt from the contracting out of services in social care.

Firstly, I have come across some exceptional private care providers but they are a rarity rather than the normality that they should be. That breaks my heart as I move from social worker to care manager. How much confidence can we have in recommending care packages when we know there will be issues in the quality of service provided by profit-making agencies.

We can see with the story that was in the news recently regarding Jamie Merrett, a 37 year old man who is tetraplegic following a road accident and who was reliant on care being provided by nursing staff. A nurse was supplied via an agency who was not able to manage his care and she switched off his  life support machine which lead to permanent brain damage.

Jamie had installed cameras into his home as he was concerned about the quality of care provision and it was this camera that allowed this error to be highlighted.

It isn’t the nurse at fault so much as the agency that sent her. The nurse Violetta Aylward was not trained in ventilator care. She was probably cheaper for Ambition 24 (the agency) to supply as a result.

The agencies must be held to account as much as the individual nurses especially if the nurses have been sent into situations that they are not trained to manage by the agencies.

This agency, Ambition 24, received ‘three stars’ from the CQC in their last inspection round. It will retain those three stars as the star system doesn’t exist any more so no new inspections will be made and those star ratings will not be changed.

Anyone seeking to use them (and I include procurement teams in local authorities and the NHS) might be swayed by those now, redundant three stars which are resplendently displayed on their site.

They are a large multinational firm that provide nursing care through a number of agencies internationally – no doubt making massive amounts of money and the question  has to be asked about the corner cutting that leads to incidents such as this. Where is the morality in the private sector? I know it exists  but it also seems to cost. That is the price that not all commissioners are willing to pay.

Yes, this is one case. One incident. But I could tell a few stories about multi-national care agencies providing poor care at high cost and cutting corners on the day to day care to maximise profit – unfortunately, they are not my stories to tell but rather the stories of those who are most affected.

This is what happens when private companies serve public authorities for profit-making purposes. Sure, they can lower some costs,  but what what cost?

How many people whose family have been actively affected would say that they get a better quality service from agencies than from the directly provided services that have now been decimated through the ideology of the previous Conservative government?

Some would, I’m sure. I think there would be a majority who would despair at the fall in the quality of care provided.

Direct payments and personal budgets will help some people recruit directly, possibly bypassing agencies but not everyone has the same level of choice. A part of my difficulty with personal budgets is that everyone should be equal but some (those who are able to manage their budgets themselves or have active family members to assist) are more equal than others and more likely to get the better services.

Remember for every case we hear about, for every Jamie Merrett who saw to put in a video camera into his home, there are probably thousands who don’t complain, who can’t complain and who we never know about because they either lack the capacity to have an understanding of the quality of care that is being provided or because they don’t want to ‘make a fuss’ because they fear their own carers or they just can’t speak out because the damage has been done.

Most of the safeguarding investigations I undertake involve formal carers. Those are just the ones we know about.

This is what happens when independent providers are left to patch up the gaps in public services and make profit from the care that they provide.

As I say, I know it isn’t all carers or nurses that work for private agencies but it is the agencies that I blame rather than the carers. They push people to work in areas that they are not trained to. They don’t pay for travel between service users’ homes and turn a blind eye or actively encourage shortened visits and less attention to care.

Equally, the local authorities bear a responsibility for caring more about getting services at the absolute lowest cost rather than judging by quality. Contracts are tendered and granted on the basis of cost.

It is a similar story with residential and nursing homes. Local authorities are pushing the payments down, providers are more concerned about the figures than the quality of care. If you pay someone minimum wage for doing such a vitally important job, you don’t provide them with the training and support they need, you don’t keep staffing levels up to staff levels then you will have increasingly poor quality care provided.

This should be a lesson to have been learnt from pushing the privatisation agenda.

Combined with a paring back of all regulatory bodies, this is dangerous. It will be those with the quieter voices who suffer the most.

My plea to the government would be ‘look at the history before you destroy the future’.

I know it is in vain but that won’t stop me shouting as long and hard as I can.

This is why I fear for the NHS in the future. We have seen the future. It doesn’t work.

6 thoughts on “Lessons from the Care Sector

  1. It’s a tricky one isn’t it? how do you instill a service culture in state-run services? My memory of care services run by the local authority is that they were often complacent and that the client had little power in the relationship – homecare services was all that there was and if you don’t like it then off you go. Likewise LA care homes can think of themselves as being top of the heap and untouchable when, in reality, their lack of concern for the individual client leaves much to be desired. But, as you say, the alternative as the increasingly unfettered free market is not serving clients well and is not going to do so without a degree of scrutiny and a dose of reality.
    Care agencies providing domestic care are largely in it for the money. The council gives them the cash and turns a blind eye as to how a carer can see 10 clients for half an hour each on a 3 hour round – until something goes wrong. In a local care economy some agencies will get more business than others and end up being the only ones with the ability to provide the level of care required, pushing out their competitors until they are the only show in town. Once an agency gets powerful in this way then the only difference between them and the old LA providers is that they are taking a profit.

    But how are do we expect quality care in a care home or domicilary care when we do not increase fees year-on-year and staff continue to be minimum wage? How does that encourage them to see the work as something they might want to do for a while and get good at when there are no rewards for actually doing it well? It reflects society’s view of the elderly – out of sight out of mind, unproductive, dehumanised; people we don’t have to worry about because someone else is looking after them, until something goes wrong and we can be furious that it was allowed to happen.
    But how much longer can people go on being furious at the poor quality of care when all the messages from those who know about it say that the care is consistently poor? When the cuts hit I fear for many vulnerable people in our society, particularly those who are frail & old, or who have dementia.

    Contracting out care and care management will be cheaper, but will be a poor substitute for actually meeting people’s needs as we would understand it today.

  2. An excellent, albeit depressing, blog. I share your fears about future care provisions, if robust systems are not in place for monitoring, assessing quality and calling people to account. I hadn’t even considered the fact that providers such as Ambition 24 would be able to retain an unwarranted star rating simply because the awarding body, CQC, is no longer there to re-rate them. What a gift to any cynical marketing manager!
    If shouting is all that is left to us, then we will just have to make sure that as many of us as possible keep shouting as loudly as we can!

  3. An interesting article that mirrors my own experiences at work, although my son currently receives excellent support from a voluntary agency.

    The thing that bothers me about the particular example highlighted here is not that CQC is no more (that’s bad enough) but that they missed the obvious issues. I’ve seen that before too. CQC and its predecessor are hardly a loss, but there needs to be a body with real teeth to sort out the mess.

  4. Rosemary – Thanks, I appreciate that

    tmwJackson – Maybe I’m idealising local authority services as I started working just as they were phasing out.. there’s no ‘perfect’ balance between quality and cost but one of my big worries is that the CQC is being scaled back and inspections are not as thorough as they were (that I know is a fact!) and so this perpetual downward movement in pursuit of lower costs is virtually unregulated. At least councils paid living wages and supported training for employees..

    Frances – Thanks – as I said above, it is the nature of the CQC and regulation that is most worrying perhaps.

    charles47 – the CQC still exists, it’s just the star systems don’t however it doesn’t have as many teeth or as many resources as it did in the past. I completely agree with you about stronger regulation with spot checks etc with more teeth.

  5. I agree totally with your blog, I used to work in the statutory sector of the Home Care Service as a Team Leader we did our best to deliver excellent care but due to cuts some of us were made redundant, I then decided to work in the private sector part time, all they are interested in is profit for themselves, you do not get good supplies of protective clothing training is a laugh, you can be on duty from 7 am and finish 10pm and only be paid 4 hours for what you have actually worked,this was considered one of the better companies as they gave you 15 minutes travel between service users for a payment of 60pence which is also to cover your petrol, there was no plan for staff to have service users in one demographic area so you used huge amounts of petrol driving from one end of the town to another.
    The service was run in a chaotic manner, if a two carer call was needed and they did not have enough staff they would send one member of staff ignoring all H/S.
    I no longer work for them and will never work in care again, bearing in mind that I worked in care for 25years.
    I fear for my own old age as I do not relish the thought of needing care.
    No body can say that care in the community is good there is no CARE now.

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