COVID-19 was a threat to the whole nation. Now it’s increasingly a threat to those who suffer the greatest inequalities. Alex Fox, CEO of Shared Lives Plus, argues that we need to see a rapid shift from the ‘command and control’ leadership style which arguably saved the NHS a few weeks ago, to a much more devolved and collaborative style which is the only chance of saving social care now.
There can be few more daunting challenges than safeguarding an entire population against a deadly virus. There is a widely published photograph of the head doctor at the London Nightingale Hospital waiting for his first patient at a lighted door in a vast metal shutter. It’s a heroic image which captured something of the scale of both the challenge and the achievement; the bravery, defiance and at times, loneliness of the NHS staff and leaders on the frontline.
The NHS did not collapse and the Nightingales remain largely unused. But the UK is in the unenviable position of leading European tables of the number of the deaths. While the spotlight was on the vast and justly celebrated achievements in acute care, the social care sector took weeks to persuade leaders to focus on the tragedy which was quietly unfolding in our care homes, until the numbers became too huge to ignore.
We may never even know how many more people who use social care died isolated at home following visits by untested and poorly equipped social care workers. While the challenge of building a vast hospital from scratch was achieved in a matter of days, we are still lost in the gaps when it comes to the much more diffuse challenges of bringing testing, PPE and resources to the thousands of social care providers who need them to function.
Moving from universal to tailored care
These gaps between national intention and local realities indicate the change in mindset we need as we move from health and care for a whole nation in peril, towards protecting and supporting those groups and communities who remain at greatest risk. This will mean stepping away from the very leadership style which created rapid results, towards an approach which feels much less adrenaline-fuelled, messier and less immediately impactful on a large scale. That change will be particularly difficult because it will require us to be clear eyed about the human failures as well as the service successes of the past weeks.
Moving from big, whole-nation solutions, to a focus on the inequalities of COVID-19 is the kind of challenge that the NHS – and government more broadly – has never been good at. It means identifying groups we reach and serve least well, and being prepared to listen to them and work with them to create highly localised or even individually-personalised forms of support.
PPE and testing for the people living and working in social care services failed to materialise firstly because those people were scattered through thousands of decentralised provider organisations without the centralised, powerful voice of the more unified and bigger-budget NHS. But then when the plans were put in place, they were often not a good fit.
Often we found that delivery plans were only designed with care homes in mind, and had forgotten tens of thousands of community based services. There are well over 100,000 disabled people and families employing their own personal assistants in lieu of receiving an off-the-shelf service. Some were supported by their councils to adjust care plans rapidly; many report feeling left to sink or swim.
The exigencies of at-scale-and-pace national approaches have also been an uneasy fit with the outpouring of community support during the crisis. The NHS’s call for volunteers was a huge success in generating 750,000 would-be volunteers. But it has proved much harder to fit all the volunteers into a few nationally-defined roles. It is likely that the entirely grassroots, decentralised mutual aid group movement has provided more support, because people were free to ask and offer whatever worked best for themselves, their family or their street.
If the volunteering approach can’t adapt to fit with the varied needs and ways of working of thousands of community groups, many of those NHS volunteers will be lost, not just to the current crisis, but perhaps, in disillusionment, to volunteering for good. This underutilisation of communities could be just as disastrous in the long term as the potential overwhelming of the NHS. A nation whose least advantaged communities will suffer the twin evils of higher unemployment and higher work-related infections and deaths is likely to be one where community cohesion is strained to breaking point. Government must not try to take over community action, but it can invest in it at a time when thousands of charities say they are going or will go bust.
The care and health services which will meet the COVID equalities challenge will be those which can combine formal support with community action. Those will be the ones able to keep people supported, safe and well in their own homes at a time when large building-based services are likely to continue to see outbreaks, but also when the pre-existing loneliness pandemic is being exacerbated with enforced, open-ended social isolation for many older and disabled people.
An asset-based approach
None of this suggests that what we need now from health and social care leaders is big structural reforms, such as the health/care merger which some are now talking about. That would entrench the current inequalities. Instead, we need to establish and share an overarching health and wellbeing goals across health, care and public services.
In my book, A new health and care system: escaping the invisible asylum, I argued pre-pandemic that we could take the values and practices I see in the growing movement of asset-based services like Shared Lives, which bring people together into chosen, extended and much more reciprocal support relationships, and bring them into all of long term health and care services. Ultimately, it is the core support relationship at the heart of public services that needs reimagining, not the bureaucracies within which brief professional/client transactions are organised.
If we share the same goals for living well at home, we will pay as much attention to supporting people to connect and support each other, and to how services work with mutual aid, as we do to how services respond to medical emergencies. Instead of statutory budget holders discussing amongst themselves whether to fund the voluntary sector, they will co-commission with community organisations and the communities only they can reach.
That shift in power, values and behaviours is set out in the new Asset-Based Area model as part of a suite of resources for local areas from the Social Care Innovation Network.
Let’s not redesign services around what we were good at during the crisis – but around what we need as a nation if we are to have a future we can look forward to again.
Alex Fox OBE is the Chief Executive of Shared Lives Plus, the UK network for Shared Lives and Homeshare. www.sharedlivesplus.org.uk. He is an RSA Fellow, Vice Chair of the Think Local, Act Personal partnership and a member of the NHS Assembly. His book, A New Health and Care System: Escaping the Invisible Asylum is published by Policy Press.