Why social care is different from double glazing by The Masked AMHP

The Masked AMHP

The Masked AMHP

There is a school of thought, which has its origins in some fuzzy concept of “Victorian values”, that there is something inherently wrong with the State intervening in health and social care. This reaches its apotheosis in the USA, where the Republicans regard Obama’s idea of ensuring that there is some basic form of health care accessible to even the poorest as little less than Satanic in conception.

Real Victorian concepts of philanthropy encompassed the idea that doing good was not only inherently virtuous, but was also a pragmatic and utilitarian solution to the problems that impacted on society. When large numbers of the populace are poor or sick, this affects everyone, even the rich. One of the factors that drove the development of National Insurance and improvements to social housing after the First World War was the discovery that many of the men seeking to enlist in the Armed Services were in very poor physical health. You couldn’t fight a war with unhealthy men.

There have been efforts to introduce market forces into the provision of health and social care for many years. The first Thatcher Government introduced the NHS & Community Care Act in 1990. One of the changes it introduced was the concept of the “purchaser/provider split”: this created an internal market, and essentially meant that those who “purchased” social care services should not be the same people that provided them. Until then, nearly all home care services were provided by the local authority. After that, at least 80% of services had to be purchased from private or voluntary providers

I was working in a local authority social services department when these changes came into effect in the early 1990’s.

This is how it worked before the Act. As a generic social worker, I would receive a referral for an elderly person living alone who wasn’t managing very well. I would go out and assess them and establish whether or not they needed a service: a home help to assist with cleaning or preparing meals; aids and adaptations to their home; or residential care.

I would then consult with our Occupational Therapist, who would assess for aids and adaptations, or the Home Help Organiser, who could assess precisely the level of home care services required, and then arrange for one of her Home Helps, who was employed by the local authority, to deliver that service. Some of these home helps could even be neighbours, who might be employed specifically to provide a service for that individual.

This is how it worked after the Act. The social worker would assess the person. They would then have to decide themselves exactly how much time in a week that person required a cleaning service, or preparation of meals, or someone to shop for them, or someone to help them get up in the morning or go to bed at night. The social worker would then go to the Home Care Manager, as they were suddenly called, and tell them what was required, and the Home Care Manager would then have to work out how to provide that service, using a combination of “in house” staff and external agencies.

Since then, this process has accelerated, to the point that more and more local authorities have sold off or out sourced all of their care services, and many are actively looking at how they might out source social workers, too.

The recent reforms in the NHS, centring on the GP led Clinical Commissioning Groups, are creating a culture in which it becomes imperative to provide health services via private service providers. The premise, behind the smokescreen of the mantra of “customer led” service, is that private providers can deliver cheaper and more efficient services.

There is a basic fallacy in all this: health and social services are inherently and fundamentally different from the manufacturing or service industries. You cannot apply models of the private market to the public sector.

This is what might happen if it really were the case that the health or social care service user was the “customer”.

Jeremy’s windows are draughty and let in water. He decides he needs double-glazing. He gets several companies to give him quotations for replacement windows, then makes a decision based on price and quality.

A few months after his new windows have been installed, Jeremy starts to worry about pains in his lower back. He looks these up on the Internet and decides that he must have problems with his kidneys. So he contacts the Renal Department of the local hospital, sees the consultant, and insists that he needs a kidney transplant.

The second scenario is clearly absurd. It is necessarily the role of specialist doctors to assess a patient’s health problems, and it is ultimately their decision as to what treatment the patient requires. Equally absurdly, if we were to apply this to the first scenario, then Jeremy would simply be told what sort of double glazing he needed by the expert double-glazing salesman.

Because in reality users of public services are not “customers”: it is the GP’s, via their CCG’s, who are the real customers. They are the ones who want specific services for their patients, and they choose what service they will go with.

The concept of “Payment by Results” and “clustering” currently being implemented as a means of service delivery in national mental health services is, in the words of the Department of Health, “a major change in the way that mental health care is currently funded, a shift from block grants to Payment by Results currencies which are associated with individual service users and their interactions with mental health services.”(1)

And there is revealed the true state of affairs: in this brave new world, users of public services are not “customers”, they are “currency”.

(1) 2012-13 Mental Health PbR Guidance, DoH, 06 Oct 2011

The Masked AMHP

I am a social worker, Approved Mental Health Practitioner, practice educator and trainer. I write The Masked AMHP blog, and manage the popular Masked AMHP Facebook forum, where mental health and other professionals and service users can discuss aspects of mental health.

Care to Share Magazine volume 1 issue 1


3 thoughts on “Why social care is different from double glazing by The Masked AMHP

  1. Hi MaskedAMHP. Thankyou for this.

    One of the things I like most about your blog (which I can recommend to readers, by the way) is the way you take some ostensibly complex issues and boil them down to basic issues and principles.

    The comparison between double-glazing salesmen and care professionals does that beautifully. I think that it will help many people to understand the argument so many are making about the way services are funded and organised today in UK.



  2. As a community nurse supporting people with dementia specifically I identify with all the problems mentioned here. Also due to further government cutbacks there is now a waiting list for allocation of a social worker and then more delays whilst assessment and commissioners provide care. People who need care need to be prophetic to get help in a timely manner but of course this doesn’t happen hence crisis and admissions.

  3. Thank goodness someone is able to unmask the nonsense being talked about regarding choice in health services. I do however think our Masked marvel has missed out some of the bigger things in social care about choice and control and that social care users do need (personalisation is about choice and control), including older people. I don’t quite understand the point you make in terms of your memories of the 90’s and what you organised for the person or what, it seems, you thought they needed. For example, is the neighbour you talk about one of those Neighbourhood watch dudes that Norman Lamb was talking about? I am sure you can see why I am struggling with the examples you give. Social care users need choice but the agencies bought by local authorities to deliver care should be chosen by the individual not the social worker, not the local authority but the individual. But this isn’t ‘consumerisim’ – this is where someone who is receiving personal care or ‘home help’ should have more of a say in who delivers such a service.
    But this isn’t consumerism.
    I want the Government to remember something that was thought about when people paid national insurance and taxes and thought – if not a right to social care – the country would at least honour the contribution people make to society by looking after them. The Govnt have cleverly introduced Healthwatch as some kind of ‘consumer watchdog’ – bloody dangerous. They can’t take away patient and public involvement and dress it up as a ‘consumer watch dog’. Isn’t that what Which is for? We need to protect the role of the state in this and those Governing the state should be held accountable. Yes we need choice in social care but not about gold, silver, or bronze services! We are not after a bloody smartphone or something are we?! Health services should be protected under the NHS but patients don’t need choice – they need good health services everywhere. Social care users do however need choice but not in some kinda ‘consumer society’!
    I am therefore a bit confused with the later points abot the demise of ‘block contracts’. The end of block contracts is necessary in social care is it not? Sorry – I think I just had a rant – hope it makes some kinda sense. Importantly I think I get your argument too so thanks MaskedAMHP – you made some brilliant points and agree about dangers under CCGs where privatised health care providers have got a big ‘in’!

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