Bob Hudson Consulting

Transcription

1 Bob Hudson Consulting Working for People: The workforce implications of Putting People First A report for the Department of Health By Bob Hudson & Melanie Henwood May 2009

2 Acknowledgements This report was commissioned by Brian Cox at the Department of Health from independent consultants Bob Hudson and Melanie Henwood. Bob is also a visiting professor at the University of Durham, while Melanie is the Vice Chair of the General Social Care Council. We are grateful to various people for their comments on earlier drafts of the document, or for their contributions in shaping our thinking, particularly: Brian Cox; Neil Paterson; Moira Gibb and Mike Wardle. The views expressed in this document are those of the authors and are not necessarily those of the Department of Health, the GSCC or any other organisation. The report has been written as a contribution to discussion about the future of the social care workforce. It is intended to inform debate around the Adult Social Care Workforce Strategy and the Social Work Task Force.

3 Contents Page Executive Summary i Introduction 1 Section 1 The new context of personalisation 3 Section 2 Response & Development 17 Section 3 Recruiting & Retaining 29 Section 4 Reinventing 49 Section 5 Reshaping the role of management & leadership 68 Section 6 Relating 80 Section 7 Regulating 92 Section 8 Conclusions & Recommendations 111

4 Executive Summary Executive Summary 1. The social care workforce is the subject of recurrent concern and debate. Much of this, particularly in recent times and following high profile child protection failures, has been focused on social work. However, the social care workforce is much broader than social work and numbers up to 1.5 million people (with fewer than 100,000 of these being social workers). Issues of both quantity and quality of workers are vitally important. 2. These issues are being considered largely separately in children s and adults services. However, it is important that these debates do not continue along parallel and potentially diverging tracks. While in children's services the major concern is with improving safeguarding and protection, the central policy in adult services is the development of personalisation and achieving transformational change set out in Putting People First. This will necessitate new and innovative approaches to the workforce and the development of new services. 3. This paper has been prepared as a contribution to the workforce debate; it is mainly concerned with addressing the adult social care agenda, but it also explores areas of interface, and tension, with developments in children's services. The paper draws upon a wide range of material across many disciplines that is already in the public domain, but which hitherto has not been pulled together for focused analysis. 4. The new paradigm of personalisation requires support for people tailored to their needs, and organised in ways that maximise the choice and control. This requires what the government has described as nothing less than "the transformation of adult social care. This has direct implications for the culture, behaviour and skills of all people working in social care. 5. These concepts of self-directed support are also finding resonance in policy for children and young people, and in health services. When individual budgets were piloted in social care between they did not include NHS resources. Following the recommendations of the Darzi Next Stage Review a pilot programme will now explore the potential of personal health budgets. The children and young people's workforce strategy was published in December 2008 and was the springboard for the establishment of a Task Force on social work practice in both adults and children's services, due to report in autumn The interim statement on a workforce strategy for adult social care published in June 2008 recognised the implications for "the capacity, competency and commitment of the social care workforce." Six strategic priorities were identified, and reaffirmed in the full workforce strategy published in April 2009: recruitment, retention and career pathways; workforce development; remodelling; leadership, management and commissioning skills; joint and integrated working across sectors, and regulation. 7. The response of key agencies to the personalisation agenda and to the workforce challenges is important. We review the position of major organisations including: the Social Care Institute for Excellence; Skills for Care; the General Social Care Council; the Skills Academy for Social Care; the Association of Directors of Adult Social Services; and the Local Government Association. Much of this activity and response is fragmented; it is also at an early stage of development. i

5 Executive Summary The evidence base 8. We have refined the six strategic priorities of the workforce strategy to provide the 5R framework of: recruiting and retaining; reinventing; reshaping; relating; and regulating. Under each of these headings we draw on a range of national evidence and qualitative research to illuminate debate. Recruiting and retaining 9. The adult social care workforce is characterised by difficulties in both recruiting and retaining. This is important for the personalisation agenda because progress will be limited if there are insufficient workers with the right commitment, training and support to meet the unique needs of people using social care services. Initiatives to address these issues have had limited success and have done little to resolve underlying difficulties such as those associated with the gendered nature of social care employment and its low paid character. 10. The implementation of Putting People First will further fragment the employer base and potentially increase the isolation of the workforce with the growth in the numbers of people employed as personal assistants. The implementation of the adult social care workforce strategy must include these dimensions within its remit, and not assume that everything to do with personal assistants is simply a private matter. Reinventing 11. Personalisation has particular implications for the role of social workers and may indeed require a 'reinvention of the professional task and purpose. Illumination of some of these issues has also been explored by the recent review of the individual budget pilots (IBSEN). Social work has experienced repeated reinvention since its origins in the 19th century. The current incarnation, which can be characterised as the 'bureaucratic-rationing paradigm', has a poor fit with the requirements of the emerging personalisation paradigm. 12. Personalisation is only one factor in influencing the shape of social work, and more negative forces are being generated in the public debate around the quality of social work in the face of apparent catastrophic failure. Such a climate will not necessarily generate the most constructive or positive model. It is imperative that both structure and culture are addressed in seeking paradigmatic change. Reshaping 13. The transformation agenda has direct implications for leadership and management. The new vision demands additional skills and competencies from commissioners, managers and senior leaders. Transforming leaders will be expected to create the conditions for others to transform realities, to galvanise innovators and to inspire, communicate and operationalise the new vision. Committed and effective leadership will be essential if personalisation is to succeed, but the training and support opportunities for leaders are limited, particularly by comparison with those available in children s services and in the NHS. ii

6 Executive Summary Relating 14. Different professions and organisations need to relate to one another at all levels, from front line to middle and senior management and at system-wide levels. Questions of partnership and inter-professional working have tended not to be explored in relation to personalisation, but these issues are highly pertinent. The management of change, and the significance of 'boundary spanners' are issues that are recognised as significant in transformational change. The workforce implications are less in evidence, not least because these roles depend on various personal attributes rather than simply knowledge-based skills. 15. The personalisation imperative requires consideration of the whole system, how its parts interact and crucially - how it can secure major cultural change and transfer of power from professionals and providers towards people who use services and their carers. The accompanying workforce strategy needs to be correspondingly broadly defined and targeted across professional and agency boundaries, and beyond traditional definitions of workforce. Regulating 16. Regulation needs to be addressed not only in terms of social care but within the wider regulatory framework. Understanding of and belief in such regulation has undergone major challenge following the apparent failure of Financial Services regulation. The concept of light regulation is increasingly being replaced with the idea of right regulation', which is proportionate but also sufficient. 17. The regulatory framework in health and social care is changing with the implementation of the Health and Social Care Act The establishment of the Care Quality Commission is an attempt to unify the framework across health and care, and across public and independent sectors. 18. The funding and regulation of direct care staff is complex; different funding sources are involved and a number of agencies including central government, Skills for Care and the Learning and Skills Council, have specific responsibilities. The complexity of this situation creates confusion, duplication and a lack of clarity about the approach to qualifications and workforce requirements. 19. The regulation of social work education and training is also increasingly coming under scrutiny, and questions have been raised about the adequacy of preparation to practise. The position of newly qualified social workers in child protection has been recognised by the Laming report as one which should be shielded from excessive caseload demands and ensuring opportunities to consolidate knowledge. Adult social care looks set to offer similar forms of support. 20. The approach to social care workforce regulation pre-dates the new model of personalisation and self-direction. Modern regulation must find an approach which is consistent with promoting choice and control while also offering appropriate safeguards. This inevitably raises questions about whether and how the remit of regulators should be extended particularly when the regulated workforce could represent a diminishing proportion of the overall social care workforce. iii

7 Executive Summary Conclusions and recommendations 21. The challenges of workforce development and transformational change must be addressed in tandem. Increasingly, the workforce cannot be described simply in terms of local authority or independent sector, but must also include PAs, family carers, volunteers, advocates and brokers. Our recommendations and conclusions address each section of the 5R framework. An important first step must lie in securing agreement on the vision required to deliver both workforce redesign and transformation. At the heart of this is the belief that the quality of an organization's output and achievement is determined by the quality of its workforce. 22. There are increasingly different imperatives driving the children's and adult social care agendas. It is essential that the interconnections of these are identified and reinforced if they are not to lead to irrevocable separation and division. Contrary to popular belief, the social care workforce is not in a state of crisis or failure, but on the cusp of radical and comprehensive change at all levels. The importance of linking workforce development to current and future policy dynamics is clear; failure to do so will ensure recurrent crises in the supply and quality of the workforce, and will result in failure to deliver transformational change across both children's and adult services. iv

8 Introduction 1 Introduction 1.1 The social care workforce is the focus of considerable attention. For some years there has been mounting concern about the supply of the workforce, i.e. recruitment and retention, particularly in the light of increasing demographic pressures, rising expectations and growing demand for social care workers. In addition, there is parallel attention directed towards the quality of the workforce, both of frontline staff and of managers. These two issues are closely inter-related, and indeed are in some tension with each other. Thus, the more criticism and vilification there is of social work, the greater the problems of recruitment and retention and the corresponding challenges of raising the status and quality of the workforce. 1.2 These matters are being considered separately, but in parallel, in both children s and adults services. A strategy for the children and young people s workforce was published in December and a final strategy for adult social care was published in April The publication of the Children s Strategy also announced the setting up of a Task Force focusing on the nuts and bolts of frontline social work practice, and to advise on social worker training, recruitment and leadership. At the time of the Strategy s publication social work was the focus of much scrutiny and criticism following some high profile child protection cases (most obviously that of Baby P). While the Task Force was initially viewed by the media as a response to the perceived problems in social work for children and young people, subsequent Ministerial comments moved to underline that the task force would also focus on adult social care and social work. 3 In the meantime, the House of Commons Children s, Schools and Families Select Committee has decided to set up its own inquiry into the training of children and families social workers. 1.3 Another vital dimension to the workforce debate is the changing context for social care in the emergence of personalisation as the core objective of support. The new agenda puts the needs and wishes of people at its heart and is geared to supporting independence and promoting choice and control for people who use services. The transformation that this requires in public services has implications not only for the supply and quality of the workforce, but for the very nature of the support they provide. In place of traditional social 1 DCSF (2008), 2020 Children and Young People s Workforce Strategy. 2 Department of Health (2009), Working to Put People First: The Strategy for the Adult Social Care Workforce in England. 3 Social work taskforce will not major on children, Hope assures adult care, Community Care, 8 January

9 Introduction care roles, personalisation will necessitate new and innovative approaches and the recruitment of people with a variety of skills and experience. 1.4 In this paper we draw upon a range of recent empirical evidence and analysis of policy and other official documents to illuminate some of the important workforce issues in the light of the personalisation imperative. We focus primarily on adult social care, but we also reflect on wider issues where appropriate, especially those in the fields of children s services and the NHS. Furthermore, we are concerned with the workforce in very inclusive terms, thus we explore the social care workforce in both the statutory and independent sectors, leaders, managers and frontline social workers, as well as care workers providing hands-on support and assistance. Importantly, we also address workers who are already within the scope of regulation; those who are expected to come within the next groups to be regulated, and those particularly Personal Assistants who are currently outwith any regulation. 1.5 The paper has been written as a contribution to the debate around the future social care workforce; it is complementary to the workforce strategies and provides an evidence-based in-depth analysis of some of the hurdles and challenges that need to be addressed if the personalisation agenda is to succeed and people needing support from social care are enabled to exercise choice and control in their daily lives and to attain the independence and aspirations they desire. 2

10 Section 1: The new context of personalisation Personalisation and Social Care Workforce Development 1 The New Context of Personalisation Introduction 1.6 In the 1980s adult social care began a process of paradigmatic change from the unified collectivist model ushered in by the Seebohm Report towards a new model based upon quasi-market principles. Provision has been increasingly separated from purchasing and commissioning, with councils contracting out the bulk of their service delivery to the voluntary and private sectors. All of this has brought huge implications for the adult social care workforce. 1.7 Now a new paradigm is emerging which, in many fundamental respects, will change the quasi-market settlement the personalisation paradigm. Inevitably this will also have consequences for the workforce, but equally the state of the workforce will have consequences for the policy, for the personalisation paradigm will fail to be successfully established unless the workforce dimension is properly addressed. As was pointed out in Options for Excellence, 4 the workforce not only accounts for 80% of the total expenditure of social care, it also can account for 100% of the service user s experience of social care. 1.8 The ASC Final Strategy (2009, op cit) demonstrates a clear understanding of the relationship between policy change and a compatible workforce. In his Foreword to the strategy the Care Services Minister acknowledges that the delivery of Putting People First will depend heavily on ensuring the development and support of a confident and competent adult social care workforce is now placed centre stage...we must ensure that we have the right workforce, with the knowledge, skills and behaviours, and the right continuing professional development and other support. 1.9 In essence, personalisation is about achieving support for people that is best suited to their particular needs, while also doing so in ways that maximise the choice and control that people are able to exercise. As we will explore in this section, these developments find particular expression in the development of personal or individual budgets, but they also go much wider, and self-directed support should be the experience of everyone using social care services whether or not they choose to do so by means of a Direct Payment. 4 Department of Health/Department for Education and Skills (2006), Options for Excellence: Building the Social Care Workforce of the Future. London: Department of Health. 3

11 Section 1: The new context of personalisation 1.10 The Community Care (Direct Payments) Act of 1996 introduced the power (from 1 April 1997) for local authorities to make cash payments, or a combination of cash and services, to people eligible for social care in lieu of local authority commissioned social services. Initially this applied only to disabled people aged between 18 and 65 who were willing and able to take responsibility for their own care arrangements. From February 2000 eligibility was extended to people aged over 65, and from April 2001 to carers, parents of disabled children, and to year old young people Since April 2003 regulations have existed which change the power for local authorities to offer Direct Payments into a duty to do so; it is therefore mandatory for local authorities to offer Direct Payments as an option to people eligible for them. The Health and Social Care Act 2008 further extends Direct Payments to people who lack the capacity to consent to their receipt, and to people who are subject to some mental health legislation following the modernisation of law in the Mental Health Act Direct Payments provide the foundation for all subsequent evolution in self-directed support and personalisation. The table below summarises the key developments that have occurred or are in the process of emerging. What is evident is that in addition to formal pilot developments, a range of other activity around various models of self-directed support is developing apace. Table 1.1: Personalisation in health and social care: Key developments Personalisation and Personal Budgets Direct Payments In Control Scope and coverage Introduced in 1997 and extended to different groups of service users. Since 2003 there has been a duty on local authorities to offer Direct Payments to people eligible for social care. Take up remains patchy both geographically and with variation between different user groups. In Direct Payments accounted for 7% of net expenditure on community services. As a proportion of total gross expenditure on adult social care 2.50 of every 100 was spent on Direct Payments. 5 Established as a social enterprise organisation in 2003, In Control conceived and developed the concept of a personal budget to use within a new model of active citizenship and self-directed support. Local authorities can join In Control as members, and the vast majority are now members (currently 122 out of 150 in England). There are also 5 Commission for Social Care Inspection (2009), The State of Social Care in England , London: CSCI. 4

12 Section 1: The new context of personalisation Personalisation and Personal Budgets Scope and coverage sites that are embracing Total Transformation (21 sites in December 2008) who are approaching personalisation as a rapid whole system change. Other variations of self-directed support have also been developed that focus on children (Taking Control currently working with 25 Children s Services); and Staying in Control - a learning community of 37 PCTs and their local authority partners exploring how self-directed support can be developed in health settings. Individual Budget Pilots Individual Budget Pilots for families with disabled children Thirteen local authorities took part in the piloting of Individual Budgets. These began operating in autumn 2005 and continued until December They were all the subject of independent evaluation. 6 While personal budgets of the type pioneered by In Control had focused on social care funding, the IB pilots attempted to bring together additional funding streams (Access to Work; Independent Living Fund; Supporting People; Disabled Facilities Grant; local Integrated Community Equipment Services). To be launched by DCSF in 2009 Personal Budgets Health The Health Bill, published in January 2009, sets out new measures that will make it possible for Direct Payments to be made to NHS patients for the first time. These personal health budgets will be piloted, and subject to legislation this could begin in mid Personalisation 1.13 The clearest statement of the objectives of personalisation was provided in Putting People First, a Concordat published by the Government in December On first sight this appeared an insignificant document (just a few pages), but a measure of its importance was indicated by the back page. Here were the signatures of six Secretaries of State across as many government departments and the Treasury, plus the signatures of the Chairs and Chief Executives of major health and social care regulators and representative 6 Glendinning C., Challis D., Fernandez J L., Jacobs S., Jones K., Knapp M., Manthorpe J., Moran N., Netten A., Stevens M., Wilberforce M (2008), Evaluation of the Individual Budgets Pilot Programme Final Report, Social Policy Research Unit, University of York; Personal Social Services Research Unit, Universities of Manchester, Kent, and London School of Economics; Social Care Workforce Research Unit, King s College, London. 5

13 Section 1: The new context of personalisation bodies. The title of this document said it all; Putting People First was concerned with setting out a shared vision and commitment to the transformation of adult social care The central idea of Putting People First is personalisation. A personalised adult social care system is to be developed in which person-centred planning (with an emphasis on self-assessment) and self-directed support become mainstream, and personal budgets are available for everyone eligible for publicly funded adult social care. In place of the limited options available from a standard menu of services, people should be able to choose the nature of the support they receive; who provides it, and should have control over when and where such support is provided The broad cultural implication of this for workforce development has been succinctly expressed by the two relevant ministers (Ann Keen and at that time Ivan Lewis) in their Foreword to the SfC/SfH publication on principles to support self-care: The vision is of people who use services, empowered with advice, support and information, having choice about the services they want, being able to take more responsibility for their health and their lives, and a more active role in managing their own care if this is what they want. This will only be achieved by significant cultural change and changing the attitudes, behaviours and skill base of all people working in health and social care This has two immediate implications for the workforce. First, there needs to be a sufficient range of services and staffing available including new and innovative services as well as advocacy and brokerage to support people in planning their care and support. Second, existing services and workforces will need to be part of the new model, and the battle for hearts and minds (particularly of frontline staff) is a crucial one. It is already clear that whilst there is widespread support for the principles of personalisation amongst the workforce, there is also suspicion of the practicalities of implementation, and this suggests the first task will be to focus upon the cultural dimension identified by the Ministers As part of the support for delivery of the personalisation agenda a toolkit was developed by the Care Services Improvement Partnership in Conceived as an on-line resource the Personalisation Toolkit sought to maximise the value of learning from the Individual Budget pilot evaluation. 8 The toolkit rightly addressed the key stages councils need to 7 Skills for Care/Skills for Health (2008), Common Core Principles to Support Self-Care. 8 Department of Health (2008d), Putting People First: Transforming adult social care. An introduction to the Personalisation Toolkit. Care Services Improvement Partnership. 6

14 Section 1: The new context of personalisation address in planning for transformation (such as the self-directed support process and selfassessment; understanding the resource allocation system; support planning and brokerage, and managing the money). It appeared to pay relatively little attention, however, to workforce strategies It is obviously important that councils understand the concept of self-directed support and can put in place the systems and processes required to support both pilot activity and wider transformation. At the same time it is essential that the organisational vision includes the workforce. There are direct implications for commissioning strategies and engaging with service providers to stimulate new and innovative services, but there are also issues for the council as an employer and for understanding that the future organisation may look quite different. Children and Young People 1.19 These concepts of self-directed support and personalisation have so far been developed furthest in respect of adult social care. However, the ideas are also migrating into policy for children and young people, and even into health care. The disabled children s review published in 2007 stated the intention to pilot individual budgets to give families and disabled young people real choice and control to design flexible packages of services which respond to their needs. 9 These objectives are consistent with the outcomes framework set out in Every Child Matters which emphasise choice and involvement in decision making, ensuring children are healthy, stay safe, enjoy and achieve, make a positive contribution, and achieve economic wellbeing Building Brighter Futures published in 2008 presented the Government s vision for the next steps for the Children s workforce, including everyone who works with children, young people or their families, including volunteers as well as those in the paid workforce. The focus throughout the document was on prevention, early intervention, personalisation and effective working with children and their parents, and with young people. 10 Thus the ambitions for 2020 are that world class, personalised and integrated services need to be 9 HM Treasury, Department for Education and Skills (2007), Aiming High for Disabled Children: Better support for families. 10 Department for Children, Schools and Families (2008), Building Brighter Futures: Next steps for the Children s Workforce, para

15 Section 1: The new context of personalisation available to every child. 11 The document also acknowledged that it was important to ensure that the cultural change required to deliver such services does not simultaneously dilute the specialist skills and knowledge of people. In providing highly personalised support, the document restated the Government s commitment to continue to drive up the quality and capacity of those working in the children s workforce, and underlined the vision for integrated working to deliver the outcomes for children As with the adult social care agenda, the vision for children emphasises both universal provision, and more specialist assessment and provision where necessary. The vision for personalised services is clear: Every child and their family has access to personalised (early) learning and childcare, family support and health services, geared to their level of development. Every young person will have access to learning and positive youth activities relevant to the individual Building Brighter Futures also announced the establishment of an Expert Group to advise on the development of a long term strategy for the children and young people s workforce. In December 2008 the Children and Young People s Workforce Strategy was published, presenting a long term vision to The vision states that everyone who works with children and young people should be: Ambitious for every child and young person; Excellent in their practice; Committed to partnership and integrated working; Respected and valued as professionals The strategy set out a number of areas for improvement including: A more integrated approach to the development of leaders and managers; A strategic approach to recruitment, including raising the profile of jobs in the children s workforce; 11 Op Cit, para Op Cit, P, 45. 8

16 Section 1: The new context of personalisation Supporting people to develop their skills to work effectively in partnership with children, young people, parents and with each other; Ensuring that qualifications, training and progression routes are accessible, high quality and help people in the workforce develop their skills; Ensuring people have the skills and knowledge to support children who are particularly vulnerable; Developing a knowledge bank for the workforce to ensure practice, training and workforce development are based on evidence about what makes the most difference The Expert Group identified problems relating to quality, recruitment and retention and clarity of purpose. This was the springboard for the establishment of the Task Force (mentioned in our Introduction) to examine front line social work practice, and to advise how improvements should be made to social worker training, recruitment and leadership. The Task Force (Chaired by Moira Gibb) was to report to Government in the summer of 2009, and is now expected to do so in October The Strategy document is strikingly quiet on the issues of personalisation that featured so prominently in Building Better Futures. It could be argued that the objectives are implicit in the approach of the Strategy, but the failure to address them head on is significant. Personalisation is not solely about the values of services and their focus on the needs of each individual child, but it also means that meeting those needs will have direct and indirect implications for the workforce. This will be especially true where services are commissioned through individual budgets The decision to establish the Task Force provides a welcome opportunity to address social worker training, recruitment and leadership issues across both children s and adults services. The absence of this comprehensive approach to the workforce to-date is a matter of some concern. While there are distinctive issues that arise in both children s and adults services, there are also major areas of shared interest. If these are not addressed coherently there are risks of the workforces being developed down parallel and possibly diverging paths, with separate career paths that could exacerbate existing challenges. This dilemma is further complicated where close working with NHS professionals is identified as a priority but a separate NHS workforce strategy is being developed. 9

17 Section 1: The new context of personalisation Long Term Conditions 1.27 The importance of personalisation in care planning has been increasingly emphasised. This approach has been longer established in some fields, such as the Care Programme Approach in mental health services, and Person Centred Planning for people with learning disabilities. Attention is now focused on making this the general experience for people requiring long term care (including end of life care). Importantly, this is not starting from scratch with a new offer but building on established good practice The 2006 White Paper Our health, our care, our say 13 set out an expectation that by 2010 everyone with a long term condition would be offered an integrated care plan. The NHS Next Stage Review (the Darzi Report) similarly set out the objectives for the 15 million people with one or more long term conditions to be offered a personalised care plan developed, agreed and regularly reviewed. Guidance issued in January 2009 set out the approach to care planning that should be embedded in local processes. The first stage of this process is that the individual, their needs and choices to support them to achieve optimal health and well-being are at the centre. 14 This emphasis is also consistent with the vision for World Class Commissioning. Personalised care planning focuses on choice and individual needs, but commissioners need also to address how to aggregate this information from the micro level to inform macro level commissioning The commissioning guide underlines the point that personalised care planning should drive demand for a wider range of services, and remarks that it is important that commissioners understand any shift in demand for services as a result of personalisation, and that this information is fed into commissioning and decommissioning plans. 15 As the covering letter to commissioners also noted, the key principles for personalised care planning are in essence about people being equal partners with their health and social care professionals in how services are delivered with carers also being seen as experts and partners in care. 16 While it is essential for commissioners to examine their policies and practice against the guidance, it is also evident that cultural transformation will be required and for the workforce to change many attitudes towards people who use services and their families. 13 Department of Health (2006), Our health, our care, our say: A new direction for community services, London. 14 Department of Health (2009a), Supporting People with Long Term Conditions. Commissioning personalised care planning. A guide for Commissioners. London. 15 Ibid, para Department of Health (2009b), Personalised care planning for people with long term conditions: A guide for commissioners, Letter from Mark Britnell and David Behan. 19 th January. 10

18 Section 1: The new context of personalisation 1.30 Guidance for the workforce is expected in early However, the current commissioning guidance emphasises that all staff (including those in the third sector) need to be aware of personalised care planning and their role in delivering it. It identifies the following skills, approaches and behaviours that will be required in care planning: Equal partnership Shared decision making Negotiation Support for self-care Providing information Good communication Gaining trust Management of risk 1.31 In addition to the benefits of care planning and self-care in terms of supporting choice and being geared to individual preferences, other potential benefits are identified for individuals, which also have wider benefits. Supporting people to remain healthy, independent and to achieve or sustain social inclusion, for example, enhances the ability to work and reduces sickness absence. Similarly, improved outcomes at the level of the individual should also reduce: crises and unnecessary hospital admissions; outpatient and GP visits and admission to permanent residential care. Improved decision making and risk management are also expected to improve value for money and clinical cost effectiveness. In addition to greater efficiency generated by people self-managing their condition, there will be greater satisfaction and fewer complaints. In short, this is seen as a win:win for the health and care system and for the people who use its services The guidance recognises that personalised care planning may appear intangible to commissioning managers, and should not be thought of as a single service or entity that can be commissioned, so much as a process of delivering care and support requiring training, time and high quality information resources. 17 In addition to working in partnership with people who use services, care planning demands more familiar good practice in terms of joint working and information sharing across the health and social care workforce. Such joint working needs to be evident at the level of services, but also underpinned at the strategic level (such as through Joint Strategic Partnerships; Joint 17 Department of Health (2009a). Op Cit, para

19 Section 1: The new context of personalisation Commissioning Boards and Local Area Agreements). The commissioning guidance observes that the introduction of personal health budgets could see the scope for choice widened even further as people choose to use different services and support (including alternative therapies) Personal Health Budgets 1.33 When individual budgets were piloted in social care between , they did not include NHS resources and could not be used to purchase health care indeed, policy statements repeatedly indicated that it was unlikely that the model would be extended to health care. The 2006 White Paper (Our health, our care, our say) stated: It has been suggested that we should extend the principle of individual budgets and Direct Payments to the NHS. We do not propose to do so, since we believe this would compromise the founding principle of the NHS that care should be free at the point of need. Social care operates on a different basis and has always included means testing and the principles of self and co-payment for services However, the issue was raised again during the Next Stage Review when many regions argued that personal health budgets should be tested. The review agreed 19 and announced that there would be a pilot programme to explore the potential of personal health budgets in the NHS. A personal health budget could be deployed in different ways including: A notional budget held by the commissioner. A budget managed on the individual s behalf of a third party, and A cash payment to the individual a heath care Direct Payment It is anticipated that the pilot programme will stimulate widespread local innovation in personalising healthcare, with personal health budgets as an element of this. Innovation is already underway, not least through the 37 PCTs and local authority partners participating in Staying in Control (see Table 1). Both notional budgets and real budgets held by a third 18 Department of Health (2006), Op Cit, para Department of Health (2008), High Quality Care for All: NHS next stage review, Final Report. 20 Department of Health (2009), Primary care & Community Services: Personal health budgets: First steps. 12

20 Section 1: The new context of personalisation party are already possible for PCTs to make available, but currently PCTs do not have the power to make Direct Payments for healthcare to patients. The Health Bill (2009), currently before Parliament, is seeking powers to allow Direct Payments to be tested in pilots. Subject to parliamentary approval it is expected that the powers will be in place to start piloting personal health budgets using healthcare Direct Payments from mid The implications of personal health budgets for the workforce are significant. The Department of Health acknowledges that effectiveness will depend on staff at all levels, and that change management will be a considerable challenge. In addition to the role of staff in supporting people who wish to use a personal health budget, there are questions which NHS staff will have about how this development may affect their own employment terms and conditions, training and development and career progression. The First Steps document observes: As personal health budgets develop, so will our understanding of the skills, roles and responsibilities, and the changes needed in training. For instance, all staff will need brokerage and advocacy skills to be able to offer support, guidance and signposting to individuals who are interested in using a personal health budget While the development of personal health budgets will have implications for all NHS staff, it seems highly unlikely that everyone will need skills as brokers and advocates, and indeed the experience from personal budgets in the social care field is that these are specialist roles often best separated from social services (where they may get muddied by decisions about eligibility and resource rationing), and many would argue are best provided by userled organisations The implications for front line care workers are of particular importance. In both the health and social care arenas there have been concerns expressed (particularly by some Trades Unions) about the potentially negative consequences in reduced terms and conditions and limited training. At the same time there is also evidence that people who employ personal assistants are keen to be good employers, and that their staff at times enjoy better pay and terms and conditions 22. The current state of development and understanding of personalisation is further advanced in local authorities than in health communities at the present time. Nevertheless there continues to be major challenges in achieving change in social care, and this is despite a commitment to the social model of disability, and 21 Department of Health (2009), Op Cit, P IFF Research (2008), Employment Aspects and Workforce Implications of Direct Payments, London: Skills for Care. 13

21 Section 1: The new context of personalisation considerable experience of engaging with people who use services. The difficulties of introducing the model into the NHS environment can be expected to be commensurately more demanding At a broader level the personalisation imperative in social care, children s services and health fits in with the vision of public services recently identified by the Prime Minister in the review of public service delivery 23. In his Foreword, the PM says: What matters is not big or small government, but whether it values opportunity, responsibility from all, and fairness for all. That is why renewed and reformed public services are the key to strong communities and a more socially mobile society. What follows are two challenges: how do we ensure that the teachers, doctors and nurses who deliver public services can respond in new and innovative ways to the diverse personal needs of those they serve? And how can we ensure that the quality, sense of personal touch, and responsiveness that exists in the best of public and private sector practices is available to all users of public services? The answer is said to be clear personalised services and greater choice - with personal budgets helping people choose the specific care they most need. The Workforce Strategy 1.40 The local authority circular on transforming social care acknowledged that the vision for a personalised approach has huge implications for the workforce of the future. 24 Given changing demographics in both the population and the workforce, combined with the changing expectations of people who use services, the current and future workforce need to change radically to meet the challenges it will face. The circular also recognised the need for frontline staff, managers and other members of the workforce to be on board recognising the value of the changes, being engaged in designing and developing reform, and crucially having the skills to deliver it HM Government (2009), Working Together: Public Services on Your Side. 24 Department of Health (2008c), Local Authority Circular, Transforming Social Care, LAC (DH) (2008)1, 17 th January. P Ibid. 14

22 Section 1: The new context of personalisation 1.41 An interim statement on the workforce strategy for adult social care was published by the Department of Health in June The strategy takes it as given that the vision for social care is unambiguous and agreed. Social care is there in order to ensure that people achieve their maximum potential, have full and purposeful lives, and exercise real choice and control over how they do this. Similarly, the final ASC Strategy, published in April 2009, emphasised the vision for a confident, enabled and equipped social care workforce able to deliver truly person centred care In order to deliver the vision, there will need to be a transformation in the ways in which social care is currently organised, practiced and delivered. 28 Specifically, delivery of the outcomes of Putting People First will rely on the capacity, competency and commitment of the social care workforce. Clearly, exactly the same can be said of the workforce in respect of children and young people, and in the NHS; these challenges are not unique to adult social care. The workforce will need to behave differently in the future; the interim strategy encapsulates this in a more proactive and enabling role on the one hand, but less direct management control over people s lives on the other. New ways of working will require social care staff to be less risk averse, while also accepting that there is still a duty of care. Essentially the new relationship is envisaged as one of true partnership between social care workers and people using services, their carers, volunteers and the wider community The transformation that is envisaged for the workforce will not mean that everything changes, but that development will build on good practice. While some of the changes required will be minor, others will be nothing less than radical, completely new ways of working. The interim statement identifies six strategic priorities that need to be addressed in developing the Adult Workforce Strategy, these are: Recruitment, retention and career pathways. Workforce development. Workforce re-modelling Leadership, management and commissioning skills. Joint and integrated working across sectors. 26 Department of Health (2008d), Putting People First Working to Make it Happen. Adult social care workforce strategy Interim statement. 27 Department of Health (2009). Op Cit. P Ibid, para 2. 15

23 Section 1: The new context of personalisation Regulation (quality improvement) The final Strategy presented a similar (and re-ordered) structure around the six key themes, and setting out broad intentions in each area. In later sections of this report we will return to a modified version of these priorities to provide a framework for analysing current and future workforce issues. Conclusions 1.45 In this introductory discussion we have explored the formal policy context of personalisation and its evolution across services for adults, as well as for children and young people. We have seen that to-date much of the development has focused on social care, but the reach of personalisation is extending into education and health care, and indeed into other areas of government policy. As the Department of Health has pointed out, the agenda cannot be delivered by social care alone: To achieve this sort of transformation will mean working across the boundaries of social care such as housing, benefits, leisure and transport and health (...) Across Government, the shared ambition is to meet the aspiration to put people first through a radical reform of public services In the next section we turn to explore how other key agencies and national bodies are responding to this transformation agenda and addressing the implications for the workforce. 29 Department of Health (2008c), Op Cit. 16

24 Section 2: Response and Development 2 Response and Development Introduction 2.1 There are a number of key agencies and national organisations who are centrally involved in shaping the environment for personalisation in general, and the social care workforce in particular. In this section we explore how these bodies are responding to the agenda set by government. The key organisations with which we are concerned are: Social Care Institute for Excellence (SCIE) Skills for Care General Social Care Council Skills Academy for Social Care Association of Directors of Adult Social Services (ADASS) Local Government Association (LGA) 2.2 The first three of these bodies are relatively young organisations, having come into being since the Care Standards Act These three organisations are also the focus of a Department of Health review looking at their role and purpose, statutory functions, governance and funding. The report of the review is expected to recommend some rationalisation. It is immediately apparent that there are several organisations involved in the regulation or development of the workforce and there is scope for overlap and confusion. The establishment of the Skills Academy for Social Care was announced in October 2008, and is expected to be operational in autumn It is the first welfarerelated skills academy and will target training and development support to the estimated 1.5 million social care workers in England. The Skills Academy will be funded by the Learning and Skills Council and the Department of Health; social care employers will also contribute. 2.3 Products planned for the first three years of operation include programmes addressing: Personalised care Leadership Quality assurance and kite marking 17

25 Section 2: Response and Development Career development and workforce retention Recruitment and broadening the workforce. The personalised care programme will include small employers (such as people who directly employ personal assistants), and will address the business skills required by responsible employers, while related programmes will also address commissioning skills at individual levels. SCIE 2.4 The Social Care Institute for Excellence exists to identify, synthesise and spread knowledge about good practice to the large and diverse social care workforce, and to support the delivery of personalised social care. SCIE has responsibilities in respect of both adults and children s services. Since 2005 SCIE has produced a number of resources relevant to personalisation including briefings, discussion papers and knowledge reviews around Direct Payments, 30 choice, control and individual budgets 31, and the role of people who use services in driving change. 32 SCIE is also engaged in a range of activity on workforce development, recognising that the successful transformation of social care services will depend on a more flexible and skilled workforce. SCIE s role is in supporting organisations directly responsible for teaching and training in social care, particularly through producing and disseminating resources that help in improving existing skills and developing new ones. 2.5 The concordat Putting People First stated that SCIE will be expected to promote, identify, and disseminate best practice and innovation, acting as a catalyst for system-wide transformation. In 2008 SCIE published a rough guide to personalisation, 33 and also in collaboration with the Department of Health, the Improvement and Development Agency (I&DeA), and the LGA a briefing for elected members. This latter document touches on issues which are of particular significance. As we will explore in the next section of the report, there is evidence that many elected members are as yet poorly engaged with or driving the personalisation transformation agenda. The briefing had apparently little to say about the workforce beyond noting that a key task for lead members and officers will reside 30 SCIE (2005), SCIE Guide 10, Direct Payments: Answering frequently asked questions. 31 SCIE (2007), Research Briefing 20, Choice, control and individual budgets: Emerging themes. 32 SCIE (2007), Knowledge Review 17, Developing Social Care service users driving culture change. 33 Sarah Carr (2008), Personalisation: a rough guide, Adults Services Report 20, London: SCIE. 18

26 Section 2: Response and Development in developing a workforce strategy to ensure the right people with the right skills and resources will be available The rough guide was intended to sketch out our current understanding of personalisation at this very early stage of implementation. The guide did not present a SCIE position on personalisation, so much as setting out the messages from innovation and pilots, drawing on the experiences of early implementers and emerging research findings. 35 One of the major changes that will have greatest significance is the impact of personal budgets and Direct Payments which will enable people to make their own arrangements for support, including employing personal assistants. As the SCIE guide observes, this raises issues about employment rights, pay, health and safety and safeguarding. 36 Skills for Care 2.7 Skills for Care is the English sector skills council for social care. It is an employer-led body that addresses the training standards and development needs of the social care sector which includes an estimated 38,000 employers and 1.3 million staff. We explore the Skills for Care programme on New types of Worker later in this report in section 4 (Reinventing). In October 2008 Skills for Care published an extremely brief document setting out its seven principles of workforce redesign aimed at workforce leads and managers working in any social care setting. The principles are summarised in Box 2.1 below. Skills for Care suggests that organisations use the principles to audit how they are undertaking the process of transformation and to identify how they can enable everyone to work differently. 37 The principles were said to incorporate the values and principles of the General Social Care Council Codes of Practice and the Common Core Principles for Self- Care produced by Skills for Care and Skills for Health, while also drawing on the eight principles for involving people who use services and carers, jointly agreed by the GSCC, the Commission for Social Care Inspection, Skills for Care and the Social Care Institute for Excellence. 34 SCIE, I&DeA, LGA, Department of Health (2008) Social Care Transformation: Elected Member Briefing. 35 Carr (2008), Op Cit, P Carr (2008), Op Cit, p Thomas J & Balman M (2008), The principles of workforce redesign, London: Skills for Care. 19

27 Section 2: Response and Development Box 2.1 Skills for Care: Principles of Workforce Redesign 1. Take a whole systems view of organisational change. 2. Recognise how people, organisations and partnerships respond differently to change. 3. Nurture champions, innovators and leaders. 4. Engage people in the process acknowledge and value their experience. 5. Be aware of the ways adults learn. 6. Change minds and change systems. 7. Develop workforce strategies that support transformation and recognise the shape of resources available in the local community. 2.8 In February 2009 a further document was issued providing 'notes and resources for the framework. This added further detail to each principle by identifying relevant management theory and further reading. The approach builds on earlier work by the Local Government Association, the Audit Commission and the Social Services Inspectorate all of which identified successful organisations and the factors associated with transformative change. Skills for Care states that each principle is "underpinned by an assumption that in social care the workforce is the organisation s most valuable asset; and that people who use services have a critical role in the shaping, development and on-going support of those resources." 38 These principles of workforce redesign are to be reviewed and refined by practice experience; they provide a starting point for those engaged in transforming the way in which people are supported." General Social Care Council 2.9 The GSCC is the workforce regulator for social care. It was established by the Care Standards Act 2000 to promote high standards of conduct and practice among social care workers. It s main functions are: 38 Skills for Care (2009), The Principles of Workforce Redesign Notes and Resources. P.2 20

28 Section 2: Response and Development To establish a Code of Practice for social care workers and employers, and to have a system for investigating alleged misconduct. To set up and maintain a register of social care workers in England. To regulate social work education and training In September 2006 the Ministers for Children and for Care Services in England commissioned a statement of social work roles and tasks for the 21 st century. The statement was prepared by the GSCC, working with the Commission for Social Care Inspection, Skills for Care, the Children s Workforce Development Council and the Social Care Institute for Excellence. A reference group of wider stakeholders, including organisations representing people who use services and carers, as well as employers, practitioners, academics and allied professions, also advised The statement identified four aims: To tell people who use services what to expect of social work, and increase the confidence of the public in what it offers. To clarify the distinctive contribution social work makes to implementing government policies, joint working with other disciplines, and the wellbeing of the community. To focus and improve social work practice, raise its status and enable scarce professional resources to be better used. To underpin social work education, training and regulation, and inform workforce planning and development The statement located social work within the context of a constantly developing framework of policies and legislation for children s and adults social care, and for related fields like health and education. It also acknowledged the policy emphasis contained in Putting People First and the Children s Plan and the departure from a one-size-fits all approach in favour of personalisation and responses to the circumstances, strengths and aspirations of particular children, adults and families. 40 The statement also emphasised the importance of social work being flexible and working across professional boundaries: 39 GSCC (2007), Social Work at its Best: A statement of social work roles and tasks for the 21 st century. London: GSCC. 40 Ibid, P.6. 21

29 Section 2: Response and Development In enabling people to exercise control and choice, social work must respond to demands for more personalised solutions, to be flexible in finding new ways of working, and adapt to people s changing situations To-date the GSCC has opened its register to qualified social workers and social work students, but it has plans for the registration of other social care workers. The Care Standards Act of 2000 required the GSCC to establish and maintain a register of social workers and of other groups of social care workers of any description, specified by the Minister. The next groups to join the register will be home care workers and managers. The Government has stated its ongoing commitment to registration and discussions are taking place about the best way forward. The ASC Workforce Strategy stated the expectation that GSCC will introduce a register of home care workers from early 2010, initially on a voluntary basis. 42 However, the next groups will only include those care workers who are working in regulated services. The ASC Final Strategy does not propose at this time to include in the scope of registration those acting as personal assistants, or family members and friends who may offer personal care or assistance to people who use services, where these have been commissioned directly by an individual (para 106). The ASC acknowledged that there are arguments for including personal assistants within the scope of registration but identified concerns about the possible impact on choice and whether value would be added. Nonetheless, given the significance of this area of work with the expansion of personalisation and personal budgets, the GSCC announced in June 2008 that it will consult on a system of regulation for personal assistants. The consultation will assess whether there is support for the regulation of personal assistants, and the following key principles will shape the approach: A register must add value to the experience of people employing PAs. It must enable people to make informed choices when employing a PA. The form of regulation must fit with the new freedoms and flexibilities granted to people who use services under the personalisation agenda The plans to undertake consultation (which has not yet commenced) were announced at the publication of research on the employment and workforce implications of Direct 41 Ibid, P Department of Health (2009), Op Cit, P GSCC (2008), Consultation announced on the regulation of personal assistants, 30 th June

30 Section 2: Response and Development Payments co-sponsored with Skills for Care. 44 The study found that few employers of PAs had funded or arranged training for their staff, and lack of funding for such training was the major prohibitive factor. Almost a third of Personal Assistants indicated that they would welcome further training particularly in relation to healthcare tasks - while the great majority of employers (84%) did not agree that any further training was necessary. 45 This is significant not just because of the issue of training per se but also because the associated lack of development opportunities and career prospects were identified as the main reasons why PAs may leave work in the near future (this was cited by a quarter of PAs who said they would stop working as personal assistants within the next five years). Moreover, almost half of those who thought they would leave also expected to leave care work altogether The research also explored views on the registration of PAs. 46 The majority of employers (79%) thought that registration would be useful, with 58% believing it would be very useful. One in six employers did not see a register as any use to them. Not surprisingly, this issue is seen as less relevant by people who employ relatives or friends as PAs (where 21% do not see its value); while people who employ only staff they have not previously known are more likely to see the value of a register (with only 12% not seeing it as useful). Almost the same proportions of employers were in favour of compulsory registration (46%) or a voluntary system (41%) Personal Assistants responding to the self-completion survey also generally favoured regulation, with 70% viewing registration as a very good idea, and a further 17% regarding it as a fairly good idea. PAs were much more likely to support compulsory registration, with 86% of respondents favouring this model. When asked about the impact of registration, PAs were likely to point to the positive benefits for the security of employers and the quality of care. A few (14%) of PAs also thought that registration would have positive consequences for them, with access to development opportunities and the chance to become qualified Further investigation of the issues around regulation of Personal Assistants is required. The approach outlined by the GSCC to its planned consultation is one which emphasises that regulation must add value to the experience of people employing PAs, and must fit with the personalisation agenda by offering flexibility. This raises particular questions about 44 IFF Research (2008), Employment Aspects and Workforce Implications of Direct Payments, London: Skills for Care. 45 Ibid, Ch Ibid. Ch

31 Section 2: Response and Development whether regulation in this area can or should be compulsory. The research from Skills for Care does not fully reflect the controversy that exists in many areas. There is considerable resistance from some people who use services to any attempt to regulate PAs, as the following comment illustrates:..the whole idea of personalisation is to allow disabled people and other service users to have more control - something the independent living movement has fought to get for over 30 years. Registration of PAs appears to be the direct opposite of this new freedom and a desperate attempt by professionals to retain control in an era when they are losing it Because of objections of this nature it is possible that a voluntary registration scheme might be favoured, for example: One answer is a system of voluntary registration - in which it becomes more of a quality mark, both for training and safe recruitment - enabling users to make an informed choice about PAs. This would ensure people could hire those closest to them without having to put them through the process of registration A voluntary system would nonetheless have some disadvantages, in particular it would mean that a two-tier workforce developed, with registered PAs having to comply with certain requirements (such as training and CRB checks), while unregistered PAs did not. The practicalities of any scheme would probably also need to distinguish between arrangements involving friends and relatives, and those where people employed PAs through the open market. This will be a complex territory to resolve, and the consultation led by GSCC will merely be the first step. Local Government Association 2.20 Thus far we have examined the response of organisations that are all involved as part of the regulatory framework for social care. We turn now to consider two organisations that represent councils (LGA) and directors of adult services (ADASS). The LGA has produced two papers on the future of social care, focusing particularly on how a simplified locallybased system of care and support would address current challenges which make the 47 Simon Stevens (2008), Personal assistant registration: the pros and cons, The Guardian, 2 July. 48 Mithram Samuel (2008), Registration of personal assistants the great divide, 2 July, The Social Work Blog, 24

32 Section 2: Response and Development existing system unsustainable. The new social care agenda redefines social care, the LGA argues, away from a model of a residual welfare net and towards one that:..also has implications for income and employment, transport, social contact and community participation, training and education, and suitable housing. This is why councils, with their responsibility for the locality and the wellbeing of local people, are the obvious focal point for the co-ordination and delivery of this range of support. Councils know from experience with Direct Payments and individual budgets in social care that people find that the ability to design their own support has transformed their lives The LGA position is that support for people should be coordinated at local level. It has stated its support for the system-wide transformation that will be required to deliver personalisation of social care, and identified the challenges if this is to develop as a universal support and wellbeing service. The LGA argues there are particular issues in the tensions between the desire for national consistency and equity on the one hand, and local decision making and accountability on the other. 52 This implies a basic, universal, standard with councils able to adjust for local circumstances (such as local cost variations being reflected in the Resource Allocation System for personal budgets) As a representative body for local government, the LGA also reflects the experience and views of councils as major social care employers. Each year it publishes the results of the local authority social care adults workforce survey, which collects information on a range of issues including recruitment, retention, training and qualifications of staff working in adult social care. Latest data indicate ongoing recruitment and retention difficulties, for example 54% of authorities reported difficulties recruiting field social workers, and 42% for home care staff. 53 The survey report commented: The main reasons for difficulties varied according to the type of job. For field social workers, and to some extent occupational therapists, the main reasons cited were a lack of suitably qualified applicants, applicants lacking relevant experience, competition from the 49 LGA (2008), Our lives, our choices. Fit for the future: a new vision for adult social care and support, London: LGA. 50 LGA (2009), Facing facts and tomorrow s reality today: the cost of care, London: LGA. 51 LGA (2008), Op Cit, P LGA (2008), Op Cit, P Local Authority Workforce Intelligence Group (2007), Adults social care workforce survey: Main report 2006, London: Local Government Association. 25

33 Section 2: Response and Development statutory sector and unattractive pay; for home care staff the main reasons were the nature of the work, competition from the independent sector and whole economy, and pay. 54 Association of Directors of Adult Social Services 2.23 The major response from ADASS to the personalisation agenda has been the creation of a National Director for Social Care Transformation (a post supported by a consortium of ADSS, the IdEA and LGA, and with the support of the Department of Health). The post holder (Jeff Jerome) is charged with leading local government s contribution to delivering the Putting People First agenda, and ensuring that personalisation is integral to social care delivery. Clearly this is a significant post and its creation underlines the importance of personalisation to all councils with responsibilities for adult social care ADASS organises itself through various policy networks; in addition to those organised on client group lines are networks on both personalisation and workforce development. ADASS describes the personalisation network as the youngest of the ADASS Policy Networks and we were set up as a direct result of the government's promotion of personalisation within its social care Transformation Agenda. The workforce development committee produced a document in 2007 on commissioning the social care workforce. The paper defined three main levels of commissioning activity - the individual, the locality or community of interest, and strategic. It also identified the need for these to be integrated in a common structure and system, and stated: 2.25 The implication of this person-centred, outcomes-based, whole systems approach is that workforce strategies to implement it need to be very broadly defined and targeted, operating at several levels, across professional and agency boundaries and well beyond traditional definitions of the workforce as paid employees in commissioning and provider bodies. 55 This is a refreshing and helpful approach, but beyond listing the various stakeholders who would need to be involved, little further was offered, other than the statement that: it will be for the directors of adult social services and directors of children services, working with directors of public health and other senior managers, to provide clear, practice 54 Ibid, P ADASS (2007), Commissioning the Social Care Workforce.P

34 Section 2: Response and Development leadership in taking charge of the strategic workforce development agenda for their authority In June 2007 ADASS and the Care Services Improvement Partnership (CSIP) issued a framework for delivering the future workforce. 57 The framework is described as a tool to ensure that whatever model of workforce planning is used, it takes account of all elements and local variations. The framework highlights the fact that commissioning needs to be considered at the three levels of individual, local and strategic, and that these must be interconnected. Conclusions 2.27 In this section we have explored the ways in which key agencies are responding to the twin policy pressures of personalisation and workforce development. As we have discussed, all the key agencies are aware of these demands and are responding to them to a lesser or greater extent. It is also clear that despite areas of collaboration, much of this activity is fragmented, at times duplicative, and would arguably be strengthened by a more integrated approach. Furthermore, it is also apparent that much work is at an early stage of development and couched in terms of considerable generality, rather than setting out clear strategies for responding to the policy agenda Change of the scale that is required by the Putting People First vision cannot be achieved overnight. However, it is vital that there is a momentum to change and strategic leadership is demonstrated. Failure to do so risks all of these agencies, but particularly those with the most direct roles in regulation or service provision, being forced into a defensive and reactive position. As we outlined in Section 1, the establishment of the social work Taskforce to examine frontline practice, training and leadership is an indicator of the crisis of confidence which now assails social care. While it is important that there is adequate investigation of these important questions, there are also two key risks. First, that planning blight is generated which effectively constrains further development while the outcome of the work of the Taskforce is awaited. Second, there are dangers of a knee-jerk response by the Taskforce itself and recommendations for major structural change that could prove highly disruptive without delivering the desired improvements in service quality. 56 Op Cit. P,22 57 ADASS/CSIP (2007), What does a commissioning framework look like? A framework for delivering the future workforce. 27

35 Section 2: Response and Development 2.29 As we have explored in this section, the workforce questions that need to be addressed are about far more than social work. The changes that are required in social care to achieve the goals of personalisation are many, and we turn now to examine the evidence base on progress and prospects. 28

36 Section 3: The Evidence Base: Recruiting & Retaining 3 Personalisation and the Adult Social Care Workforce: The Evidence Base Introduction: The 5r Framework 3.1 As noted in Section 1, the Interim Statement on a workforce strategy to underpin Putting People First identified six strategic priorities, and these have been confirmed in the Final Strategy (in a slightly revised order): Recruitment, Retention and Career Pathways: developing creative local strategies to attract workers from across the population. Workforce Development: local workforce development plans developed in partnership by the statutory and independent sectors. Workforce Remodelling: New models of care need to be understood, led and championed by the workforce. The document emphasises the need for strategic market development, bringing together skills across different professional groups, identifying different ways of working, and spelling out the changing requirements within professional roles. Leadership, Management and Commissioning Skills: The key tasks here will be to provide support and encouragement for leaders and managers, and provide the environment to think creatively, use their entrepreneurial skills and engage with a broad range of constituencies. Joint and Integrated Working Across Sectors: there will be a need for greater coordination of services in order to generate new forms of joint support and service provision. Regulation (Quality Improvement): The reforms will have implications for models of regulation, and require a new balance between creativity, innovation, and proportionate regulation and risk management. 3.2 We have modified this to develop our 5R Framework to encapsulate all of these priorities and reflect additional considerations. The framework consists of: Recruiting and Retaining: personalisation requires an adequate and stable supply of quality workers to match the anticipated levels of need and to also ensure continuity of support. 29

37 Section 3: The Evidence Base: Recruiting & Retaining Reinventing: personalisation requires a different way of working on the part of all staff involved in assessment, commissioning and provision. Reshaping: personalisation implies developing a radically different operating system which will need high quality transformational leadership. Relating: personalisation requires sophisticated partnerships between people who use services, carers, organisations and professions new and seamless relationships geared towards meeting user outcomes. Regulating: personalisation raises new issues about the nature and scope of regulation of the social care workforce. 3.3 In this and the following sections of the report we will analyse each part of this framework, drawing on a range of national evidence and qualitative research findings. Recruiting and Retaining The Adult Social Care (ASC) Workforce Map 3.4 The first step in achieving an adequate and stable workforce to meet the new challenges of personalisation is to develop the best possible understanding of the current workforce map. A clearer picture is slowly beginning to emerge, especially following the development of the National Minimum Data Set - Social Care (NMDS-SC), though this is generally confined to direct care staff in the independent sector. Accordingly this part of the report concentrates upon direct care staff rather than professional social workers, whose position is explored in the following section. 3.5 NMDS-SC is a collection of standard workforce data items developed by Skills for Care in conjunction with a wide range of partners. It was launched in October 2005, has been online since November 2007, and collects data from adult care providing and organising establishments. Data are collected on both organisations and the individuals working in them. By 2008 the NMDS held 21,100 organisational and 585,000 individual worker records (55% of CSCI registered establishments), mainly in the private and voluntary sectors. Although there is still some way to go, this all represents a huge improvement upon the pre data. Local authority data is currently collected separately via the SSD001 forms, but the expectation is that the latter will soon be subsumed within NMDS to deliver a more 30

38 Section 3: The Evidence Base: Recruiting & Retaining comprehensive workforce picture. There is also the possibility at some point of incorporating NHS staff data into the NMDS-SC. 3.6 Using a combination of different sources of the most recent data, Eborall and Griffiths (2008) 58 estimate that the adult social care (ASC) workforce in England alone amounts to 1.39 million people, with the breakdown shown in Table 1 below. Table 3.1: Estimated Size of the Adult Social Care Workforce, England 2006/7 Service Setting Private and Voluntary Sector Local Authority NHS Direct Payments TOTAL Residential care 584,000 51, ,000 Domiciliary Care Community, inc. NHS and management of care Workers not directly employed 274,000 48, ,000 34,000 90,000 60, , ,000 67,000 11,000 78,000 Day Care 29,000 28,000 57,000 % of Total Workforce TOTAL WORKFORCE , ,000 60, ,000 1,389, A key feature of this workforce is its stratified nature. Unlike education and health, the social care workforce is characterised by a distinction between the smaller professionally qualified workforce, of whom the majority are social workers but which also includes other professionals such as occupational therapists, and the larger direct care workforce, such as 58 Eborall, C and Griffiths, D (2008), The State of the Adult Social Care Workforce in England Third Report of Skills for Care s Skills Research and Intelligence Unit. Leeds: Skills for Care. 31

39 Section 3: The Evidence Base: Recruiting & Retaining care assistants or home care workers. The majority of the latter either have vocational qualifications or do not possess any type of formal qualification, and they are the prime focus of this section. 3.8 A further important feature of the workforce map is the changing nature of ASC employers. Since the contracting out of social care services in the 1990s the workforce has shifted from one primarily employed by local councils to one in which the majority of workers, especially those whose roles do not involve statutory work (such as undertaking assessments), are employed in the private or voluntary sectors. 70% of social care staff now work in the independent sector, with care provided through 35,000 different employers, and this brings new workforce issues into play. 3.9 As we explored in Section 1, the personalisation agenda means there will be an increasing number of people working directly for individual service users, sometimes offering nontraditional modes of support. This will also mean a more dispersed workforce and dispersed individual employers, both of which will be more difficult to support, monitor and regulate. The emergent status of the PA workforce means that as yet relatively little is known about it, but a major step forward in our understanding has been the research undertaken last year by IFF Research for Skills for Care. 59 This revealed a number of important findings about both the employers of PAs and PAs themselves In the case of PA employers: The vast majority (79%) say they are very satisfied with their PA, with most of them also viewing this support as superior to that previously organised by the local authority. The incidence of problems with the reliability, punctuality and quality of care delivered by support workers has declined under Direct Payments, and the incidence of abuse directed at employers has decreased. For the most part employers are generally confident about taking on the responsibility of becoming an employer, though sizeable minorities stated that they find the responsibility daunting (27%) and almost a third find it difficult to cope with administration (31%). Elderly employers are most likely to express these concerns. Just under half of PAs were known to their employer personally before being employed by them, with most employers seeing this as their preferred route for recruitment. 59 IFF Research (2008), Employment Aspects and Workforce Implications of Direct Payments. 32

40 Section 3: The Evidence Base: Recruiting & Retaining Only 40% of employers have issued their PAs with formal contractual job descriptions. Large proportions of employers state they would like more help from their local authority and/or its DP support scheme Some of these findings have been recurrent themes in other qualitative research which has explored the experience of people employing PAs. In Scotland, SPAEN (Scottish Personal Assistants Employers Network) exists to be the authoritative voice of PA employers, though it seems to have no equivalent in England. SPAEN is a user-led organisation providing personnel, management and employment law support, advice and indemnity cover, information, training and Disclosure Checks for people who manage their own support package and employ their own PAs. Nevertheless, a recent investigation by UNISON and SPAEN 60 reveals some ongoing difficulties, including: lack of awareness amongst employers of where to access support on such matters as training and funding for training for themselves and their PAs; most employers did not have an equal opportunities policy, and most employees were not paying into a pension fund; a significant minority of employers expressed difficulty in knowing how to deal with managing issues of employee competency and capability; a large number of employers had no contingency arrangements for such matters as staff sickness or holiday cover, and those who did keep such a fund found that the local authority clawed this back as being unused In the case of PAs themselves the IFF survey reported that: There are around 125,000 PA roles in England currently funded through Direct Payments, and this is bound to be increasing significantly. Most are female (87%), around two-thirds have some prior experience of working in the health and social care sector, and 42% have qualifications in health and social care. 40% have other jobs outside their PA roles. 33% had no previous paid employment involving providing social care or support to others, suggesting that the work is attracting new entrants to the sector. 60 SPAEN/UNISON (2008), Creating and Supporting an Informed Employer and Employee Relationship within the Self-Directed Support Sector: Interim Report. 33

41 Section 3: The Evidence Base: Recruiting & Retaining 3.13 Around 20% of the PA workforce in the IFF survey had been displaced from elsewhere in the sector, which could have problematic consequences for the workforce as a whole, with workers torn between employment by an organisation and employment by an individual budget holder. There are considerable market risks for home care services which arise with the emergence of personalisation. The shift away from block contracts and a reduced role for local authority commissioning will mean many home care agencies struggling to find their place in the new market. At the same time, agencies may risk losing their staff to selffunders (including people using their own resources, as well as those using a personal budget). Direct payment rates are typically below the cost of independent sector home care, which increases the likelihood of people who switch to direct payments ceasing to use an agency or endeavouring to employ the care worker directly Research for IDeA carried out by the Social Care Workforce Research Unit 62 reports some home care staff leaving a service to work for people receiving direct payments because salaries are higher due to lower overheads, but it is too early to determine whether this will spread. Although there will be some greater security in staying with an employing agency, there is also evidence that staff are often unhappy with their terms and conditions of employment. The same study reports: travel time and mileage are often not paid to home care workers; home care staff do not always have guaranteed hours and can lose a proportion of their income if a regular client goes into hospital; no time for service development or improvement some contracts are so tight that if supervision takes place at all it is in unpaid time Again, these findings have been reported in other research on direct payments and were also a feature of the experience of people using the Independent Living Funds. 63 Further points are made in DH Guidance on collaborative solutions to social care recruitment 64 which suggests that being able to develop good relationships with people who use services makes a significant contribution to feelings of satisfaction for both the user and care worker. It notes anecdotal evidence that some home care workers prefer to apply for nursing 61 Sawyer L (2008), The personalisation agenda: threats and opportunities for domiciliary care providers, Journal of Care Services Management, volume 3 No.1 pp IDeA/Social Care Workforce Research Unit (2008), Lessons from Outsourcing Adult Social care: the workforce issues. 63 Henwood M and Hudson B (2007), Review of the Independent Living Funds, London: Department for Work and Pensions. 64 Department of Health (2006), Collaborative Recruitment Solutions in Social Care. 34

42 Section 3: The Evidence Base: Recruiting & Retaining auxiliary posts because the short visits they are required to make in home care give no time to build any kind of relationship with service users The position of support workers more generally has been recently explored in a scoping review by the Social Care Workforce Research Unit. 65 The authors define the role as: a person who is employed on an individual basis to foster independence and provide assistance for a service user in areas of ordinary life...and who may take on secondary tasks in respect of advocacy, personal care and learning. In line with the emergence of personalisation, this definition is a departure from the traditional usage that would have referred to an unqualified worker supporting another professionally qualified worker. In terms of the role, the report emphasises the importance of being both practically helpful and emotionally supportive, and raises the issue of the vulnerability of support workers to exploitation by virtue of the human ties that form outside of any contractual arrangement. This is especially likely to arise with direct payment employees who live near to their employer and may be subject to boundless obligations. The IFF survey of PAs (2008, op cit) found that around a fifth of workers said they were required to work too many hours We have examined already (in Section 2) some of the workforce implications of the growth of PAs, and one of the striking features of the SCWRU review is the preference of employers for the absence of professional characteristics. Employers were generally not keen to employ people with a social services background which was felt to imply a one size fits all mentality; rather employers wished to customise training on the job. This finding is highly consistent with other research in this area over a number of years. Glendinning et al, for example, found that users of Direct Payments attached very considerable importance to providing their own, on-the-job training for new personal assistants Whether support working is a first step on the professional ladder is not currently informed by any study that has taken a longitudinal approach. There remains some concern that whilst the discussion of policy ends (on choice, control and independent living) has been fairly clear, the discussion on means (the PA market) has been relatively neglected. Hence whilst the scale of direct payment awards is monitored and measured, the actual care or support workers themselves are neither monitored nor regulated. 65 Manthorpe, J and Martineau, S (2008), Support Workers: their roles and tasks. A Scoping Review. 66 Glendinning C., Halliwell S., Jacobs S., Rummery K, & Tyrer J (2000), Buying independence. Using Direct Payments to integrate health and social services, The Policy Press. 35

43 Section 3: The Evidence Base: Recruiting & Retaining 3.19 Finally, there has also been an increase in self-employment. Until now, self-employment has not been a feature of the sector beyond the very small numbers of social workers working in adoption or as counsellors or therapists (a little over 2% of registered social workers describe themselves as self-employed 67 ). However, the government s personalisation agenda which aims to increase the number of individuals managing their own budgets to purchase care may offer potential for an increase in the number of ownaccount care workers All of the discussion thus far addressing the difficulties of recruitment and retention in social care might suggest that people wishing to employ personal assistants could face major problems in finding staff. Certainly there is empirical evidence to support this, but there is also research that indicates people are able to find creative solutions in some circumstances. People use the networks already available to them, including friends, neighbours and on occasions other people they employ, as a study for CSCI on supporting people with multiple and complex needs found: You see lots of our clients are already employing people. They are already employing cleaners and gardeners. So that s not unusual for them; they are used to employing people Even when people are looking for a PA who is able to provide highly personal care, more innovative approaches to recruitment can be successful. The same study found people seeking out PAs from different walks of life, and not from care backgrounds. 69 People with complex needs may need to employ several PAs and to create a bank of people they can draw on and here again different approaches to marketing can attract a range of people beyond the normal social care recruitment pool. Other innovative approaches to matching people's needs to social care services and support are emerging. For example, a new website developed by In Control with technological support from Valueworks is being launched that will make use of the EBay style of customer ratings and comments to inform other users Personal communication from GSCC: in March ,663 registered social workers out of a total of 78,466 describe themselves as self-employed in social care services. 68 Henwood M and Hudson B (2009), keeping it personal: Supporting people with multiple and complex needs. A report to the Commission for Social Care Inspection, London: CSCI. P Henwood and Hudson (2009), Op Cit. P The Ebay of social care, The Guardian 18 March

44 Section 3: The Evidence Base: Recruiting & Retaining Turnover and Vacancies 3.22 The estimated turnover and vacancy rates for direct care staff (derived from NMDS data) is shown below. Table 3.2: Turnover and Vacancy Rates in Adult Social Care Care Setting Turnover rate (%) Vacancy rate (%) Adult Care Sector Care Only Homes Care Homes with Nursing Domiciliary Care The vacancy rates are higher than the national average in 2006 the Learning and Skills Council 71 suggested the rate was double that for all types of industrial, commercial and public employment, and compared unfavourably with less than 1% for secondary school teachers and qualified nurses. In the same year, CSCI described recruitment and retention problems in social care as chronic. 72 However, vacancy rates can vary considerably between councils, with rates in London and the South East approaching 30%, compared with less than 1% in Yorkshire and the Humber. The most recent State of Social Care Report from CSCI 73 reports that the number of vacancies notified to Job Centres for care workers, social workers, occupational therapists and other care and support-related occupations exceeded 100,000 in the second half of 2007, and has remained at these high levels during the first half of Over 80% of the vacancies are for care workers A recent survey by Community Care 74 has revealed a 10.9% vacancy rate for social workers across councils in England. London has the highest rate (18.6%), followed by the West Midlands (17.8%), with the North East the lowest at 6.5%. Perhaps surprisingly, the survey finds no great difference between the vacancy rates for adult care (12.1%) and children s social work (13.0%). The percentage of agency staff nationally stood at 6.9%, but was much higher in some struggling councils. 71 Learning and Skills Council (2006), National Employers Skills Survey 2005: Main Report. 72 CSCI (2006), The State of Social Care in England Commission for Social Care Inspection (2009), The State of Social Care in England Community Care, April 16 th 2009, p4/5. 37

45 Section 3: The Evidence Base: Recruiting & Retaining 3.25 The turnover rates shown in Table 3.2 constitute a potential threat to a personalised service, especially in direct social care-giving where close and continuous relationships with people who use services are so important. High turnover also creates high and unsustainable costs of advertising, selecting, inducting and training a high proportion of the workforce on an ongoing basis - SfC estimates that the cost per worker of an initial training package alone is around NMDS data suggests that the often reported loss of staff from social care to work in retail (the shelf-stacker narrative) is false, with only 3% of staff leaving to go into retail. Much more common (in 18% of cases) is a move to another social care provider (i.e. what is known as churn ), though it remains the case that around half of all workers are lost to the sector completely Turnover rates are higher amongst independent providers an annual rate of 17.9% compared with 8.6% in the council workforce (CSCI 2009, op cit) and this makes it difficult for independent providers to ensure that workforce qualification targets are met, and continuity of care secured. Part of the explanation for high staff turnover is low pay, and the incentive to leave a post for a relatively small wage increase for all services, the highest turnover and vacancy rates are associated with lower grades. Social care is the third largest low-paying sector in the UK economy, with over a million jobs being paid at or around the level of the minimum wage. 75 Based on 2007 data from the NMDS-SC, the median gross hourly pay rate in the private sector was 5.73 for care workers and 6.00 for senior care workers (care workers with an average of three years experience and/or vocational qualifications at NVQ level 3 or higher) Career development in social care is therefore not associated with higher monetary rewards the hourly rate for senior care workers is only 27p higher than for care workers. Where the pay structure bears no positive relationship to qualifications, length of service, employment status and the needs of service users, it will inevitably be difficult to recruit, retain and develop a skilled, committed and stable workforce. The ASC Final Strategy (2009, op cit) recognises the need to develop new career pathways to move from one level of experience to another (para 50), but this will be hard to accomplish without an accompanying financial reward structure which differentiates such experience. There is also the more fundamental issue of bringing together a career development route that bridges NVQ levels and qualifying learning and education. 75 Low Pay Commission (2008), National Minimum Wage. Low Pay Commission Report 2007, Cm London: Low Pay Commission. 76 Skills for Care (2007), NMDS-SC Briefing 3: Pay. 38

46 Section 3: The Evidence Base: Recruiting & Retaining 3.28 Rates of pay for care workers were higher in the voluntary ( 6.19) and statutory sectors ( 7.53), but this represents only a minority of workers compared with the numbers employed in the private sector. It has been noted in DH Guidance (2006, op cit) that a common concern among social care employers is that the relevant labour market is quite limited, with everyone fishing in the same pool. Understanding this may act as a spur to working collaboratively to find solutions rather than simply competing for a dwindling supply of suitable staff. What is not yet clear from the data is the impact of the recession upon recruitment and turnover rates logically the former should rise and the latter fall The Final Strategy notes that while the Department of Health does not set the pay, terms and conditions for adult social care workers, the Government recognises that there needs to be a renewed focus on ensuring that when commissioning for services, there is a clear remit to include quality commissioning for fair workforce terms and conditions. It is stated that:- The solutions here will not be straightforward and will need to be considered carefully as a long-term challenge against the backdrop of the economic efficiencies that government departments, local authorities and service providers need to deliver in the current challenging economic climate. (para 52). This does not suggest any immediate change can be expected Recruitment and retention issues are not, of course, confined to direct care staff. The social care workforce inquiry by the All-Party Parliamentary Group on Social Care 77 notes that: despite the Government-sponsored recruitment campaigns and other measures, the lack of public understanding of social work and social care is a major problem. (p2). This situation can only have deteriorated in the wake of the media reaction to the Baby P and other high profile child protection cases which have gone badly wrong Figures showing a breakdown of vacancy and turnover rates amongst different types of ASC workers are available from Skills for Care. Data from CSCI s 2007 self-assessment survey indicated a quarter or more of all councils reporting recruitment and retention difficulties with field social workers in adult social care, particularly in mental health services (where this was the case in 35% of councils). 78 Data for 2006 indicate a vacancy rate of 9.4% for field social workers, and a turnover rate of 7.8%. 79 Higher vacancy rates were reported for residential home care staff (10.8%) and occupational therapists (10.3%), and turnover was also higher in domiciliary care (13.6%) and in care homes for older people 77 All-Party Parliamentary Group on Social Care (2008), Social Care Workforce Inquiry 2007/8. 78 Eborall C and Griffiths D (2008), The State of the Adult Social Care Workforce in England, 2008, London: Skills for Care. P Ibid. P

47 Section 3: The Evidence Base: Recruiting & Retaining (13.2%). The position in children s services has been well publicised. The most recent figures (quoted in Lord Laming s Progress Report 80 ) suggest that the vacancy rate for children s social workers in local authorities stood at 9.5% in 2006 (compared with 0.7% for teachers), with turnover rates also high at 9.6%. In 2008, 64% of local authorities were said to be reporting difficulties in recruiting children s social workers. In the worst cases this can lead to alarming reliance upon inexperienced staff Laming notes that in some of the authorities visited in preparation for his report, over half of all the social workers were newly qualified with less than a year s experience, while also facing heavier caseloads than in the past (para 5.2) The LGA has recently launched a campaign to try to persuade an estimated 5000 social workers to come out of retirement to work in child protection. Haringey Council, for example, was reduced to making an urgent appeal to all London councils asking to borrow social workers to ease its recruitment crisis following Baby P an appeal turned down by most councils on the ground that they were themselves experiencing major recruitment difficulties and increased child protection cases One key issue in improving retention could be the introduction of a supportive probationary year for newly qualified entrants. Laming unfavourably compares the position of social workers to that of teachers, where the introduction of teaching assistants and advanced skills teachers, along with greater preparation time, has helped to support the profession s newer recruits. The Department of Health is currently working with SfC, GSCC and SCIE to develop a Newly Qualified Social Worker (NQSW) scheme in adult care a similar scheme is being introduced for NQSWs in children s services. SCIE is in the process of drafting a statement of the core elements of social work practice so as to enable a NQSW to demonstrate after an initial year in employment that they are a competent social worker. Such an approach has parallels with other professions, such as medicine, where it is not assumed that a newly qualified person is immediately competent to undertake all aspects of practice. In social work, attention to this issue has been focused in part by evidence that inexperienced social workers are often left to cope with excessive workloads and responsibilities. The draft outcome statement covers twelve areas: - referral; assessment; planning and intervention; review; safeguarding; relationships; communication; recording and sharing information; service development; multi-agency working; community-capacity 80 Lord Laming (2009), The Protection of Children in England: A Progress Report. HC 330. London: The Stationery Office. 81 Curtis, P (2009) Baby P council issues urgent appeal for staff, The Guardian, P.4, 26 th January. All-Party Parliamentary Group on Social Care (2008), Social Care Workforce Inquiry 2007/8. 40

48 Section 3: The Evidence Base: Recruiting & Retaining building; professional development and accountability. This seems to be a fairly traditional conceptualisation with only a limited reference to the potential impact of personalisation Although the recession is likely to have some impact on social care employment, the trend is towards an increase in the size of the ASC workforce to match the growing demand for support. The ASC Final Strategy (2009, op cit) reports that there has been an overall increase of 8% in the workforce since 2006/7, and it is important that workforce strategies plan for a post-recession scenario. This longer term focus is a key theme of the recent report from the UK Commission for Employment and Skills 82 which argues that over the period to 2017, employment is projected to continue to rise with the creation of two million new jobs. Nature of the Adult Social Care Workforce 3.35 The two most striking characteristics of the ASC workforce relate to age and gender. Adult social care is often said to have an ageing workforce. Analysis of NMDS data at May 31 st shows no date of birth information being given for just under a quarter of the 90,000 worker records received at that time, but it is nevertheless possible to build up a reasonably accurate picture. The key findings are that around one third of workers are aged 45 or over, with 15% aged 55 or over, and that around two-thirds of workers do not start working in social care until they are aged 30 or over. Other research 84 suggests that the reasons for social care being attractive to older workers include: job satisfaction; flexibility of hours; workers becoming more aware of care work as they get older; and the nature of the work increasing in interest as workers themselves get older. One interpretation of this analysis is that having an older workforce may be sustainable, with age being a reason for joining the sector rather for leaving it Gender is the other key feature of the workforce, with social care still predominantly a female occupation. While men comprise only 54% of the UK economically active population, women make up 82% of the social care workforce rising to 90% in direct care posts - though they make up only 67% of senior managers. Care setting makes some minor difference men make up 16% of the workforce in care homes with nursing, 13% of careonly homes, and just 11% within domiciliary care. The sector is especially reliant upon 82 UK Commission for Employment and Skills (2009), Working Futures Skills for Care (2008), NMDS-SC Briefing Issue 5: Age and Gender. 84 Skills for Care (2007), National Survey of Care Workers: Final Report. 41

49 Section 3: The Evidence Base: Recruiting & Retaining women who want to combine part-time paid employment with other family or caring responsibilities. The gendered nature of the work has, in turn, made it hard to attract men to work in the sector. The main explanation for the reluctance found among many men to seek employment in this field centres upon the perception that it is gendered work associated with women While traditional occupations for men have declined, this has not generally been accompanied by a move by men into areas such as social care. A further explanation for this situation is that the gender pay gap means that occupations in which women predominate tend to be paid less, so average earnings in social care are less for both men and women Despite all of this, there is evidence of growing male recruitment into the sector currently at around 18% of the workforce compared with 12% in the early 1990s. The last big proportionate increase in the male component of the social care labour force occurred in the early 1990s, the last time the economy was in recession. It may well be that more men will be interested in working in the sector over the next two years as the current recession begins to bite. The position in teaching is apposite. Here the Training and Development Agency for Schools has recently reported an increase of 10% in applications for teacher training and web enquiries up by 45%. However, the most recent UCAS figures show an increase of only 0.7% for the social work degree compared with an increase of 15.8% for the nursing degree. One explanation for this may well be the media vilification of social workers during the Baby P case coverage Notwithstanding the high vacancy and turnover rates there is some evidence of a relatively high degree of job satisfaction. The national survey of care workers undertaken for Skills for Care in showed that 88% of care workers said they were either happy or very happy in their work, and that 64% expected to stay in this work for the next five years. Similarly the survey of PAs by IFF Research (2008, op cit) reported that the vast majority of PAs are happy in their current role, and generally happy to be flexible in terms of working overtime and on an overnight basis. 85 Moriarty, J et al (2008), Staff Shortages and Immigration in the Social Care Sector. Web published by the Migration Advisory Committee. 86 Skills for Care (2007), National Survey of Care Workers: Final Report. 42

50 Section 3: The Evidence Base: Recruiting & Retaining The Growing Demand for Social Care 3.40 Whatever the issues on the supply side, there is general acknowledgement that the demand for social care support will grow. The demographic imperatives are well-known: by 2036 the number of people over 85 will rise from 1.055m to 2.959m by 2025 there will be 42% more people in England aged over 65 the number of people with a long-term condition will rise by 3m to 18m the number of people with dementia (currently around 600,000) is expected to double in the next 30 years the number of people over 50 with learning disabilities is projected to rise by 53% by In the case of older people, Wittenberg et al 87 have estimated that to keep pace with demographic pressures over the next 50 years in the UK, residential and nursing home places need to expand by around 150 per cent, and numbers of hours of home care by around 140 per cent. Other work also undertaken by the Personal Social Service Research Unit on behalf of Skills for Care (Eborall and Griffiths 2008, op cit) has estimated that by 2025 the size of the workforce required is projected to increase to between million workers, compared with the current figure of around 1.4 million. This range was based on three different assumptions: the base case (broadly the status quo), maximising choice (an increase in direct payments for all those who wish to receive them) and reining in (reduced access to care and greater use of family care and self funding). This work has highlighted that the key issue in terms of assessing current and future demand for care workers has to include both long and short term planning One important way in which some social care employers have bridged the gap between demand and supply has been the use of migrant labour, particularly in using staff from Eastern Europe. Moriarty et al (op cit) calculate that 17% of staff employed in the independent sector and 11 percent of all whole time equivalents staff employed by local councils in England are from a minority ethnic group compared with eight percent in the population as a whole. Regional differences are pronounced - in London, 68% of care 87 Wittenberg R, Pickard L, Malley J, King D, Comas-Herrera A, Darton R (2008) Future Demand for Social Care, 2005 To 2041: Projections of Demand for Social Care for Older People in England, Report to the Strategy Unit (Cabinet Office) and the Department of Health, PSSRU Discussion Paper 2514, Personal Social Services Research Unit, London. 43

51 Section 3: The Evidence Base: Recruiting & Retaining assistants were born abroad, whilst at the other extreme, in the North East and Wales fewer than six percent of care assistants were born abroad In 2008 the Migration Advisory Committee (MAC) decided not to include social care on the list of shortage occupations to be exempted from immigration restrictions which would prevent non-eu care workers taking up permanent jobs in the UK. Following strong representations from the care sector to the Home Office, this decision has now been partially overturned. The Home Office has asked MAC to review fresh evidence on the matter and report back by March 2009, but controversially it has accepted MACs recommendation to limit shortage status to posts paying 8.80 an hour or above. As has been seen earlier in this report, this would exclude almost all of the current adult social care direct provision workforce. Recently the Care Services Minister has asked Skills for Care to produce a workforce plan to help local authorities determine the number of social workers they need, and work with universities to ensure supply meets demand. 88 The announcement follows news that 23% of the 6000 graduates to register with the regulator in described themselves as unemployed in the GSCC s annual report. Initiatives and Programmes 3.44 There have been several initiatives of a general nature that have been applied to social care, notably those arising from the Leitch Review of Skills 89 which rested upon the assumption that investment in skills, learning and development enhances and sustains the quality of public services delivered to, and accessed by, service users. The Government accepted the ambition and recommendations of the Review, and subsequently introduced three main tools for achieving the Leitch targets on skills, literacy and numeracy Train to Gain, the Skills Pledge and Apprenticeships. The application of these measures to adult social care has been the subject of a recent report by Sue Milsome commissioned by the Cabinet Office Community Care, Feb 19 th 2009, p4. 89 HM Treasury (2006), Prosperity for All in the Global Economy world class skills (the Leitch Review) 90 Milsome, S (2008), Learning and Skills in Adult Social Care. Cabinet Office/LSC 44

52 Section 3: The Evidence Base: Recruiting & Retaining Train to Gain 3.45 Train to Gain (TTG) is the primary vehicle for demand-led funding of adult training the national skills service that supports employers of all sizes and in all sectors to improve the skills of their employees. Until 2008 it funded free training for those needing Basic Skills or without a Level 2 qualification, but since August 2008 there has been an assumed employer contribution of 42.5% for Level 3 qualifications. In the case of social care the number of learners embarking on TTG reached just over 50,000 in the 2007/8 academic year, mainly care workers but also including administrative and support workers, and Milsome reports high satisfaction with the training amongst front-line workers However, TTG is also reported to be problematic in some respects. Firstly funding goes to the training provider rather than the employer, and some employers would prefer to determine their own training requirements rather than be approached with an offer by a training provider. This is likely to be even more the case with individual employers using a direct payment/personal budget. Also funding is generally accessed by employers on a regional basis, but differences in the way regions allocate funding is causing complications for relatively small providers whose provision spans regional boundaries. Secondly, an advice service on training provision is provided through skills brokerage, but these brokers are generalists who may not sufficiently understand the adult social care sector. The proposal to introduce regional lead skills brokers for ASC this year may help here. The Skills Pledge 3.47 The Skills Pledge, launched in May 2007, is a public, voluntary commitment by an employer to support the skills of their staff employers making the Pledge are able to access Government support to deliver their commitment through the TTG service. Almost 700 social care employers have signed up to the Skills Pledge, mostly employers with between 50 and 250 staff only around 1.5% of all ASC providers. Milsome s research reports a sense that employers signing the Pledge are already committed to training, and that little is being done to reach those employers who need to do more. Some employers preferred to use Investors in People as a signal of their commitment and see the pressure to sign the Pledge as simply an unwelcome external pressure. 45

53 Section 3: The Evidence Base: Recruiting & Retaining Apprenticeships 3.48 Apprenticeships are available to people of all ages and are a mixture of work-based training and education. The content is defined by the relevant Sector Skills Council, generally lasts around a year, and leads to a Level 2 NVQ. An Advanced Apprenticeship lasts around two years and leads to a Level 3 NVQ. In January 2008 the Government published proposals to establish a National Apprenticeship Service to improve and expand the programme. Also in 2008 the Department of Health lifted the minimum age restriction of 18 which prevented employers taking on apprentices aged 16-18, meaning that care workers under 18 can now deliver personal care provided they have completed (or are undertaking) an Apprenticeship in ASC The Chancellor has announced in the 2009 Budget that under the new scheme, Care First, there will be 50,000 new traineeships with social care employers for suitable young people. Social care providers will receive a subsidy for offering sustained employment and training to young people who have been out of work for 12 months, giving them the skills and experience they need for a career in the sector. Up to 75 million will be made available. It has also recently been reported 91 that NHS Trusts are being urged to offer more apprenticeships to reduce unemployment levels, even though places have risen by 34% in the past year around half of all the apprenticeships that adults can apply for are said to be in health. The Darzi Next Stage review committed the NHS to doubling investment in apprenticeships by Milsome reports mixed views on Apprenticeships. A small minority of employers value them highly, but many do not know that ASC Apprenticeships exist. Others could not see the point of taking on an apprentice who will take a year to attain a Level 2 NVQ when someone employed in the normal way will get an NVQ in six months the pressure from regulators to meet National Minimum Training standards allied to the cost of backfill will only exacerbate the preference for this quicker route which bypasses college attendance. There are also problems in progressing to NVQ Level 3 with an Advanced Apprenticeship since funding is provisional upon the individual being in a post that involves Level 3 work. This makes a career pathway in a small or medium sized organisation more problematic, prompting employees to leave in order to make progress a further explanation of high staff turnover. 91 Health Service Journal, Feb 26 th 2009, p11 46

54 Section 3: The Evidence Base: Recruiting & Retaining The Qualification Credit Framework 3.51 In 2010 Skills for Care plans to launch the Qualification Credit Framework (QCF) to standardise the way credits are awarded for completed courses. Currently there is thought to be confusion, duplication and a lack of clarity about what qualifications should be undertaken some meet only part of the skills and knowledge needs, and there are some workers who feel current options do not meet their needs at all. The aim of the QCF is said to be to allow a flexible mix and match approach to meeting the different development needs of the workforce by assigning a credit value and a level to every unit and qualification in the framework. Under QCF it would, for example, be possible to take some aspects of NVQs and link them to some dementia knowledge units to create a single qualification for dementia services Under QCF, one credit represents ten hours of learning, therefore the credit value shows how much time it takes to complete. The level shows how difficult the unit of qualification is, and this can be anywhere between entry level and level 8. There will be three sizes of qualification in the QCF: Awards (1 to 12 credits), Certificates (13 to 36 credits) and Diplomas (37 credits or more). Thus it will be possible to have an Award at any level, from 1 to 8 because the qualification type represents the size of a qualification not how difficult it is. Each qualification will therefore have three components: the level of the qualification from entry level up to level 8; the size of qualification whether it is an award, certificate or diploma; details indicating the content of the qualification In respect of the personalisation agenda, the QCF could be viewed as an attempt to locate employer needs and worker skills and knowledge within a flexible framework that enables the development of a more customised approach. Conclusion 3.54 This review of the first R in our framework has shown the ASC workforce to be characterised by difficulties in both recruiting and retaining. This is important for the personalisation agenda, for progress will be continually hampered if there are insufficient workers with the right sort of commitment and training to meet the unique needs of individuals who require support. We have also seen that in some circumstances people are 47

55 Section 3: The Evidence Base: Recruiting & Retaining able to find their own solutions to these challenges. The various initiatives established in recent years have yet to demonstrate that they can address the underlying difficulties, especially those associated with gendered work and low pay One of the consequences of implementing Putting People First will be a further fragmentation of the employer base and the potential isolation of the workforce because of the expansion of people working as personal assistants. It is the task of a national ASC workforce strategy to ensure that this does not result in exploitation, poor quality care or a shortfall in numbers and workforce quality, while maximising the positive aspects of choice, control and flexibility that people who use services are able to experience by directly employing care staff. It is also vital that a workforce strategy addresses the issues that arise across the social care workforce in its entirety and does not assume that the challenges which confront people employing PAs can be left simply to individual resolution. 48

56 Section 4: The Evidence Base: Reinventing 4 Reinventing 4.1 In this section we focus largely (though not entirely) upon professional social work, for it is here that personalisation seems to imply a significant change of role a reinvention of professional purpose. There is considerable talk of professional social workers having the opportunity to return to their roots and doing real social work, though there is uncertainty as to what this entails and whether or not such an opportunity would be relished. Despite the assurance of the ASC Final Strategy (2009, op cit) that social work has a central role in delivering personalised services (para 63), the emergence of personalisation as a policy goal is raising fundamental questions about the nature and purpose of professional social work. The strategy itself does little to address these questions, preferring to await the proposals from the Social Work Taskforce. Concern (and even outright professional opposition) to the implications of personalisation for professional social work practice is already emerging. BASW 92 has expressed concerns that local authorities are reducing (or not increasing) the numbers of qualified social workers in adult services on the grounds of their expense; that new assessment paperwork is inadequate for the development of a robust care plan; that new processes are reinforcing a tick-box approach, especially when combined with quantitative targets around the speed and numbers of assessments; and that care management for people whose needs are not complex is shifting to unqualified staff. Indeed, the CEO of BASW has written to the Care Services Minister calling for explicit guidance on the role of social workers in delivering personalisation. The Ambiguous Role of Social Work 4.2 Pinning down the role and remit of social work has been problematic since the inception of the profession and this underlying uncertainty has, in turn, affected the shape of training and qualifications. In the post-war years - from Barbara Wootton s blistering critique in the 1950s 93 through the Marxist critiques of the 1970s 94, the Barclay Report of the 1980s and 92 Community Care, April 16 th 2009, p Wootton, B (1959), Social Science and Social Pathology. London: Allen & Unwin 94 Bailey, R and Brake, M (1976), Radical Social Work. London: Edward Arnold 49

57 Section 4: The Evidence Base: Reinventing current reviews (outlined below) - the role of social work has been a source of contention. Indeed, the judgement of the 1982 Barclay Report 95 still seems apposite: Too much is generally expected of social workers. We load upon them unrealistic expectations and we then complain when they do not live up to them. There is confusion about the direction in which they are going and unease about what they should be doing and the way in which they are organised and deployed. They operate uneasily on the frontier between what appear to be almost limitless needs on the one hand and an inadequate pool of resources to satisfy those needs on the other. (Barclay 1982 p.vii) 4.3 More recently In Options for Excellence (Department of Health/Department for Education and Skills 2006,op cit) it was stated that social work has a specific focus on: promoting people s ability to maximize their own capabilities and life options, including participation in education, training, employment, social and leisure activities; developing people s ability to form positive relationships within their family and their social network; helping people to create and maintain independence, and, when this is not possible, to benefit from alternative forms of support that protect their dignity, rights and choices; protecting people s human rights, and promoting the exercise of their rights and responsibilities as citizens. 4.4 Again, the recent review of the changing roles and tasks of social work for the GSCC by Blewett et al 96 refers to the impossibility of reaching one comprehensive, uncontested definition of social work. They suggest that on the basis of service user experiences, the key features of being a good social worker include: someone who sees the person in a holistic way, treats them with respect and listens to them; someone with the right personal qualities; 95 Barclay, P.M. (1982), Social Workers: Their role and tasks, London, Bedford Square Press. 96 Blewett, J, Lewis, J and Tunstill, J (2007), The Changing Roles and Tasks of Social Work. London: GSCC. 50

58 Section 4: The Evidence Base: Reinventing someone with the capacity to use their skills to empower others, rather than be paternalistic. 4.5 The subsequent statement on Social Work at its Best issued by the GSCC distinguished between roles (i.e. the broad purposes of social work and the outcomes it enables people to achieve), and the tasks (the activities required to deliver those outcomes). 97 The statement argued that the roles tend to be particular to social work, while the tasks may be carried out by social workers or shared with other social care staff and with other disciplines. The ASC Final Strategy (2009, op cit) also notes that in the new context, people want care and support that meets their needs; care and support which is empowering and not limiting. 4.6 In both of the most recent reviews the conceptualisation of the social work role and task would seem to be consistent with the tenets of personalisation. Indeed, the GSCC statement is clear that increasingly social workers will work in partnership with people to coproduce solutions, and to enable people to exercise choice and control. 98 What is less clear is how social workers are thinking and behaving in their daily encounters with colleagues, people who use services, and carers. A clearer understanding of the values underpinning routine practice is essential if the rhetoric of personalisation is to become a reality. The Basis of Decision-Making 4.7 The contested nature of the role and purpose of social work has left the basis for decisionmaking uncertain. Encounters between practitioners and service users do not take place in a cultural vacuum and, even where practitioners do not demonstrate an explicit value base, they will have some various and loosely organised understandings or meanings to guide them in exercising their judgement. This is critical to the success (or otherwise) of the personalisation imperative, for the basis upon which social workers make decisions will need to be consistent with the value-base of the new policy. A brief review of the limited evidence identifies a number of tensions between the dominant professional discourse and the emergent policy framework: 97 GSCC (2008), Social Work at Its Best. A statement of social work roles and tasks for the 21 st century. London: GSCC. 98 Ibid. P

59 Section 4: The Evidence Base: Reinventing The Professional-User Relationship 4.8 Social work has sought to use the process of developing a relationship between the practitioner and the user of services as a means of facilitating change and problem solving in people s lives. Traditionally, this therapeutic role has been seen as core to the profession 99, and closely linked with the idea of reflective practice but in the 1970s and 1980s it came under sustained critique from the radical social work school 100, particularly with the influential publication Case Con. However, in the late 1980s and early 1990s following the NHS and Community Care Act of 1990 there was a move to case (later care) management that appeared to minimise this core function, with the social worker becoming primarily the commissioner rather than the deliverer of services and support. 4.9 When first envisaged, care management was to be linked with the devolution of financial responsibility to care managers but this has not happened often in practice. In their review of evidence for the Wanless Report, Knapp 101 et al conclude that: It could reasonably be argued, therefore, that the model of care management seen in most parts of the UK today undeveloped, unsupported by information systems, without devolved budgets, overly bureaucratic, unresponsive to users preferences is of unproven effectiveness and cost-effectiveness This situation does not appear to have satisfied either people using social care services or many social workers. Research examining the impact on social workers ability to fulfil their key roles has often portrayed a demoralised and dissatisfied workforce trying to cope with implementing the ideals of community care in a practice context characterised by ambiguity, markets and conflicting demands In this milieu, professional judgement is felt to have been supplanted by regulations, procedures and guidelines 104, with staff concentrating on the minutiae of putting care services together, rather than seeing themselves, and the skills developed through training, as a resource. 99 Halmos, P. (1965) The Faith of the Counsellors, London, Constable. 100 Bailey, R. And Brake, M. (1976), Radical Social Work. London: Edward Arnold. 101 Knapp,M, Fernande z, J, Kendall, J, Beecham, J, Northey S and Richardson, A (2005) Developing social care: the current position London SCIE. 102 Sullivan, M.P (2008), Social Workers in Community Care Practice: Ideologies and Interactions with Older People. British Journal of Social Work Advance Access. 103 McDonald, A et al (2008), Barriers to Retaining and Using Professional Knowledge in Local Authority Social Work Practice with Adults in the UK. British Journal of Social Work, 38, pp Harris, J (2003), The Social Work Business. London: Routledge. 52

60 Section 4: The Evidence Base: Reinventing 4.11 The most recent survey by Community Care of 450 social workers 105 generally reinforces this picture. It finds social workers lacking in supervision, support from employers, time for reflection or up-to-date reliable information to make decisions based on sound evidence. The GSCC code of practice for employers requires effective supervision as well as training and development opportunities, but the code is currently voluntary (unlike the code for employees). Lord Laming s recent Progress Report (op cit) has proposed putting the code on a mandatory footing (a development which the GSCC has also sought), and it is widely expected that the Social Work Task Force will produce guidelines on guaranteed supervision time for social workers. The Government s response to the Laming report (published in May 2009) indicated that the DCSF and DH will support GSCC in reviewing the Code of Practice for Employers and will seek to legislate appropriately at the earliest opportunity For McDonald et al (2008, op cit) this context raises barriers to the retention and use of professional knowledge at three levels, each of which would need to change radically in the light of the new personalisation paradigm: at a structural level, where a rigid hierarchical system does not encourage the use of practitioner knowledge; at management level, where practitioners experience supervision that concentrates on workload management rather than professional issues and dilemmas; at practitioner level, where staff struggle with gaps in their knowledge and work defensively and procedurally, rather than proactively and creatively. Balancing Risk and Protection 4.13 In an early text in the 1950s, Florence Hollis 107, then a doyen of social work education, stated that: the right to self-direction is never an absolute...the caseworker must decide when the principle of self-determination is superseded by the necessity for protection or direction (p46). Decisions on where (and how) to draw the line between risk and protection are as contentious now as when Hollis was writing, but the development of personalisation 105 Community Care, April 23 rd, HM Government (2009), The protection of children in England: action plan. The Government s response to Lord Laming, 107 Hollis, F (1955), Principles and Assumptions Underlying Casework Practice. Social Work. London. 53

61 Section 4: The Evidence Base: Reinventing as a policy goal has brought the issue into ever sharper relief, and few social workers today would describe the dichotomy in quite such stark terms as Hollis The profile of the safeguarding adults agenda has increased greatly in recent years. The 2000 No Secrets guidance 108 created a framework for multi-agency action in response to the risk of abuse or harm, with local authority social services tasked with playing a lead role. It listed the main forms of abuse and the main responsible and relevant agencies, together with mechanisms for monitoring, review and accountability. Subsequent adult protection policy, such as the 2006 Safeguarding Vulnerable Groups Act, broadened the notion of vulnerability to cover all disabled people, making it more likely that they may be perceived as unable to manage their own risks. 109 All of this is likely to have increased the likelihood of defensive social work which minimises risk-taking situations The Protection of Vulnerable Adults (POVA) scheme introduced the POVA list whereby employers of social care staff have been required to refer workers dismissed for misconduct that harmed vulnerable adults, or placed them at risk of harm, to the POVA list. Since July 2004 there has been a statutory requirement on providers of care to check whether a person is included on the POVA list before they offer them employment in a care position in a care home, providing personal care in people s own homes, or caring for a person in an adult placement. 110 From January 2009 the Independent Safeguarding Authority (ISA) replaces POVA, POCA (the equivalent list in children s protection) and List 99 (a list of people barred by the Secretary of State from working with children in education). A barring decision by the ISA will have the same effect as POVA listing Alongside this, however, there are now fresh expectations around the balance between risk, choice and user empowerment with the publication of new guidelines from the Department of Health on best practice in supported decision making. 111 The governing principle behind the guidance is said to be that people have the right to live their lives to the full as long as that doesn t stop others from doing the same (p12). To put this principle into practice, it is said that those supporting people who use services have to: 108 Department of Health/Home Office (2000), No Secrets: Guidance on developing and implementing multiagency policies and procedures to protect vulnerable adults from abuse. 109 Stevens, M et al (2008), Making Decisions about Who Should be Barred from Working with Adults in Vulnerable Situations: The Need for Social Work Understanding. British Journal of Social Work Advance Access, October. 110 Department of Health (2006), Protection of Vulnerable Adults Scheme in England and Wales for adult placement schemes, domiciliary care agencies and care homes. A practical guide. London. 111 Department of Health (2007), Independence, choice and risk: a guide to best practice in supported decision-making. 54

62 Section 4: The Evidence Base: Reinventing help people to have choice and control over their lives; recognise that making a choice can involve some risk; respect people s rights and those of their family carers; help people understand their responsibilities and the implications of their choices, including any risks; acknowledge that there will always be some risk, and that trying to remove it altogether can outweigh the quality of life benefits for the person Whilst this is all consistent with the new personalisation agenda, it also sets up some major tensions with the protection agenda, and already there is evidence of tension between user-led organisations and professional social workers. Some disabled people maintain that as the purpose of self-directed support is to put the service user in control, that person should therefore have the right to choose what safeguards they want in place without having requirements externally imposed. Not all practitioners feel comfortable with this position. The recent CSCI study on safeguarding adults 112, for example, reported that: Some council staff expressed concern about the ease with which people using Direct Payments could become targets for intentional abuse...they feared that if employment checks are voluntary, people with criminal records may be able to persuade the person employing them that checks are not necessary. There is also concern that the increasing number of people having Individual Budgets or Direct Payments managed by family members could leave some people open to financial abuse. (p32) 4.18 This evidence is replicated in the national evaluation of the Individual Budget pilots (known as the IBSEN study) 113 which reports widespread concern amongst professional staff about financial and individual risks for IB users, though whether such apprehension is justified is not clear. Front-line staff voiced concerns about poorer quality services, misuse of resources, financial abuse, neglect and harm; about the level of responsibility that should sit with vulnerable adults; and about the lack of Criminal Records Bureau checks on people employed by IB holders. Although there was little evidence of the actual incidence of 112 CSCI (2008), Safeguarding Adults: A study of the effectiveness of arrangements to safeguard adults from abuse. 113 Caroline Glendinning., David Challis., José-Luis Fernández., Sally Jacobs., Karen Jones., Martin Knapp., Jill Manthorpe., Nicola Moran., Ann Netten., Martin Stevens., Mark Wilberforce (2008), Evaluation of the Individual Budgets Pilot Programme Final Report, University of York. 55

63 Section 4: The Evidence Base: Reinventing increased risk, it is possible that these concerns may have inhibited creativity on the part of front-line staff (p.249) 4.19 Work undertaken for CSIP also found social workers expressing concerns about the balance between self-direction and the council s duty of care; a balance of risk and freedom which for many respondents was a matter of considerable concern and uncertainty. 114 While research for exploring personalisation for people with multiple and complex needs similarly highlighted issues around balancing choice, control and safety In all the fieldwork councils people drew attention to the risks that can arise when people using I employ personal assistants who they may not know, who are currently unregulated, who may not have CRB checks, and who are accepted on face value. As this independent advocate remarked: I have very real concerns about (...) rushing headlong into personalisation (...) I think it s a solution for some people but, in the case of people with complex needs, personalisation often means placing responsibility in the hands of another organisation or individuals who may or may not have the individual s best interests at heart, and what safeguards are there for that? Social workers are therefore left with the difficult task of balancing their role in implementing personalised approaches with a duty to minimise harm and maximise protection. The current balance of evidence suggests that many will err on the side of caution, but the ASC Final Strategy (2009, op cit) states that leaders should be developing a service user led culture in the workforce that is risk aware and not risk averse promoting independence, understanding, interdependence and not simply managing risk. This, it is said, will be a challenging but necessary task to make service transformation a reality. Assessment and Rationing 4.22 Assessment has always been at the heart of social work. The Single Assessment Process (SAP) introduced in April 2004 aimed to achieve an approach to assessment that is personcentred, standardised and outcome-centred, but it is not clear how these objectives will be 114 Henwood M and Hudson B (2007), Here to Stay? Self-directed support: Aspiration and Implementation, London: CSIP. 115 Henwood M and Hudson B (2009), Keeping it personal: Supporting people with multiple and complex needs. A report to the Commission for Social Care Inspection, London: CSCI. 56

64 Section 4: The Evidence Base: Reinventing achieved, or how a social worker can exercise the skill to achieve them when using a standard assessment tool. The current consultation to establish a new Common Assessment Framework (CAF) 116 again is characterised by calls for a person-centred approach, the key principles of which are stated as: encouraging those who can and wish to undertake an assessment of their own needs (a self-assessment) to do so with support as necessary; if a more formal professional approach is appropriate, involving people fully in the process; identifying and agreeing on risks associated with any care and support plan; involving close family members and carers where appropriate; focusing on a person s capacities and things that are important to them This is all highly consistent with the principles of Putting People First, but research studies consistently identify the countervailing impact of organisational rationing policy in focusing assessments. Research undertaken for CSCI on Fair Access to Care (FACS) highlighted the poor quality of life for many people who seek support from social care but are deemed ineligible by local eligibility criteria. 118 A subsequent review commissioned from CSCI by the Department of Health highlighted tensions between the implementation of FACS and new approaches to prevention and personalisation. 119 Indeed, written evidence submitted to the CSCI review identified this tension, as the following examples illustrate: The structure is incompatible with the personalisation agenda and increasing choice and control in that it is wholly based on the notion of professionally led assessment, care planning and service provision. [Council] The principle of fair allocation of funding based on equivalent levels of need is partly at odds with the philosophy of personalisation, which allows for variations in responses tailored to people s individual circumstances. [SCIE] Department of Health (2009), Common Assessment Framework for Adults London: The Stationery Office. 117 Department of Health (2009), Op Cit, Para Henwood M and Hudson B (2008), Lost to the system? The impact of Fair Access to Care: A report commissioned by CSCI for the production of The state of social care in England London: CSCI. 119 CSCI (2008), Cutting the cake fairly. CSCI review of eligibility criteria for social care, London: CSCI. 120 CSCI (2008), Op Cit, para

65 Section 4: The Evidence Base: Reinventing 4.24 The CSCI review accepted the inescapable need to ration public resources and proposed replacing the FACS criteria with a model based on priorities for intervention. This approach would also offer some level of universal assistance and advice to everyone seeking care and support. The proposals were intended to offer a way for councils to ensure that support goes to people who need it while addressing the confusion in the current system between assessment of needs and the allocation of public funding for ongoing care and support Although the personalisation agenda seems to be proposing a radical shift with the emphasis (in the In Control model) on self-assessment, there is evidence of professional reservation and organisational resistance to this model. The IBSEN study (op cit) notes some caution in many of the pilot sites, with several stating that they were running IB assessments in parallel with traditional community care assessments for new referrals. Part of the reason for this was explicitly to uphold the skill and professionalism of social workers, which they felt was at risk of being eroded with the introduction of self or assisted self-assessments (p146). Even where self-assessment had been introduced, most of the sites also incorporated an element of support or checking by care managers, with most IB Lead Officers feeling that professional assessment was necessary in addition to selfassessment Similar findings were reported in the study for CSCI on personalisation and complex needs; care managers did not generally see self-assessment removing the need for professional support. On occasions this meant more meetings than with traditional assessment, and although care managers were generally supportive of the model they emphasised that it could be very time consuming. 122 The study also found care managers expressing concerns that self-assessment would be inadequate and that people using services would underestimate the nature and complexity of their needs. The approach to assessment is clearly undergoing change and many care managers indicated that while there was a move towards self-assessment, the full transition would take some time to achieve, for example: It will take five or six years. The first step will be care management by another name because a lot of people will say oh I m happy with the way you are doing it. But gradually it will change CSCI (2008), Op Cit, para Henwood and Hudson (2009), Op Cit, p Henwood and Hudson (2009), Op Cit, P.67 58

66 Section 4: The Evidence Base: Reinventing 4.27 The evidence from Sullivan s research (op cit) is that social workers have themselves internalised their gatekeeping role and see eligibility criteria as necessary to guarantee objective assessments and subsequent resource allocation. Organised (or even loosely organised) ideological principles as a premise for best practice were rarely evident in her study. She argues that her findings demonstrate how readily a new form of practice wisdom can become established as part of the worker s repertoire of understandings. She notes how this is introduced to people using services during initial short assessment visits and how it effectively blocks the client from introducing his/her own frames. Even more disturbingly, Sullivan found that preferential treatment was accorded those older clients who showed gratitude, whereas those deemed less compliant or grateful were given a lower priority This paternalistic model of care is the precise opposite of what the Government is anticipating with its personalisation agenda. The interesting question is why these barriers exist and persist in staff that have been educated (some quite recently) to use professional knowledge and skills. McDonald et al (op cit) resist the simplistic view that practitioners forget or wilfully ignore everything they have learned. Rather they conclude that instead of relying upon their knowledge, practitioners become fearful of blame for their actions and accordingly dependent upon a raft of procedures and routines. In effect they conclude that staff have become institutionally captured by the dominant bureaucratic-rationing paradigm What is also clear is that whatever assessment mode is used, there will still be a need for a gatekeeping role to ensure some compatibility between assessed need and available resources. The introduction of self-assessment and the Resource Allocation System (RAS) will not change this situation, and the IBSEN study shows some of the ways in which councils are attempting to deal with this task - in the majority of cases a panel of senior managers was involved in either determining or signing-off the indicative budget. A key question for the future is whether social workers will continue to be part of this rationing process or whether they will take on new and external roles that explicitly focus upon people s needs rather than organisational constraints a brokering or care navigator role. Reinvention: Brokerage and Care Navigating 4.30 When the Interim Workforce Strategy refers to some need for radical change in the social work profession, it is likely that this is a reference to the new focus on brokerage, which is widely seen as vital for ensuring that individual budgets work effectively for those who 59

67 Section 4: The Evidence Base: Reinventing receive them. The broad idea is far from new. In 1959, Wootton (op cit), saw just such a role as suitable for social work in the modern complicated world. She noted that: The range of needs for which services now provide, and the complexity of relevant rules and regulations have become so great that the social worker who has mastered these intricacies...and who can mobilize these facilities intelligently and efficiently to suit the requirements of particular individuals, is both skilled and honourable...she is as essential to the functioning of a welfare state as is lubrication to the running of an engine. Without her the machinery would seize up. (P 296-7) 4.31 Official interest in a more sophisticated version of this idea can be traced back to the 2005 Green Paper on adult social care 124 which talked about the introduction of a care navigator/broker model where a care broker is someone who might help the individual formulate the care plan, negotiate funding and help organise and monitor services (p36). Subsequent official publications have been more blunt, with the Transforming Social Care circular (Department of Health 2008, op cit) stating that: The role of social workers will be focused on advocacy and brokerage rather than assessment and gatekeeping. (p4) All of this rests upon the assumption of a consensus on the nature of brokerage and the way in which it will be organised; neither assumption currently holds. The most substantial official account of brokerage is that produced as part of the Putting People First Personalisation Toolkit 125 which states that the concept is best understood by its features: a clear value base that promotes self-determination and social inclusion; an aim to identify barriers to social inclusion and put in place responses which tackle these barriers; independent of making decisions about funding in the resource allocation process; the person for whom brokerage is provided makes the decision (with assistance if necessary) about how the resources are used; provision of information about the range of options, and in a format suited to the person concerned The consultation paper on the Common Assessment Framework (Department of Health 2009, op cit) seems to suggest a similar sort of role where it promotes the notion of care 124 Department of Health (2005), Independence, Wellbeing and Choice: Our Vision for the Future of Social Care for Adults in England. 125 Department of Health (2008), Good Practice in Support Planning and Brokerage. 60

68 Section 4: The Evidence Base: Reinventing coordination a named contactable person for those with more complex needs. The role would include coordinating the assessment or self-assessment processes and the development and management of a care and support plan and any associated risks (p11). However, the paper is agnostic about who might undertake such a role, and acknowledges that some people might be willing and able to coordinate their own support, with adequate training and assistance (p12) While some of this is familiar social work territory, the key dilemma is the suggestion that brokerage is divorced from decisions about funding, which raises the issue of whether it is appropriate for a broker to be employed by a local authority. The Toolkit is ambivalent (even evasive) on this point: Whilst the obvious lack of independence from the statutory sector can create a conflict of interest, if people are aware of any potential conflict of interest, it does not need to become a barrier to the provision of effective brokerage support. (p35) 4.35 The GSCC, on the other hand, seems to assume that professional social workers will indeed be undertaking the new role and the task is to ensure they are equipped to do so: We agree that social workers should be freed up to spend less time on assessment and care management and more time on support, brokerage and advocacy activities, for which their skills, knowledge and values make them ideally fitted. (GSCC 2008) In the meantime the recent Valuing People Now strategy on learning disability 127 states that DH will develop and test a support broker role as a lead professional for adults with moderate to severe learning disabilities the role will be introduced in a number of areas from September 2008 and evaluated through to (p92). In reality there is much uncertainty about what this change will mean in practice the view expressed in a 2006 CSCI discussion paper 128 is still valid: It is not yet clear where brokers will come from, who will recruit, train and pay them (and on what basis), whether they will be self-employed or employed by a service provider or by the council, or whether the brokerage function will be operated by social care professionals. 126 GSCC (2008), The GSCC Response to Putting People First Working to Make it Happen 127 Department of Health (2009), Valuing People Now: A New Three Year Strategy for People with Learning Disabilities. 128 CSCI (2006), Support Brokerage: A Discussion Paper. 61

69 Section 4: The Evidence Base: Reinventing 4.37 In a very useful analysis of the issue Scourfield 129 emphasises the notion of a dual mandate in social work that whilst there is accountability to the individual, there is also accountability to the employing organisation and the laws and policies that guide it. For some advocates of support brokerage (and especially those in user-led disability organisations) there is a belief that for support brokerage to work effectively the broker must be solely accountable to the individual for whom they work. Such a stance leaves the current role of registered professional social work in some doubt, even though the current political discourse portrays brokerage as an opportunity for social workers to throw off the procedural burdens of care management and return to their professional roots Debate about brokerage roles has been further confused by ideological positions. For example, the early position adopted by In Control was that it was preferable for people using self-directed support to be responsible for developing their plans and organising the support they required with help from friends and family where necessary. The idea of outside support including from paid staff or brokers was one of last resort. The National Development Team has followed an approach to brokerage which defines it more narrowly than many others would be comfortable with, emphasising that the role must be independent, non-professional and offered as a paid service It is far from clear how all of this will work out in practice, and this makes strategic workforce planning very difficult. The evidence from the IBSEN study is that care managers usually take on the role of supporting people on the use of their Individual Budget, with independent brokers identified in only a minority of cases, but this may change in the future. Most people using services were reported to be satisfied with this arrangement, but social workers themselves were split some saw it as an opportunity to rekindle traditional social work skills, others felt it was a further erosion of professional social work. A review on selfdirected support undertaken for the Department of Health in 2007 found a similar split of views, but with differences reflecting how recently or otherwise social workers had qualified. Those with long experience of the profession were more likely to see the virtue of a brokerage and support role that would resemble traditional social work activity, whereas more recently qualified social workers who had known nothing other than the care management process would find it harder to adapt Scourfield, P (2008), Going for Brokerage: A Task of Independent Support or Social Work? British Journal of Social Work, Advance Access, October. 130 Dowson S (2008), Choice and Control: The training and accreditation of independent support brokers, National Development Team. 131 Henwood M and Hudson B (2007), Op Cit, P

70 Section 4: The Evidence Base: Reinventing Other Occupational Groups 4.40 Although this section concentrates upon social work, there are other groups of workers who may need to reinvent their role, and other instances in which new occupational groupings emerge. Occupational Therapy 4.41 Occupational therapy (OT) is the largest Allied Health Professions group employed in social care and has a key role to play in enabling and supporting independent living. The number of OTs in social care services as a whole rose from 1520 in 1998 to around 1990 in Although these numbers are small (accounting for only 2% of the ASC workforce), OTs are estimated to deal with around 35% of the referrals for ASC services. In 2007 the Department of Health commissioned the College of Occupational Therapists to review the role of OTs in the light of the Options for Excellence, and the study was published last year OTs have traditionally been employed by local authorities to meet specific legislative requirements (notably the Chronically Sick and Disabled Persons Act and recommendations for Disabled Facilities Grant) rather than to contribute to the broader social care agenda. The review acknowledges that the profession will need to diversify and develop new roles in the light of Putting People First, and calls for a career structure that supports multi-professional working, professional leadership and equal opportunities for progression into strategic management posts in ASC services. Opening up career opportunities in this way is also seen as a way of tackling the recruitment problems in ASC/OT a vacancy rate of 10.3% was established by the 2006 ASC workforce survey. New Types of Worker (NTOW) 4.43 Pinning down the concept of a NTOW is not simple. At a broad level it has been described as: 132 Department of Health (2008), Occupational Therapy in Adult Social Care in England. 63

71 Section 4: The Evidence Base: Reinventing Any change to the way social care services are provided (or planned, commissioned or monitored) that aims to improve the lives of people using those services but is not yet available to everyone or recognised as a mainstream job, role or service 133 The NTOW concept might usefully be distinguished from two alternatives - skill substitution, where one type of worker takes on some of the roles typically undertaken by others, and role extension where existing practitioners undertake a wider range of tasks than normal All nine regions of Skills for Care are undertaking mapping projects on NTOWs and the intention is that these projects will be synthesised into a national summary report. Currently only one region (Eastern) seems to have published an evaluation (Faife, op cit), but there is a more substantial earlier national evaluation of the first phase of the NTOW programme covering the years by Kessler and Bach. 134 The latter study identified four types of new roles: coordinators, organising activities and networks among staff and people who use services; specialists, focusing in a dedicated way on a particular activity or services group; boundary spanners, working across organisations or client groups; people who use services performing the role themselves likely to be a growing category since the publication of the evaluation This national evaluation did indeed find evidence of new roles based upon newly generated or created activities, as opposed to a simple re-labelling of traditional jobs or a re-packaging of existing tasks. Moreover, these roles were seen as contributing positively to different stakeholder outcomes. Nevertheless three recurring difficulties are also identified. First, the importance of funding to secure change - both evaluations note that any such re-invention is more likely in the statutory (than the voluntary) sector, probably because local authorities have specific funding and greater capacity to apply for it. However these funding streams do tend to be complex and fragile, raising the dilemma of longer term sustainability A second factor is the iterative nature of change. The NTOW projects often unfolded in unpredictable ways that required more flexibility than funders were always willing to allow. Kessler and Bach particularly note: 133 Thomas, J, quoted in Faife, D (2007), New Types of Worker and New Ways of Working: Mapping Project. Skills for Care, Eastern Region. 134 Kessler, I and Bach, S (2007), New Types of Worker Stage 1 Evaluation Report. Skills for Care. 64

72 Section 4: The Evidence Base: Reinventing the difficulties faced in recruiting people to new roles that require an unusual combination of skills and competences; the administrative responsibilities placed on the post-holder; the shifts in emphasis as the role unfolds; the responses of other internal and external stakeholders; the loss of key personnel at crucial times Finally there is still little evidence of substantial workforce reinvention. Kessler and Bach note that in the main the roles they identified involved, at best, a handful of employees and more typically a single post holder. This is not to detract from the importance of these new roles to the delivery of improved services, but it is to highlight the modest nature of the changes in workforce structure fostered by the programme. 135 However, their research is now a little dated and the picture may look different in In the children s services field there is the interesting example of social pedagogy, which is to be the subject of a three year pilot in thirty residential care homes in England. The role of social pedagogues is commonplace across Europe and they undertake a role that can traverse social care, education and health. The distinctive features of the role are the enduring relationships built up with the children and young people with whom they work (extending well into young adulthood), the advocacy role and the direct hands on work. Although the Government pilot is focusing on residential care, the role in Europe is used across all children s services. The Children, Schools and Families Select Committee inquiry into Looked after Children welcomed the Government s pilot plans but urged broad and creative consideration of the model of social pedagogy across the whole care system, rather than looking to import wholesale a separate new profession. 136 Conclusion: The Implications for Workforce Development 4.49 The broad implications of personalisation for workforce development strategies can be usefully teased out from the IBSEN study (Glendinning et al, 2008 op cit) and include: 135 Kessler and Bach (2007), Op Cit, P House of Commons Children,Schools and Families Committee (2009), Looked-after Children, Third Report of Session , HC 111-1, London: The Stationery Office. Para

73 Section 4: The Evidence Base: Reinventing The Need for an Adequate Training Budget: The budgets for IB-related training in the pilot sites were small, and often considered to be insufficient. Whilst a small budget might be acceptable for a pilot programme, it is not appropriate for a programme of transformational change as is now envisaged with Putting People First. The Need to Reshape Existing Training: The new personalisation agenda has to be urgently reflected in existing training opportunities. In the later stages of the IBSEN study it was noted that IB issues were beginning to be integrated into mainstream workforce development work, including NVQ awards, the social work degree and (in one case) PQ arrangements. The Need to Engage Users and Carers: Personalisation will fail if users and carers do not comprehend the new possibilities it can offer. Encouragingly the IBSEN study found that training and communication activities aimed at service users were afforded nearly the same priority as those for staff. The Need to Engage Professional Staff: There was recognition in the IBSEN sites that front-line staff may see IBs as a threat and that steps had to be taken to avoid alienation. It is not evident that this was done successfully. Many staff were said to strongly feel that they were working with users before they fully understood IBs themselves. The important task here is to involve staff in developing the assessment and support planning tools in order to improve their understanding and generate ownership. The IBSEN study also notes that team managers were struggling with the new ideas and processes as much as front-line staff, and this limited the value of staff supervision This section has concentrated upon professional social work and has highlighted issues of culture rather than structure. Social work has already been through several reinventions since its inception in the nineteenth century, the most recent of which the bureaucraticrationing paradigm is at odds with the emerging personalisation paradigm. It is far from clear whether professional social work will be receptive to the new paradigm, not least because the implications for the workforce are still so unclear, and particularly when the distinctive contribution of social work in the new paradigm is as yet poorly defined or articulated. The fact that the profession has already reinvented itself several times in its relatively short history demonstrates that cultural change is indeed possible, but this needs to go hand in hand with the structural change that is already developing. Moreover, the emergence of personalisation is only one of the drivers that are currently influencing the 66

74 Section 4: The Evidence Base: Reinventing shape of social work. More negatively, the criticisms of the profession and public concern about apparent catastrophic failures can also be a potent force for change, but will not necessarily generate the most constructive or proactive model It is normal to find some tension between cultural and structural systems, and this is best encapsulated in the concepts of structural lag and cultural lag 137 Sometimes beliefs change quickly and structures remain in a traditional mode structural lag. At other times structure moves ahead and beliefs lag behind cultural lag. In the case of paradigmatic change (as for example with personalisation) then both have to be worked on, for changing structure without changing culture is as problematic as changing culture without changing structure. The transformational leadership task is to keep structure and culture in balance a complex reshaping role that is the focus of our next section. 137 Brinkman, R.L. & Brinkman, J.E. (1997) Cultural Lag: conception and theory International Journal of Social Economics, 24(6),

75 Section 5: The Evidence Base: Reshaping 5 Reshaping: the role of Leadership and Management Leading and Managing Transformational Change. 5.1 Lord Laming s Progress Report on child protection 138 states that: Effective leadership sets the direction of an organisation, its culture and value system, and ultimately drives the quality and effectiveness of the services provided. (Para 2.1) This is as true of adult social care as of children s services. The Final Strategy (2009, op cit) suggests that ASC leaders need to: look out to people who use services and their communities be skilled at collaboration across systems and boundaries work well within complex systems be developed at all levels in the organisation keep in direct contact with front-line services as their careers develop, 5.2 Change can be understood in relation to its extent and scope. Ackerman 139 has distinguished between three types of change: developmental, transitional and transformational. Developmental change may be either planned or emergent; it is first order, or incremental. It is change that enhances or corrects existing aspects of an organisation, often focusing on the improvement of a skill or process. Transitional change seeks to achieve a known desired state that is different from the existing one. It is episodic, planned and second order, or radical. Transformational change is radical or second order in nature. It requires a shift in assumptions made by the organisation and its members. 5.3 Transformation can result in an organisation that differs significantly in terms of structure, processes, culture and strategy. Putting People First is openly transformational in language and intent. The Transforming Social Care circular 140, for example, emphasises that: 138 Lord Laming (2009), The Protection of Children in England: A Progress Report. HC 330. London: The Stationery Office. 139 Ackerman, L. (1997), Development, Transition or Transformation: the question of change in organisations, in Van Eynde, D (Ed), Organisation Development Classics. San Francisco: Jossey Bass. 140 Department of Health (2008), Transforming Social Care. 68

76 Section 5: The Evidence Base: Reshaping Reforming social care to achieve personalisation will require a huge cultural change, transformational and transactional change...it is about whole system change not about change at the margins. 5.4 This view is reflected in the Interim and Final Workforce strategies which acknowledge that this vision demands new skills and competencies for commissioners, managers and senior leaders across social care - indeed, this is identified as a key strategic workforce priority (para 56). In broad terms, transforming leaders will be expected to create the conditions for others to transform realities, to galvanise innovators, and have the ability to inspire, communicate and operationalised the new vision. Such qualities have not necessarily been the basis for career development in the past many senior managers in local government and the NHS will have been promoted on the basis of financial and operational skills rather than for strategic vision. 5.5 Many of the approaches to organisational change found in the literature give the impression that change is (or can be) a rational, controlled, and orderly process. In practice, however, organisational change is chaotic, often involving shifting goals, discontinuous activities, surprising events, and unexpected combinations of changes and outcomes. Accordingly, change can best be understood in relation to the complex dynamic systems within which it takes place. In a useful contribution, Lowndes has articulated four propositions about management change in local governance 141 to show that change is not produced simply through new language and structures; rather it involves a reworking of what is considered appropriate behaviour. Her propositions are: 1. There is no one new management but different, potentially contradictory streams of ideas and practices: Narratives about change are frequently structured through sets of dualities and oppositions (such as centralisation v decentralisation) which imposes an artificial coherence on both old and new understandings, and overemphasises the discontinuity between old and new. This could certainly be an issue with personalisation where it is juxtaposed in a pure form with a simplistic understanding of pre-personalisation practice. 2. Individual organisations and service sectors respond differently to system-wide triggers for change: Internal power relations (and the role of leadership), service characteristics and locality effects all play a leading role in structuring responses to change. Lowndes reported that whilst legislation and resource availability were the 141 Lowndes, V (1997), We are learning to accommodate mess : Four propositions about management change in local governance. Public Policy and Administration, 12(2), pp

77 Section 5: The Evidence Base: Reshaping main drivers for change, the strength and style of leadership was highly significant. Locality-specific ways of doing things sometimes impacted subtly and informally upon perceptions of what was possible and impossible, desirable and undesirable. It certainly cannot be assumed that Putting People First will be implemented in a uniform and linear fashion. 3. Management change is non-linear, involving continuities between old and new approaches, movements forward and backwards, and change at different levels: There is a tendency to overestimate the discontinuity between old and new approaches, and to portray change as an event which can either succeed or fail. In reality, old management practices can be tenacious, leading to the implementation of new ideas in old ways, often undermining top-down prescription. Change cannot be achieved simply through introducing new languages and structures; rather it requires a networking of what is considered appropriate within the organisation. 4. Management change has political significance: Lowndes reported a common perception of members and officers occupying separate cultures, with the former being seen as conservative, out-of-touch and self-seeking. She found a widespread sense of crisis concerning the role of elected members, and a concern that power was being effectively transferred to officers operating in multi-agency partnerships. The shift of power to citizens (implied by the personalisation agenda) may be viewed as equally threatening, and suggests the need for a new politics alongside a new management in local governance. 5.6 Lownde s analysis illustrates that it is not enough for a few exceptional managers to become transforming, they also need supportive environments. Maddock 142 similarly contrasts the high political interest in getting immediate change, with the lack of debate on how to go about it. This, she argues, creates the delusion that public servants can be magicians who are able to conjure up transformation from someone s checklist. A danger with the personalisation movement is the notion that ideas alone rather than ideas aligned to relationships - will drive change. Organisations are driven by the sub-cultures of staff groups, managers, members, service users and other stakeholders, and they can be in or out of tune with policy ideas and edicts. In short, policy implementation is complex, and the more profound the policy change, the greater the complexity. 142 Maddock, S (2001), Modernisation: The Verdict. Manchester Business School. 70

78 Section 5: The Evidence Base: Reshaping 5.7 In a comprehensive review of the evidence on organisational change, Iles and Sutherland 143 suggest that where a change must be implemented from the outside, and when it has not been defined as necessary by the people involved, then it is unlikely to succeed unless at least some of those involved are in favour of it. Several observers have suggested that not everyone needs to support a change, and that not everybody needs to support it to the same extent. Senge, in The Fifth Discipline, talks of the difference between commitment, enrolment and compliance, suggesting that while it is more pleasant (and reassuring) to have considerable commitment, it is not necessary for everyone to be as fully signed-up as this Senge suggests that there are a number of positions along a continuum on which individuals and groups may position themselves in response to proposed action and change each is likely to apply in the case of personalisation. The Table below (taken from Iles and Sutherland, table 3) outlines Senge s analysis of the range of dispositions. He suggests analysing what level of support is required from each of the players and directing energy to achieve that, rather than trying to persuade everybody to commit. Table 5.1: Commitment, enrolment and compliance Disposition Commitment Enrolment Genuine compliance Formal compliance Players response to the change Want change to happen and will work to make it happen. Willing to create whatever structures, systems and frameworks are necessary for it to work. Want change to happen and will devote time and energy to making it happen within given frameworks. Act within the spirit of the frameworks. See the virtue in what is proposed, Do what is asked of them and think proactively about what is needed. Act Within the letter of the frameworks. Can describe the benefits of what is proposed and are not hostile to them. They do what they are asked but no more. 143 Iles, V and Sutherland, K (2001), Organisational Change: A review for health care managers, professionals and researchers. National Coordinating Centre for NHS Service Delivery and Organisation R & D. 144 Senge, P (1990), The Fifth Discipline: the art and practice of the learning organisation. London: Doubleday/Century Business. 71

79 Section 5: The Evidence Base: Reshaping Disposition Players response to the change Stick to the letter of the framework. Grudging compliance Non-compliance Apathy Do not accept there are benefits to what is proposed and do not go along with it. They do enough of what is asked of them not to jeopardise position. They voice opposition and hopes for failure. Interpret the letter of the framework. Do not accept that there are benefits and have nothing to lose by opposing the proposition. Will not do what is asked of them. Work outside framework. Neither in support of nor in opposition to the proposal, just serving time. Don't care about framework. 5.9 There are relatively few pieces of empirical research that test these ideas out in practice. An important exception is the study of strategic change by Pettigrew et al into the factors associated with the achievement of a higher rate of strategic service change by health care organisations 145. In this research, eight health care organisations were studied consisting of four matched pairs (organisations which faced a similar agenda but which exhibited different outcomes). In line with Lownde s findings, health care organisations were found to be more or less able to manage strategic change depending on the context in which they were operating. Eight interlinked factors served to differentiate the higher from the lower performers. 1. Quality and coherence of local policy. 2. Key people leading change. 3. Co-operative inter-organisational networks. 5. Supportive organisational culture, including the managerial subculture. 6. Environmental pressure, moderate, predictable and long-term. 7. Simplicity and clarity of goals and priorities. 8. Positive pattern of managerial and clinical relations. 145 Pettigrew, A., Ferlie, E. and McKee, L. (1992), Shaping Strategic Change. London: Sage. 72

80 Section 5: The Evidence Base: Reshaping 9. Fit between the change agenda and the locale - some locales were much more complex than others. Training opportunities in leadership and management 5.9 Given the importance of leaders and managers in securing transformational change, and given the complexity of the task, there is a need for some training and other support to be offered to those given the responsibility. Compared with the situation of care staff and social workers, relatively little attention seems to be paid to training and support for managers and leaders in social care. A number of current (and emerging) opportunities that focus specifically on adult social care can be identified: 5.10 Skills for Care: The Adult Social Care Manager Induction Standards were launched in October 2008 aimed at novice or experienced managers who are new in post in all adult care settings, alongside an updated version of the Statement on what leaders and managers in social care do SCIE Social Care Leadership Development Programme: This programme run by SCIE (Social Care Institute for Excellence) in conjunction with the King s Fund, Birmingham University and the Tavistock and Portman NHS Trust has now completed its fourth year. It is aimed at people already in senior management roles in adult social care across all sectors. The core content themes are leadership for social care outcomes; personal and organisational leadership; and community leadership. This is delivered through a range of activities including whole cohort events and individual coaching. The programme is funded by the Department of Health other than for accommodation and associated costs Skills Academy for Social Care Leadership Programme: The emergent Skills Academy aims to deliver five key products over the next three years 146 of which one will be a new Leadership Programme with three components: A new trainee scheme intended to have equal status with local government, central government and health schemes; the intention is to identify future leaders in any setting and give entrants a rounded experience of different types of employment. 146 Department of Health (2008), Towards a Skills Academy for Social Care. 73

81 Section 5: The Evidence Base: Reshaping Identification and, where appropriate, commissioning, providing or accrediting programmes to inspire and develop the supervision, management and leadership skills of all levels of the workforce. A specific programme at national level for the most senior managers in social care, including DASS s and those aspiring to the role These current opportunities for social care leaders seem quite limited compared with those available in the parallel domains of health and children s services. In the case of children s services there are several national programmes. The National College for School Leadership (NCSL) began in 2000 with an initial focus on head teachers all aspiring head teachers must now receive a qualification from the College (the National Professional Qualification for Headship) before they take up a headship. This is now to be extended to children s social care and the College is subject to wider consultation - to be renamed as the National College for School and Children s Leadership, to reflect this wider remit 147. In the wake of Baby P, the Children s Secretary, Ed Balls, immediately announced that Directors of Children s Services were to be sent on intensive training programmes to help them deal with complex child protection cases. The first group of 24 directors will start the course (to be run by the NCSL in conjunction with ADCS and CWDC) later this year, and it is likely to include a three-day residential summit. Directors will also receive individual training and support, as well as executive coaching The NCSL will also be training middle management to ensure that the next generation of children s services leaders is familiar with both education and social care the Children and Young People s Workforce Strategy 148.proposed a coherent offer of support for senior and middle managers across the workforce, including in the voluntary and community and private sectors. In November 2008 the NCSL and DCSF published a Consultation Paper on National Standards for School Leadership an exercise intended to be generic and applicable to all school leaders irrespective of phase, context and type of school. The draft standards are organised into five leadership areas: leading strategically; leading teaching and learning; leading the organisation; leading people; leading in the community. All of these are also areas that would be of interest and relevance to leaders in adult social care Other more specialised opportunities are also available in children s services. The National Professional Qualification in Integrated Centre Leadership, for example, is a recognised 147 Rt Hon Ed Balls (2009), Response to the Progress Report on the Protection of Children, 12 March. 148 DCSF (2008), Children and Young People s Workforce Strategy. 149 DCSF/NCSL (2008), The National Standards for School Leadership: Consultation Paper. 74

82 Section 5: The Evidence Base: Reshaping qualification (again from NCSL) for children s centre leaders in multi-agency environments. It is aimed at both experienced and emergent leaders of DCSF designated and approved children s centres, rather than strategic leaders. Children s services, then, are well served at generic, strategic and service level leadership and management training programmes A comparable development for NHS leaders is now planned in the wake of the Darzi Review 150 with the proposal to establish later this year a prestigious NHS Leadership Council. Specifically the Review stated: We will establish an NHS Leadership Council which will be a system- wide body chaired by the NHS Chief Executive, responsible for overseeing all matters of leadership across healthcare, including the top 250 leaders. It will have a particular focus on standards (including overseeing the new certification, the development of the right curricula, and assurance) and with a dedicated budget, will be able to commission development programmes. (Chapter 5, Para 37) 5.17 The purpose of the Leadership Council is said to be the transformation of leadership capability and capacity throughout the system and it will have roles in intelligence and evidence gathering, standard setting, the funding and strategic commissioning of leadership development programmes, and in assurance that leadership capacity and capability are improving. (p2). Interestingly a paper on the development of the Council from the Judge Business School 151 states that the Council should acknowledge from the outset the importance of integration with social care including its leadership development institutions A further option for senior managers in adult social care is the newly created Academy for Executive Leadership a programme for chief executives, directors and heads of services, to be delivered jointly by SOLACE and Ashridge Business School. This initiative has arisen from the identified need to go beyond familiar day-to-day leadership issues to explore the longer-term strategic, political and democratic matters that will shape the future of local government and local communities. The AEL will comprise two 3-day residential modules held at Ashridge plus a 24 hour residential Module 3 held elsewhere on a flexible basis The Service Delivery and Organisation (SDO) network an organisation normally associated with research funding in health and social care is now developing the Chief Executive (CEO) Forum. This will provide CEOs with the opportunity to access and reflect on the latest research being produced, whilst also supporting the application of this 150 Department of Health (2008), High Quality Care for All: NHS Next Stage Review. 151 Dawson, S et al (2009), The Design and Establishment of the Leadership Council. 75

83 Section 5: The Evidence Base: Reshaping knowledge to the challenges CEOs face. Again, however, the focus of the forum is to be the NHS, rather than a whole system approach that includes senior officers from ASC What all of this raises is the issue of whether adult social care should have its own version of NCSL and the Leadership Council, or whether it is simply bolted on to programmes primarily designed for other issues and interests. Much will depend here upon the Skills Academy for Social Care in its own right and acting in coordination with other programmes. The Leadership Council, for example, is keen to operate at the lowest level possible in terms of subsidiarity and coproduction and this may open the way for some collaboration at regional and sub-regional level between the Leadership Council, the Skills Academy, RIEPs and local commissioners and providers. Developing and Utilising Research 5.20 A further means of securing transformational change is to embed and utilise the relevant evidence base for workforce development the very raison d etre of this report. There are numerous research programmes underway, along with some opportunities for developing further exploration, and it would be wasteful and counter-productive if full use was not made of them. There are two main national research programmes on adult social care workforce development hosted by the Department of Health and Skills for Care respectively. The DH Social Care Workforce Research Initiative (SCWRI) 5.21 The SCWRI covers the years , so work is well underway. It has three principal aims: to improve understanding of the individual, organisational and wider socio-economic factors affecting recruitment, retention and quality in the social care workforce; to examine the impact of developments in the social care workforce on the quality of care provided to service users; to inform the future development of workforce-related strategies designed to achieve improvement in the outcomes of social care Nine projects have been funded, varying in length from six months to three years covering recruitment and retention (3), training, skills and qualifications (2), graduating in social work 76

84 Section 5: The Evidence Base: Reshaping (2) and new ways of working (2). A brief account of the nature of the funded programmes is shown below: 5.23 The Role and Significance of Agency Workers in the Social Care Workforce (King s College, London): The Government has committed (in Options for Excellence) to reducing reliance on temporary staff supplied through private employment agencies. Little is known about agency workers, and this study is focusing upon the perspectives of 75 temporary agency workers Recruitment and Retention of a Care Workforce for Older People (Manchester Business School): This project explores influences on the recruitment and retention of the social care workforce for vulnerable older people with the objective of identifying good practice in policy, commissioning and provider practices Skill Development and Capacity Issues (Birmingham Business School): This research examines how a range of agencies and interests contribute to the development of capacity in skill formation, and the extent to which the infrastructure for skills development overcomes fragmentation and competition between employers Skill Development and Regulatory Requirements (King s College London): The aim of this research is to investigate to what extent and how skill levels are being raised under the impact of the regulatory requirements for training in the social care sector The Readiness of Social Work Graduates (Sharpe Research): The main purpose of this study is to establish how well-prepared are social work graduates in England by their degree-level education for entering the professional workforce. Fieldwork is being undertaken on a two-stage basis and draws upon the perspectives of graduates and employers The Roles and Task of Support Workers (King s College London): This study is now complete and has been reported in our section on Reinvention Integrated Working: A UK Comparison (University of Edinburgh): This study looks at the different ways in which the integration agenda is being pursued across the different parts of the UK. It focuses especially on older people and people with mental health problems, and will draw out implications for the management, support and training requirements of the social care workforce. 77

85 Section 5: The Evidence Base: Reshaping Skills for Care National Research Projects 5.30 Reference has already been made in this report to a number of SfC research programmes and projects notably the development of NMDS-SC data, the 2007 National Survey of Care Workers, the 2008 exploration of the Workforce Implications of Direct Payments, and regional research into New Types of Worker. Other currently funded national work includes: 5.31 Rewards and Incentives Research (Manchester Met): The main objective here is to analyse the links between pay, other rewards and incentives, terms and conditions of employment, qualifications and other factors, and staff vacancy and turnover rates Demand and Supply in Leadership and Management (The McKinnon Partnership): This project aims to identify the current and likely future scale and nature of provision of leadership, management and commissioning training and qualifications across England in order to guide the establishment of the National Skills Academy for Social Care Future Demand for Social Workers (Diagnostic Decisions Ltd): At the request of DH, SfC is assessing the future demand for social workers. A further planned project aims to produce estimates of the numbers of social workers, newly qualified social workers and social work assistants councils in England will need over the next seven years based upon councils own estimates Adult Social Care Workforce Scoping Study (Kay Garmeson Market Research and Planning): This project is designed to supplement the statistical information published in the SfC Annual Workforce Reports with complementary qualitative and quantitative information about the workforce in England People Employing Their Own Care and Support Workers (not yet awarded): The aim here is to quantify the size of the privately purchased and personal budget holder home care market, and the size and nature of the workforce that is providing it In addition to this specialist research on workforce development, there is also a burgeoning literature on other aspects of personalisation, and leaders and managers need to be cognisant of this work. One new opportunity lies with the emergent National School for Social Care Research established under the auspices of the National Institute for Health Research, which will aim to increase the evidence-base for adult social care practice. The School will receive funding of 3m per annum for five years in the first instance and will aim to represent a centre of world-class research excellence. The focus will be primary research on the adult social care sector in England, covering the delivery of social care by 78

86 Section 5: The Evidence Base: Reshaping professional and non-professional staff working in both statutory and independent sectors. Importantly it will include research by social care professionals as well as academics, and encourage the active involvement of service users and their carers. This offers an opportunity to develop research and analytical skills beyond the traditional academic sector, and perhaps develop the role of practitioner-consultant The importance of research and evidence has already been recognised in the children s workforce strategy (DCSF, 2008, op cit) where there is a commitment to strengthen the evidence base to support implementation by establishing a knowledge bank about what workforce practice and interventions have an impact on children s outcomes, along with the development of a joint knowledge and research strategy to address gaps in the evidence base. (Para 5.5). Conclusion 5.38 This section has explored the workforce implication for leaders and managers of the personalisation agenda. It has noted the emphasis in policy rhetoric on transformational change and contrasted this with the complexity of moving organisations and their many sub-cultures from an old to a new paradigm. If personalisation is to succeed then it will need committed and effective leadership, but currently the training and support opportunities in adult social care are limited compared with the NHS and children s services. Change will also be more robust where it is evidence-based. There is a growing body of significant research into personalisation in general, and the workforce implications in particular, but the links between research, development and practice need further strengthening. 79

87 Section 6: The Evidence Base: Relating 6 Relating 6.1 Personalisation involves thinking about individuals in a more holistic way than hitherto an approach that is not constrained by traditional organisational and professional boundaries. Whilst there has been much policy and political rhetoric about the virtues of partnership and integration, it remains the case that the bulk of services and support is planned, commissioned and delivered on a mono-organisational basis. If this is to change, there will be implications for workforce development at all levels. In this section we briefly explore four levels the front-line; middle management; senior management; and the system-wide level. The Front-Line Level 6.2 There is a long tradition of attempts to get professionals from kindred backgrounds to work together (though this report is not the place to scrutinise the literature) but the debates on inter-professionalism and personalisation tend to proceed along parallel tracks. The position of inter-professional working in the context of personalisation is unclear, especially if the only income stream to constitute an individual budget comes from adult social care. Where this is the situation, there is the problem of discontinuity in culture, structure and process, with different agencies supporting the same people in different (and sometimes incompatible) ways. Individuals leaving adult social care for continuing health care support from the NHS, for example, are likely to experience significant reductions in their degree of choice, flexibility and control. If, on the other hand, there is a radical joining-up of a range of income streams to form an IB single pot then it is reasonable to expect professionals to work together more closely than in the past to deliver integrated and personalised support. 6.3 The most recent example of this parallel debate is the current consultation on a Common Assessment Framework (CAF) 152 for adults, which aims to promote more efficient and timely exchanges of information around assessments. It is stated that the CAF will: set out core principles which should inform it; establish how best to fit information sharing into developing assessment and care and support planning arrangements, and the introduction of self-directed support and personalisation; 152 Department of Health (2009), Common Assessment Framework for Adults 80

88 Section 6: The Evidence Base: Relating establish the basis for a shared set of information; be supported by mechanisms that hold and share information securely and appropriately. 6.4 Despite the references to personalisation, CAF still seems to be under considered in relative isolation from the attempts by most councils to devise robust Self-Assessment Questionnaires to underpin their Resource Allocation Systems. Although the basis for developing CAF is the sharing of information between professionals in order to ensure person-centred care, this tends to be seen as an inter-professional mission, rather than an integral part of a new user-led personalisation paradigm. Hence where there is reference to workforce development implications, these tend to be couched within a traditional prepersonalisation paradigm. 6.5 It is said that there is still a job to do in winning hearts and minds (p14), and that professionals need to be better prepared for joint IT solutions. A further proposal is for a care coordinator who will draw together information from a variety of electronic and manual sources to deliver a fully integrated perspective (p17), but it is not clear how this ecoordinator will relate to the support and brokerage roles being discussed elsewhere for social workers. The accompanying CAF Impact Assessment 153 emphasises that full benefits realisation will be dependent on delivering cultural change so that staff across health and social services work in a way that is integrated and genuinely person-centred. 6.6 The call in the Impact Assessment for joint training between health and social care staff as a key lever to delivering the necessary cultural change could have been written in any of the past four decades. Overall, there does not yet seem to be any serious consideration of the workforce implications of personalisation for inter-professional working, and this is unlikely to happen until the personalisation agenda (and especially the self-directed support version) develops beyond adult social care. 6.7 In children s services where the personalisation issue is not yet significant there is a much sharper focus upon relating, especially at the front-line. The workforce strategy 154 bemoans the many barriers to implementing effective integrated working, and in the progress report on the Children s Plan 155 (published on the same day as the workforce strategy) announced a new 200m fund to support the co-location of services. Laming also 153 Department of Health (2009), Impact Assessment of the Common Assessment Framework for Adults 154 DCSF (20080, Children and Young People s Workforce Strategy. 155 DCSF (2008), The Children s Plan One Year On: a progress report. 81

89 Section 6: The Evidence Base: Relating focuses upon the fact that child protection (like personalisation) goes well beyond social care, and urges the Secretary of State to immediately address the wariness of staff throughout the health services to engage with child protection work. ((p6). His observation (para 1.6) that there remain significant problems in the day-to-day reality of working across organisational boundaries and cultures could just as easily have been a passage from the Colwell Inquiry Report of The Middle Level: Change Agents and Boundary Spanners 6.8 The role and significance of change agents in organisations has become a subject of considerable interest over the last two decades. Initially the focus was upon senior managers, with the change master literature highlighting the importance of strong corporate leaders in transforming their organisations through a new shared sense of mission and values. However this emphasis upon change leadership has now been complemented by a focus on the role of middle managers in implementing change individuals who adapt, carry forward and build support for strategic change. In the personalisation context these individuals are likely to be the personalisation leads for a locality, and their role will be crucial in building support for the paradigm shift implied by the personalisation agenda. 6.9 The role and status of these boundary spanners is often far from clear, and this lack of clarity has probably hindered progress on a workforce development strategy for them. At a broad level, Caldwell 157 suggests that there must be expertise in four change agendas: content: competencies with respect to the substance of change; control: competencies in project planning, monitoring and delivering to deadlines; process: competencies in communication, team building, negotiating and influencing others; backstage activities : wheeler-dealing, fixing and trade-offs. 156 Report of the Committee of Inquiry into the Care and Supervision Provided in Relation to Maria Colwell (1974), London: HMSO. 157 Caldwell, R (2003), Models of Change Agency: A Fourfold Classification. British Journal of Management, 14, pp

90 Section 6: The Evidence Base: Relating 6.10 Within this framework there may be considerable role differentiation. In a survey of network managers in the NHS, Skills for Health 158 noted that: some have direct supervisory responsibility for staff and some do not; some have budgetary responsibility, others do not; in smaller networks the manager may carry out tasks that in larger networks would normally be delegated to other staff; in larger networks the role may be shared between a number of people; there are important differences in the breadth of responsibilities, leadership scope and freedom to act; the stage of network development is important, with different activities needed to set up or expand a network compared with managing an established network The Skills for Health report goes on to identify seven key functions of network managers: 1. winning support for the network 2. organising the network 3. environment scanning and strategy setting 4. managing information communications across the network 5. leading and managing collaborative work 6. coordinating activities across network members 7. managing the network hub 6.12 The report attempts to tease out the underpinning skills and knowledge that are likely to be central to the success of network managers regardless of the level at which they operate. These are identified as: understand the different views, priorities, needs and interests of network members, and know how decisions are made in the various member organisations; listen, analyse information and employ very good communication and relationship skills; be able to address different groups in appropriate ways; 158 Skills for Health (2006), Competences for Network Managers. 83

91 Section 6: The Evidence Base: Relating be able to negotiate and to facilitate; be able to think strategically and relate local events to a bigger picture, and viceversa; be resilient, energetic and self-reliant, for working across many organisations means they may not be seen as a member of any of them Despite the established evidence that it is the activities of boundary spanners in middleranking roles who can make all the difference between a successful and a failing partnership, little or no attempt has been made to develop a customised workforce strategy. Williams 159 points out that part of the difficulty here is that the role depends upon relational and inter-personal attributes designed to build social capital, rather than just knowledgebased skills. As he notes of boundary-spanners, They will build cultures of trust, improve levels of cognitive ability to understand complexity, and be able to operate within nonhierarchical environments with dispersed configurations of power relationships (p106). In such a complex milieu, the mere possession of a set of competencies does not ensure effective or consistent performance of a role or task. Moreover, such a combination of attributes will almost certainly be in very short supply. Collaborative Leaders 6.14 The challenge of collaboration impinges just as significantly upon leadership as upon other organisational levels a point we have explored in our preceding section on reshaping. The consequence of identifying collaborative public management as different from managing within a single organizational hierarchical setting is that the requisite skills are also liable to be different. This differentiation naturally raises the central question of what form of leadership is most appropriate and effective for a collaborative public management context. Marion and Uhl-Bien 160 apply complexity thinking to propose the notion of complex leadership based on the application of five core leadership roles as follows, each of which will be needed for the transformational change required of personalisation: Fostering network construction: here leaders learn to manage and develop networks and cultivate interdependencies both inside and outside an organization. 159 Williams, P (2002), The Competent Boundary Spanner. Public Administration, 80(1), pp Marion, R. and Uhl-Bien, M. (2001) Leadership in complex organizations, Leadership Quarterly, Vol. 12 pp

92 Section 6: The Evidence Base: Relating Catalyzing bottom-up network construction: through delegation, encouragement and providing resources to subordinates, encouraging networks and empowering workers to problem solve themselves. Becoming leadership tags : providing a symbol, ideal or flag around which others rally around. Dropping seeds of emergence: by encouraging creativity, experimentation and innovation. Thinking systematically: encouraging an appreciation of the bigger picture The table below adapted from Kickert et al 161 outlines the broad differences in approach between classical management and the network model implied by the personalisation agenda. The differences are pronounced, and imply a very different form of leadership. Table 6.1: Classical and Network Management Compared Dimensions Classical Perspective Network Perspective Organisational setting Goal structure Single authority structure Activities are guided by clear goals and well defined problems Divided authority structure Various and changing definitions of problems and goals Role of manager System controller Mediator, process manager, network builder Management tasks Planning and guiding organisational processes Guiding interactions and providing opportunities Management activities Kickert et al (1997: 12) Planning, designing, leading Guiding interactions and providing opportunities 161 Kickert, W.J.M., Klijn, E.H. and Koppenjan, J.F.M. (Eds), (1997) Managing Complex Networks: Strategies for the Public Sector. London: Sage. 85

93 Section 6: The Evidence Base: Relating 6.16 In their analysis of leadership frameworks for collaboration, Crosby and Bryson 162 identify the following main leadership capabilities, each of which is relevant to those leading change on personalisation, and all of which require skills of relating to others beyond traditional boundaries. These could form the basis for a workforce development strategy for collaborative leaders Leadership in Context: In order to respond effectively to social needs, leaders must understand the context in which the needs have developed and use that understanding to assess whether and how a change effort can get underway. Specifically, they need to clarify how existing social, political, economic and technological systems the givens have contributed to the need and how trends or shifts in those systems are opening up new opportunities for leadership in the area of concern. In the case of personalisation this means being able to clearly articulate why there is a groundswell for change, and identifying what new opportunities arise from moving to a different paradigm Personal Leadership: This refers to the work of understanding and deploying personal assets on behalf of beneficial change. Among the most important leadership assets is a sense of one s leadership calling. The call to leadership stems from what an individual really cares about in other words, what is important enough to invest one s time and energy in, to risk unpopularity and failure in service of a worthy goal. Putting personalisation into practice does require the personal courage to embrace change and persuade a wide range of other stakeholders to do likewise Team Leadership: Personalisation leaders will rely on productive work groups within and across organizations in order to achieve outcomes that could not be achieved on a single agency basis. Important elements of team leadership are recruitment, communication, empowerment and leadership development of team members. Team leaders should foster communication that aligns and coordinates members actions, builds mutual understanding and trust and fosters creative problem solving and commitment. Such communication requires an atmosphere of openness, information sharing and respect Organisational Leadership: Advocates of major policy change must ensure that effective and humane organizations are created, maintained or restructured as needed. Whether leaders are launching new organizations or reshaping existing ones, they must perform three crucial overall leadership tasks - paying attention to organizational purpose and 162 Crosby, B and Bryson, J. (2005), A Leadership Framework for Cross-Sector Collaboration. Public Management Review, 7(2), pp

94 Section 6: The Evidence Base: Relating design; becoming adept in dealing with internal and external change; and building inclusive community inside and outside organizations Visionary Leadership: Visionary leaders create and communicate meaning about historical events, current reality, group mission and prospects for the future. They work with constituents in formal and informal forums to frame and reframe the problems or needs that concern them and develop a shared vision that can guide collective action in pursuit of the common good. The way that a need is framed that is, how it is named, explained and interpreted has tremendous impact on who will be concerned about that need, what kinds of remedies will be considered and the membership of a coalition that might be formed to advocate adoption of the remedies. All of this will be part of a collaborative leadership strategy for implementing personalisation Political Leadership: Much of the leadership focus on personalisation has been on officials and professionals, but the role of members (especially elected local government members) will also be critical. In a recent study of personalisation for people with complex needs undertaken for CSCI the lack of engagement of local politicians was a recurrent finding. In four out of five councils that were the focus of in-depth study, elected members were negative or sceptical in their stance on personalisation. 163 For some this was about protecting in-house providers from the perceived threat posed by direct payments, while others were alarmed at the opportunity that might be created for misuse of public money, or did not accept that people needing to use social care would be able to make their own arrangements Political leaders need visionary skills to develop shared understandings of public problems, build support for beneficial solutions and develop commitment to collective action. They also need the political skills to turn the proposed solutions into specific policies, programmes and projects that are adopted and implemented by decision makers in executive, legislative and administrative arenas. Political leaders must possess transactional skills for dealing with individuals and groups with conflicting agendas, and whilst doing so maintaining the integrity of the vision that inspired the proposed policy changes There is, therefore, an important case to be made for a specific workforce development strategy for local politicians alongside a strategic approach to the transformation agenda of personalisation. The importance of knowledge and training has also been identified as 163 Henwood and Hudson (2009), Op Cit. 87

95 Section 6: The Evidence Base: Relating vitally important for children s services in the recent Laming Review (2009, op cit). Lord Laming emphasises the need for sustained commitment from the Council Leader and Lead Member and proposes regular training to develop and maintain their knowledge base (para 2.8). The ASC Final Strategy proposes exploring the merits of identifying a lead member for adult social care (para 34), though the likelihood is that most ASC departments already have such a role or something similar. However, the Strategy is right to focus on the importance of political leadership as an essential element of the transformation agenda. The System-Wide Level 6.25 Given the wicked nature of personalisation as a policy issue, there is also a need to address the most complex of partnering tasks whole system coordination. Local partners are routinely urged to work together through their Local Strategic Partnerships to deliver on jointly agreed Local Area Agreements, parts of which will be expected to display evidence of progressing the personalisation agenda. The concept of whole system working is popular but elusive. It entered the mainstream of health and social care discourse in the late 1990s and has been used mainly in the worlds of management and service delivery. Broadly, it refers to the process of involving all stakeholders of a domain in discussion about service change all parties are encouraged to think about the way the whole service delivery system works, rather than focusing only upon their own service. 164 In the context of personalisation, an interest in whole systems thinking will reflect: awareness of the multi-factorial issues involved in personalisation which mean that the complex issues involved will lie beyond the ability of any one practitioner, team or agency to fix ; interest in designing, planning and managing organisations as living, interdependent systems committed to providing customised and seamless care ; recognition of the need to develop shared values, purposes and practices within and between organisations. 164 Hudson, B (2006), Whole Systems Working: A Guide and Discussion Paper. Integrated Care Network. 88

96 Section 6: The Evidence Base: Relating 6.26 One influential model for analysing the way a system is responding to a shared challenge is the 7S model developed by Waterman et al 165 which has also been adapted as a framework for the DH Modernising Adult Social Care research programme 166. The model (shown below) takes the form of a series of interdependent process factors each of which informs the super-ordinate goals of social care: in this case independence, well-being, and choice. These super-ordinate goals are matched by other policy goals: protection, risk management, equity, and efficiency. Any particular goal will bring into prominence a different mix of process issues, but all are required to ensure the effective working of the social care system. Workforce development issues are clearly located in this framework, which could usefully be adapted and developed for analysing a system-wide approach to personalisation. Figure 6.1: The 7 S Model 165 Waterman, R. H. Jr, Peters, T. J. and Philips, J. R Structure is not organisation. Business Horizons, June. Foundation for the School of Business, Indiana University 166 Department of Health (2007), Modernising Adult Social Care: what s working? 89