Wednesday, 10 February 2016

A house where nobody lives




A quick, genuine question. Can someone please explain to me why ‘social investment’ is such a boon to cash-strapped social care commissioners?

Take this ‘case study’, highlighted in the NHS England-led October 2015 reboot of ‘Transforming Care’, ‘Building The Right Support’ (see https://www.england.nhs.uk/wp-content/uploads/2015/10/ld-nat-imp-plan-oct15.pdf ).



Presumably this means that this is considered to be a ‘good thing’ by NHS England and a model for others to follow. To my naïve mind, this amounts to the following:

1) Bonds in my simplistic view are in effect requests for loans guaranteeing a particular rate of return over a fixed period of time – if you lend us £X, then we guarantee you’ll get £X + £Y% over Z years. If investors, whether social or not, think the risk isn’t too high for the rate of return they’ll get (compared to what is on offer elsewhere) then they’ll go for it.

2)  The money is used to buy or build property – bricks and mortar, that has to be adapted in some way to be ‘specialised’.

3) People then move into these ‘specialised’ properties, presumably mostly funded by local authorities (and maybe CCGs if they’re ‘specialised’ enough).

4)  This funding pays for the property (and more than likely, the support), and also pays back the bond ‘investment’.

5) Once the bond has been paid off (by the public purse), the investors have ended up with their slice of interest and the organisation who leveraged the money end up with the properties and the business.
This model seems to be like the Glazers’ leveraged buyout of Manchester United – borrow the money to buy the club, use the income the club generates (and maybe starve it of investment/sell stuff from time to time) to pay off the debt (while taking out handy slices for yourself), end up owning the club.

At the moment, there seem to be a lot of variants of this. Like Triodos bank underwriting the building of an apparently speculative dystopian holiday camp-style ‘specialist supported living village’ in North Shields (see http://www.disabilitynewsservice.com/alarm-over-huge-new-care-village-for-autistic-adults/ ), when local authority commissioners are saying they won’t use it (although the local councillor brags of 100 jobs being brought to the area). The accommodation will be so ‘specialist’ that the back-up plan from the developers is to turn it into bedsits for sale if the ‘care’ commissioning doesn’t work out.

Another common approach is the venture capital buyout – a small ‘care’ or ‘support’ provider, struggling to provide a decent service as public funding is squeezed, is bought out for a song by a venture capital company (or a ‘care’ chain ultimately owned by a venture capital company). Why would a venture capital company want to take on such struggling businesses? Well, there are a number of options: 1) Squeeze costs (the number and expertise of staff, primarily); 2) Sell off the bits that won’t turn a profit; 3) Recast your services as ‘specialist’, thereby requiring commissioners to pay through the nose for it.

As social services withdraw from directly providing support, and NHS Trusts are under pressure to reduce officially labelled ‘inpatient services’ from NHS England, what pattern of services/support will this amount to?

First, residential services (of whatever label) will be in the hands of big private providers (the distinction between big charities or for-profit companies is irrelevant as they behave in strikingly similar ways), with smaller support agencies (without the size and muscle to convince ‘social investors’ to invest in them when public agencies won’t or to tender via bureaucratic procurement processes) being progressively squeezed out.

Second, residential services will look increasingly ‘specialised’ in congregate ‘specialised’ buildings, which look spiffy in architects’ drawings. The option of people owning or renting regular flats or houses will become even more difficult (and current trends in social housing, housing association housing and the private rental market, let alone house prices, don’t help).

Third, these congregate residential services will require filling to keep the profits coming. Doesn’t matter where a person wants to live (and imagine someone saying they want to leave and move somewhere else?) – it’s Room 4b in the ‘Bosky Glade’ unit or nothing.

Fourth, the boundaries between what counts as an ‘inpatient’ service, a residential care establishment and ‘supported living’ will become increasingly fuzzy/irrelevant. Now, these distinctions are already increasingly irrelevant in terms of what people with learning disabilities actually experience. Will the ‘Daisy’ residential unit in the grounds of a psychiatric hospital (see http://www.gazetteandherald.co.uk/news/13803905.New_health_unit_for_Devizes/ ) feel very different to an inpatient unit for the people living there? Will the North Shields ‘supported living’ experience feel any different to a care home? These distinctions are increasingly only meaningful in terms of finances for the organisations running them and which compartment of the public purse pays for them. NHS England want to reduce the number of people in inpatient services? No problem – we’ll build some specialist residential care units instead. Social services want to reduce their residential care spending? Fine – we’ll stick in some internal doors, call it supported living, and rake in the cash from uncapped housing benefit (although maybe not for much longer…).

Fifth, the public purse will end up paying more for more institutionalised services. As public money for these services decreases, the only way this circle will be squared is for social and health services to raise the eligibility drawbridge and provide support to fewer and fewer people.

Sixth, if the money stops coming in at a suitable profit-turning rate, any residential service will close, with no regard for what people need now or in the future.

Seventh, all of the above will lead to an increasing cohort of people who don’t get any support and get themselves into real trouble, which will, of course, require more ‘specialised services’ of one sort or another. And also, an increasing cohort of people living with their parents well into their parents’ old age, again likely to lead to ‘crisis’ relocation into … a space in a specialised service.

Last, any vestige of strong commissioning will wither away and become largely a matter of selection from a limited range of glossy brochures.

One of the problems when I’m writing a blogpost is that I start pursuing the logic of my own position and usually completely gloom myself out. Note that the wishes of people with learning disabilities are pretty much nowhere in the post so far – people are simply exploitable commodities. So, is there anything that can be done to stop this juggernaut of corporate institutionalisation? I don’t know, but I think there are a few things that might help:
1) Scrap the financial distinction between supported living and residential care, because...
2)  Every person with learning disabilities should have as a basic starting point full rights as a tenant or home owner, no matter what support they are getting.
3) Through meaty personal budgets (which need to sufficient to include a housing element) and/or Individualised Personal Commissioning, every person gets a long-term (10 years at least), guaranteed budget to help them plan their life.
4) People living with their families have a similarly guaranteed budget.
5)  People can use these budgets to take out a mortgage, or invest for themselves in housing, if they want to.
6)   People can do this as individuals or with another person/people if the person wants.
7)   People don’t have to go through the ‘procurement’ processes of commissioners to get what they want.
8)  People have access to independent financial and legal advice (a role for the Citizens’ Advice Bureau?).
9)  These budgets move with the person if they move to a different part of the country.
10) And … people with learning disabilities and families should be in charge of commissioning strategy while we’re at it.


I know this is over-stating a case in a way that some service providers in particular will think is unfair. I want to put this starkly to illustrate the tide that decent service providers are swimming against. And finally, as Neil Crowther says in his excellent recent post (see https://theindependentlivingdebate.wordpress.com/2016/02/09/salvaging-opportunities-from-the-jaws-of-defeat/ ), trying to come up with positive ideas feels somewhat naïve at the moment. I stand by my naivety, however. What do you think?

NB: The title, by the way, is from a Tom Waits song - which in an oblique way sums up why home is so important https://www.youtube.com/watch?v=W0YxjH09TDU 

20 comments:

  1. This blog sums up my feelings so perfectly(as the owner/manager for the last 32 years of a small residential home for 5 adults with learning disabilities). We constantly have to fight against what appears to be a tide of antipathy at our 'residential' tag, when in fact we know this attitude has been promoted over the years almost purely because the funding comes from the 'wrong' pot, unlike supported living. The service we provide is highly regarded by those using it and the commissioners who have taken the time to come and visit. It is those who only look at the term 'residential' and not at what people get from the actual service who can tend to be derisive, so I would support you wholeheartedly on points 1 and 2 of your thoughts on how to help.
    I have also come to know many other people and their families over all these years who worry so much about the future. They do not necessarily need the kind of support and care we offer so the rest of your ideas on change could give them so much more choice and a way to plan towards the future instead of it remaining as a constant nightmare (particularly as parents get older).

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  2. 'Social Impact Bonds' are interesting and I wouldn't want to throw the baby out with the bathwater. Especially given the pressures on local authorities.

    They are not just about a rate of return but also need to produce (the dreaded word) outcomes that are measureable. There are additional risks involved above the financial.

    SIBs can also be used to develop non-capital projects for which the local authority or other commissioners will pay for outcomes that provide value. For example, reducing the amount of health interaction by supporting healthier lives would fit within the Better Care programme and also the NHS 5 Year Forward Planning document with its emphasis on place-base care.

    Perhaps I can equally be accused of naivity here?

    Re your 10 points for making improvements, I feel the first point would be a radical change that would create more variety of opportunities alone. It would also help LAs with their social care budgets so reducing pressure there.

    Sadly the direction of travel means that opportunities through one route is undermined by other changes.

    I'm optimistic for the Better Care process re delivering saving for elderly care as all parties have an interest in keeping out of hospitals and care homes. For cohorts such as LDs, the future is considerably more uncertain and depressing.

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