The Elephant in Our Care System

Adrian Roper urges the Welsh Government to take a lead on challenging and reversing the competitive market in public services

Any time now the Welsh Government is going to publish its strategic plan for health and social care. They rightly deferred the task until they’d had time to reflect on the recent Welsh Parliamentary Review, and on the responses submitted.  Before the ink dries on the new plan, I’d like to float an important idea that somehow barely features in the review. The timescale for doing something strategic with health and social care has to be measured in years, if not decades. So I’m sure there is still time for an important idea or two to find their way onto the agenda if they are not already there.

The important idea is that 30 years of neoliberal ideology, promoting the competitive market in public services, needs to be challenged and reversed.

I know the Welsh neoliberal elephant has not got as large as the English one, particularly in our NHS. But it’s still massive in our social care system. And considering that the report, and the legislation and policy it reflects, is so big on health and social care integration, it’s surely essential that this elephant in our social care system is noticed, and serious consideration given to its impact and future re-shaping.

Declaration of Interest: I work for an agency supplying care and support under contract to local authorities. It would potentially be in my agency’s interest if we were simply given an annually agreed grant and never had to compete for our work again. So let’s be upfront about the risk of complacency and self interest in such a scenario. And let’s also note that the same risk is present in arrangements for funding every statutory service, from hospitals and schools to housing departments and social workers.

The neo-liberals highlight this risk in their argument for the privatisation of all our public services. “Don’t trust public servants”, they cry, “They’ll pay themselves decent wages, and sit around all day being inefficient and ineffective”. They offer, instead, the market as a mechanism for managing this risk of complacency and self-interest that lurks within stable and semi-monopolistic services.

Thankfully, in Wales, we have been at least partly protected from the far greater risks that lurk in the neoliberal cure-all of the market. Our hospitals are not in hock to PFI schemes. Our schools are not being asset-stripped by venture capitalists. God bless Rhodri Morgan and all who put some clear red water around us.

But devolution came too late to stop the care market spreading all over the place. It was born through the 1990 Community Care Act, and it not only led to a situation where much care is being provided for private profit, it led to the re-shaping of social care professionals into contract managers, arm’s-length commissioners, and deeply frustrated subordinates to competition-obsessed 151 Officers.

And did the market reduce the risk of complacency and self-interest? Did it allow everyone to enjoy a greater sense of trust in those providing care services? (Sound of strangled laughter). No, the neoliberal market-place panacea is in fact a recipe for a very deep and wasteful distrust. And for the last 30 years, UK governments have brought this distrust into the heart of public services and it flourishes still in our Welsh care system.

This is the relational landscape in a market… Buyers don’t trust sellers. Sellers don’t trust buyers – or other sellers. Having a shared purpose for public benefit counts for nothing. None can be trusted. Everything must be tested in weights and measures and minutes and pennies. The market ideology drives beliefs and behaviours and turns care into a racket legitimised by bureaucratic structures. Under such a system, what hope is there for the collaboration and synergy to which our policy makers and report writers aspire?

And there’s more.

  • Jobs that are needed in every community, and provide a vital role in our essential, foundational economy, lose the protections of hard-won wage negotiation agreements, and wages hit the floor. Then we wonder why we can’t recruit and retain care staff.
  • Pay levels between NHS, Local Authority and non-statutory care workers, all doing similar work, become grossly and unjustifiably unequal. Then we wonder why we don’t have “One Workforce” where everyone respects each other, and where one agency’s recruitment drive doesn’t trigger a staffing crisis somewhere else.
  • Venture capitalists find ways of extracting profits from a shrinking public purse, either through exploiting workers or by piling up debts within businesses they can abandon, leaving the state to pick up the pieces. Then we wonder why so many care home inspection reports show a failure to meet required standards.

I could go on. Have a look at Chapter 4 in this Centre for Research on Socio-Cultural Change (CRESC) report for some researched facts about the elephant.

Can we sort this?

The CRESC report recommends that Wales needs to “raise the social ask” of businesses operating in foundational economy sectors like care. For example, we could make it very difficult for a care provider to extract profits by paying poor (and not uncommonly illegal) wages. We could make it very difficult for them to hide profits behind complex business group structures and dubious accounting practices. We could make it very difficult for a business to thrive if it demonstrably only cares about Welsh communities as short-term cash generators.

This isn’t just a matter of making life difficult for the private sector. The market-mind-set has infected many not-for-profit agencies too. Therefore, for all care providers, what we need is a high bar of public expectation. Financial transparency, including open book accounting, is essential. So too is a commitment to decent wages – ideally through sign-up to a Welsh Government-supported system of sector-wide wage bargaining. There’s more on that agenda here.

And we need to see a proper understanding and embrace of the Social Services and Well-Being (Wales) Act 2014. The Act puts a duty on local authorities to promote citizen well-being through the coproduction of services by citizens and professionals. The Act places a further duty on authorities to promote organisations which lend themselves to Co-production because of their openness to democratic member control and their commitment to social value. Let’s add those to our social ask of care providers. Are you open to democratic (citizen and worker) member control? Is your core purpose about social value and public benefit? (and can we see how you are achieving that, please?).

But let’s not simply aspire to build these asks into contract specifications or top-down monitoring checklists. Let’s aspire to unlock all the public money we waste on “managing the care market” and put enough of it into the hands of democratically accountable practitioners and fixers who can walk their patch, and get to know who to trust and who not to trust. And then let’s trust them to spend our money far more wisely than when we throw it into the roulette wheel of retendering exercises.

Who needs to do what?

Well, it won’t be quick and easy, and lots of agencies and interests will need to learn how to do lots of things differently. The Welsh Government can start by embracing more responsibility for the shaping of beliefs and behaviours amongst care commissioners, and it should be wary of the marketisation disease creeping into the NHS through the door marked “Integration”.

But none of the players in health and social care need to sit on their hands awaiting further central leadership. Our Welsh laws and policies are already very clear on the direction of travel:

  • Do what matters – by talking with the people and communities we serve
  • Value and enable our frontline workers – so they can do more of what matters
  • Collaborate within localities – for seamless services and shared assets
  • Pursue long-term goals – for a sustainable workforce and the prevention of avoidable dependency

If we are commissioners, we can shape what we buy in this direction. If we are providers, we can shape what we sell in this direction. If we are citizens, we can demand that our services are designed and delivered in this direction.

Together, we just might find that we are dismantling an unstable and wasteful competitive marketplace, operating at the fringes of our communities, and creating, instead, a diverse but integrated network of services, operating in every community, and serving only the public good.

You never know? My next blog will describe how such a scenario is already being shaped in a home care service in Arfon.


This blog originally appeared on Adrian Roper’s personal blog.


All articles published on Click on Wales are subject to IWA’s disclaimer.


Adrian Roper is CEO of Cartrefi Cymru

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