Special issue: The review of Social Care
Government is conducting a review of social care services. If you’ve been following my critique you’ll know I have confidence the review won’t tackle the real issues. Herewith a transcript of a recent Podcast summarising what I’ve argued thus far and, more importantly, I close by arguing that to have any hope of improving care services we need to change the way we regulate them.
I’d like you to read (or listen to) the Podcast and give me your reaction to the arguments on regulation and/or tell me how you think others will react to what I have to say.
Thanks in anticipation. I hope you enjoy the read (or listen).
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Transcript of Podcast: Review of social care should focus on changing the way we regulate.
John Seddon
Published April 29th, 2021.
If you prefer to listen to this Podcast, please click here.
I’ve always been a fan of Private Eye. Forty years ago I worked for the BOC Group. The chairman Sir Leslie Smith would say he’d read the Financial Times to find out what’s happened and he’d read Private Eye to find out what was going to happen. Private Eye does a better job of scrutiny than many of our institutions.
It was a small item in a recent issue of Private Eye that got my attention; I learned that Brendan Martin, the man who runs Buurtzorg UK, had withdrawn his support for what was described as a Blueprint for social care. I like Brendan; he’s a good man with worthy intent. I also rate Buurtzorg – a Dutch care-service organisation – as amazing, a true innovation. Private Eye reported Martin withdrew his support because the Blueprint proposed a structural change whereas he believed the reform of care services must start with the needs of the care recipients. He’s right.
So I got hold of a copy of the Blueprint. It was authored by Josh MacAlister, CEO of Frontline, an organisation funded by public money to recruit and train social workers, in conjunction with Boston Consulting Group. The Blueprint has Buurtzorg all over it; representing the UK pilots of Buurtzorg as successes. Absolute rubbish; they were shocking failures. So I did a Podcast to argue that compared to Buurtzorg in the Netherlands, the UK pilot results were, at best, pathetic and I described the reasons for Buurtzorg’s success which, in short, began with the leader realising that the problem was the system; I also described how Vanguard’s clients in care services had learned the same that the starting-point for designing a better system is understanding what’s wrong with the current system.
Then I wrote to the people listed as interviewees for the Blueprint, sharing the transcript of the Podcast with them. What astonished me was that everyone who replied – and bear in mind these were all significant people in the care-services world – told me they did not concur with the Blueprint’s plan of action. One or two were even quite cross to have been cited. One would have thought that this lack of consensus and, as the Blueprint places such heavy emphasis on Buurtzorg, whose leader had withdrawn support, the whole thing should have been re-written, shelved or at least paused for reflection.
But then I think about what I’ve learned about policy-making in Whitehall. It’s like this: you have an idea; then you get other people in the Whitehall bubble to enthuse about your idea and once you have a body of people onside you stand a good chance of the idea becoming policy. There is neither desire nor means to base policy on evidence. In that crazy world you’d want to list lots of people in any proposal to give the impression that your idea is widely supported and you’d want to ignore the inconvenience of the main argument being torpedoed by its representative in the UK.
So I began to take the view that this Blueprint is a pitch; a pitch for public money. According to Private Eye MacAlister’s organisation has already received £72m over recent years for social-worker training. That too was a plausible pitch. We have a problem… turnover of social workers is too high… it must be a training problem… that’s how Ed Balls saw it when he was the minister. It wasn’t a training problem then and it isn’t a training problem now. Social workers leave because the system is rotten. Did the £72m have any impact?
Clearly not, the Blueprint reports that as many as 55% of social workers have had enough and are planning to leave. You might have thought that Josh MacAlister would have reflected on that as his organisation was set up on the basis that training would solve the morale problem.
The Blueprint uses the word system but shows no understanding of how the system needs to change. For example, it acknowledges the current problems of bureaucracy, form-filling, mistrust, overbearing reporting to regulators and low morale and yet, again astonishingly, it asserts that the plan will adhere to all existing regulatory frameworks. Forgive my cynicism but this is either a ploy to avoid any opposition amongst the consensus-builders or MacAlister hasn’t got a clue about work as a system.
Perhaps he thinks his proposed structure represents a different system. His plan is to create a series of self-managed teams. A family-facing team that does the social work, a referral team that allocates work, an enabler team that helps the family-facing team by handling administration, an insight team that helps family-facing teams do best practice and a strategy team that guards the culture and ensures the teams are empowered.
Really? This is Big-Consultancy speak; lots of words with indistinct meaning. But then, eventually, I find out where it is going. You have to plough on to the end of the huge document, which has abundant repetition and is a tiring read, to find this: To deliver the plan in an initial 12-month phase for 2 family-facing teams the cost estimate is between one and one-and-a-half million pounds. What is delivered for this eye-watering fee? The 2 family-facing teams get 5 initial training days and 2 monthly training days in their first year.
Forgive me. But all I can say is fuck me. What a rip off. The estimate for a complete transformation of each local authority’s children’s service is 5 to 7 million.
Now here’s the thing: we have helped leaders of care services transform their services into systems that have results on a par with Buurtzorg for tens of thousands of pounds, with results in months, not years.
Camilla Cavendish, who is working for the minister on the future of care services and chairs the Frontline organisation – in other words is a collaborator with MacAlister – came across one of our clients and was impressed. My team introduced her to another client who’d taken even further strides; they sent her my Podcast on Buurtzorg as she too was a fan and had eulogised about Buurtzorg as a journalist. She replied to say she’d read the script in one gulp. Maybe it gave her indigestion. She arranged for us to speak but on the day she was busy and instead sent an American student, who is working with her, to interview me. It was a bloody awful experience. Her questions showed she either couldn’t listen or had no ability to grasp what I was talking about; I gained the impression she’d been tasked with asking me some questions Cavendish wanted answers to which, given what I’d been saying, were neither good nor useful questions.
My central argument concerned the way regulation is the fundamental cause of sub-optimisation of these services. The bureaucracy MacAlister describes demands reports up the hierarchy, and many of them. Failure to report and reporting poor results both risk damage to reputation. I have published many examples of adherence to referral, assessment and care-plan targets, a focus on budget management and the methods of commissioning, all causing sub-optimisation and the signal that things are awry is the volume of failure demand hitting care services – often over 80% of all demand. Yet managers of these systems get the green light from regulators. Boxes ticked.
Ofsted is the primary regulator of children’s services; many of the measures that drive the bureaucracy are questions you would want to ask if you want to know the extent of what’s going on with children in need. You can understand why governments might at least want to know the extent of the problem. The regulator asks: How many assessments are occurring? Are children referred and assessed in a timely manner? Do the children have care plans in place within defined timescales? Is there evidence these are reviewed? How many children are be labelled as ‘Looked-after Child’ (LAC) and ‘Child in Need’ (CIN)? How many are there in terms of percentages per 10,000 of the population? And the like. These controls help no one understand or improve the system; instead they work against any such understanding and frequently can serve to make performance worse. But adherence to these controls protects reputation. Yes, you can have a lousy service and a good rating from the regulator. The controls focus leaders on activity at the expense of purpose. So it matters that activity targets are met rather than each and every child in need being understood.
The questions you would ask if you wanted to know how we are actually doing with helping children in need would be related to purpose, not activity. I shall return to this. But first something that came to my desk recently.
A manuscript of what I hope will be published as a book, describing one family’s experience of children’s services. It began with a tragic event: A family happily agreed to take in their friend’s three children for a couple of weeks when she was admitted to hospital. She deteriorated rapidly and unexpectedly died. What began as a two-week arrangement became extended and tragic. The family wanted to take the children in and the children wanted the same but there were two issues: the family had limited resources, so funding would be necessary, and the children had an estranged father who have been sent back to his home country, Latvia, for criminal behaviour.
The protection of children is, quite rightly, governed by law. In such circumstances the law provides for our statutory services to appoint the family as connected foster carers immediately, then later as Special Guardians, leaving more formal matters of suitability to later and to offer discretionary payment. It could have been very normal very quickly.
But that didn’t happen. The motivation for the book was to share the horror of that result taking 18 months.
A hierarchy of social-work actors delayed, failed to act as agreed, told lies, threatened the family with taking the children away, contravened a judge’s direction, only to, eventually, do what mattered. It illustrates how the social work hierarchy sought to avoid bad news, for fear of personal and corporate liability. The book shows how mistakes and lies couldn’t be admitted; instead were denied, and further lies were generated to cover up; it being impossible to acknowledge the truth.
So you have to ask why. How can these people, who joined a vocational service, act this way? It’s how you survive; it’s how you climb the tree. Adherence to regulation, adherence to budget, avoidance of bad news – we have seen how scandals have driven up the number of children taken in to care, simply because it avoids loss of reputation.
Ofsted’s web site proclaims its regulatory function is insuring that services help children in need. It asserts that prerequisites for leadership, note that, prerequisites – you’d better have them – include a vision and values statement, a statement of philosophy, documentation for the structure of teams, controls on how cases move through the system, descriptions of how social work practice will be carried out, arrangements for the provision of help, protection and care for children, what the thresholds for providing services are, what services are expected to do and how services are monitored for quality and effectiveness.
And this is where regulation gets into deep water. One way to deal with all the above is to have documentation for everything, in spades. Regulators like documentation. But what constitutes ‘good’ in any of the above edicts is open to subjective judgement. Much of what is promulgated as ‘good’ isn’t good at all. Misjudgements, conflict, stress, staff turnover and claims for retribution are inevitable consequences.
It is the primary fault in our system of regulation: regulators bring theory. So adherence to their theory is the route to a good reputation. But their theory is wrong. Any of us can point to vision and values statements that are meaningless and not lived by. How cases move through the system encourages an industrial, specialised, cost-controlled design; specifying how work will be carried out impedes the system’s ability to absorb the variety of demand, the very idea of thresholds is to misunderstand how value is created for care recipients, and effective monitoring depends entirely on the measures in use; activity and budget measures do nothing to help us understand effectiveness.
Ofsted also publishes examples of good practice on its web site. In its view these things are good: Being child-centred, ensuring stable relationships (continuity) with social workers, co-producing plans with families, ensuring children grow up in their own families or extended families where possible, having a relationship with the whole family.
Well blow me down, who’d have thought? Having published this insightful list of the bleeding obvious, and despite publishing its view on prerequisites, Ofsted is at pains to point out that it favours no particular method.
And neither should it. In fact Ofsted – and all regulators of public services – should have NOTHING to say about how services should be run.
What we need is a complete re-think of our philosophy and method of regulation. We can only justify regulations if the controls they disseminate are economically and socially advantageous. The way we regulate today fails both tests. Regulation today amounts to a plethora of specifications inspected for compliance. The specifications amount to opinion; the ideas ministers, administrators and regulators like. Instead of regulation by specification and compliance we need a regulatory system that drives innovation.
There is a systemic relationship between purpose, measures and method. To say it is systemic is to assert that it exists in all organisations for good or ill. When regulators specify measures and methods they create a culture of compliance (usually with bad ideas). Regulators need to limit their edicts to statements of purpose. The leaders of services must be free to choose how to work to achieve that purpose, determining for themselves what measures and methods they will employ. When inspection comes around inspectors need only to ask what choices of measures and methods have been made, and the inspector should go see for themselves how well it is working. The consequences are that transparency will increase (the usual hiding places are removed) and the reliability and validity of inspection reports will increase. Moreover it lays the foundation for innovation. It is to change the locus of control from the centre to those who are paid to run the services.
As I said many UK local authorities have adopted the Vanguard Method to improve care services despite having issues with regulators. But regulators can’t argue with the results: significant improvements in capacity – they provide better help for more people – improvements in service – they learn to give only what is required to meet the needs of care recipients – and significant reductions in the cost of service provision. These services have been subjected to scrutiny by local scrutiny panels. But there is an example of our work that has been subjected to external scrutiny by a number of bodies including the OECD; and that’s the youth service in Amsterdam. (An easier-to-read version, written as a case study is here.) Academics who are critical of the Blueprint for its lack of evidence, among other issues, argue in a recent article that this is the example from the Netherlands that MacAlister should have paid attention to, as it is more akin to children’s services than Buurtzorg.
And here are the results: Overall savings of 30m Euros across the Youth Protection system in Amsterdam; a 50% reduction in the number of families under care; a 61% reduction in protective measures; a 53% reduction in the number of out-of-home placements; a 46% reduction in youth parole measures; a 16% reduction in child custody; a 28% reduction in referrals to youth care providers; a 75% reduction in unnecessary administration. And, of course, many more lives more quickly back on the rails.
All achieved because the service focussed on doing what matters for each and every child. They changed the whole system to respond effectively and efficiently to the children’s needs. There’s the thing: high-quality services are always lower cost. Efficiency comes from effectiveness. All of the New Public Management paraphernalia went, thrown away, by leaders who learned how irrelevant and harmful it was to performance; supported by a government that had given up on New Public Management.
My current copy of Private Eye reports that the Department for Education insists that any recommendations in the “independent” review of children’s social care – chaired, would you believe, by MacAlister – requiring funding must include ‘as robust and detailed an evidence base as possible to demonstrate how, and over what period, this would be offset by savings’. So you might assume that MacAlister’s Blueprint is dead in the water. I wouldn’t bank on it; Big Consultancies are adept at creating fictitious spread-sheets and equally adept at avoiding blame when the savings don’t transpire.
But here we are, us who never went to school with anyone in government, with an evidence base that is as robust as anyone could want, with a method that any leader can follow, that results in far better services at much lower costs, and, in services where children can be separated from families, far fewer separations and thus much lower costs across the whole system. And, in every example, demand for services falls. Happier people and communities, isn’t that the purpose of public services?
Ours is delivered, MacAlister’s is entirely speculative.
The best thing we can do with the Blueprint is chuck it in the bin.
Notes:
To listen to my first Podcast on Buurtorg, explaining why it failed in the UK, click here.
The academic article arguing our work in Amsterdam should have been MacAlister’s model can be purchased here: Dismantling the Blueprint: Buurtzorg in English child protection social work: European Journal of Social Work: Vol 0, No 0 (tandfonline.com)
One of the authors has agreed to provide free copies; contact joe.hanley@open.ac.uk.
The OECD report that includes the Amsterdam work is here.
An easier read of the case study in Amsterdam is here.
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So what do you think about my arguments on regulation?
Thanks in anticipation…
John