During the week ending 4th February 2022, the Department for Health and Social Care (DHSC) met with a group of leaders of associations representing social care providers to talk about the nature of the relationship between DHSC and providers and to ask for our thoughts on how the guidance being published by DHSC should evolve.
The meeting came during a week when the Government had started lifting the restrictions that the country has been living with for the last two years and when it really felt like the journey towards whatever the new normal is going to look like had begun. It also followed another meeting between the DHSC and sector representatives that had been particularly tense because of the way the sector was told about this week’s decision to revoke the regulatory changes about mandatory staff vaccination in non-care home social care settings.
How DHSC and providers can work together
Looking at how DHSC and providers will work together in future, ARC England’s position is that we want to see a relationship that is more mutual and based on the assumption that, in the main, it is the organisations that support people with a learning disability, autism or both, who know best what high-quality, person-centred care looks like. They, their leaders and managers, staff teams and the families and loved ones know how to make sure supported people get real person-centred care.
We think this is about reframing, in a conscious and deliberate way, a relationship that at times over the last two years has felt somewhat one-sided and characterised by the perhaps necessarily centralised command and control approach adopted by the Department. Whilst this approach may have been appropriate during the height of the pandemic, it is not how we want the future relationship between the DHSC and providers to work.
Without wishing to be unkind, two years ago the DHSC did not know the difference between a domiciliary service and a care home. DHSC colleagues have without doubt worked hard during the pandemic but no one, it seemed, had a clue about what learning disability services do, who works in them, who is supported in them or how they operate.
Guidance – lack of insight and understanding?
Whilst it is clear that the knowledge of Department colleagues has grown dramatically, it remains the case that the learning journey DHSC had to undertake often meant that the sector guidance it published revealed a lack of insight and understanding.
Guidance has sometimes been just plain wrong for the setting it is meant to be applied in, has sometimes been unworkable because of features of those settings that providers understand and work with every day and which seem obvious to them but which were unknown to the DHSC. One example of this is that, by definition, domiciliary services are delivered not in services over which the provider has control but in people’s own homes, but the guidance sometimes assumed that the provider had the same responsibility for and control over the person’s living environment as they do in a registered care home.
It has also sometimes been the case that the guidance has been unhelpful, poorly thought through and inconsistent with other pieces of guidance and regulation that providers are required to adhere to.
The latest fairly minor but nevertheless unhelpful example of this was the update removing the mandate for Vaccination as a Condition of Employment (VCOD) that I mentioned earlier.
On the Monday morning, as soon as ARC England passed the information on to members that the decision to revoke these regulations had been taken (subject to the agreement of Parliament of course but also, strangely, subject to a consultation exercise which does not appear to have the capacity to change the decision), we were having conversations with providers about what to do with staff currently going through HR processes that could lead to their dismissal.
We offered our members the suggestion that these HR processes should be paused. We did this after thinking through the implications of a decision by Parliament to agree to the revocation of the regulations and also thinking through what would happen in the event that the House decided not to do this (we took the view that the alleged consultation is not in fact real and could be ignored for the purposes of deciding what to do with staff working in these settings who did not wish to be vaccinated).
We provided our advice to our members on Monday morning, within minutes of being told about the proposed regulatory change, but it was Thursday before the DHSC confirmed that these discussions with staff should be paused.
What this tells us is that the Department had not thought through the implications of the announcement by the Secretary of State and had not understood that this raised an immediate question about staff currently in discussions with their managers that, without this week’s policy change, would have led to their dismissal.
It also tells us that it the Department does not understand the pace at which things happen in services where three hours can be a long time within which much has happened, let alone twenty-four or, in this case, the seventy-two hours that elapsed between the announcement and the guidance letter explaining how conversations with vaccine-hesitant staff should be managed.
These kinds of experiences can, of course, lead to frustration for the provider and often the role of ARC England and other membership bodies has been to seek clarification from the Department, to work through issues with DHSC colleagues, to educate them about how services work and to support the process of arriving at guidance that works and is helpful. We also see part of our role as supporting the maintenance of a productive working relationship between the DHSC and our members.
As we consider how the DHSC can play its role in supporting learning disability service providers to get out from underneath the day-to-day challenges of the last two years, we think that this is the time to take the opportunity to rethink and reframe the relationship between the DHSC and the sector and to put its relatively new-found knowledge of how these services work to good use.
It is for this reason that ARC England’s invitation to DHSC at the meeting was to consider how we will reposition the relationship dynamic so that it reflects trust and confidence in the providers that have kept supported people, their loved ones and their staff safe as they weathered the Covid storm.
Local assessment for local risks
We suggest that the relationship should be based on the belief that these are capable and competent organisations with great leadership, motivated teams and a strong and evident desire to ensure that the people they support lead the very best lives it is possible for them to lead.
There are of course organisations that need support to get to this position and we not suggesting that they should not be provided with that support but we invite the DHSC to move, in a conscious way, beyond the centralised, often prescriptive, sometimes directive communication style that has sometimes ruffled feathers during the past two years; to reframe the relationship on the basis that with helpful, relevant, accurate and well thought-through guidance, providers can be trusted to make local decisions locally and to assess and manage local risks where they present. For the avoidance of doubt, this is not in Whitehall – it is in their services.
This is because when the DHSC’s communication style has been used to communicate a guidance update to providers that is not relevant in their setting, or is flawed in some way that is obvious to the Service Manager, or is impractical to implement, competent and confident providers will, generally and perhaps through dialogue with associations like our own, work out what to do, but those providers that are less confident can easily find themselves in a tail spin.
The needs of both types of provider (there will of course be a full range in between these two extreme points) are important and we think that DHSC needs to understand what these are, understand their role in making sure all providers get the support they need but also, crucially, that departmental colleagues understand how their role fits with the role of other organisations, some of which loom large in the daily lives of people working in the sector.
We are saying here that the last thing that providers need right now is another organisation in a monitoring and compliance role – they already have a regulator and are required to work closely with their Local Authority Quality Assurance teams.
They also don’t need to be told in prescriptive ways how to operate their services, how to make decisions about locally presenting risks that are often dynamic and sometimes even highly fluid in nature.
Finally, they don’t need guidance that works at the micro level, providing detail that, the more specific it becomes, the less relevant it is likely to be in so many of the hugely different settings in which support is being delivered every day.
Trust in the willingness and ability of providers to do a great job
In relation to how the pandemic is going to play out in the coming weeks and months, Sir Jeremy Farrar said recently “I just don’t think you wake up on Tuesday and it’s finished. It’s not going to happen like that,” and we think this makes sense; this is a journey, not an event.
Our view in relation to the evolution of the relationship between the Department and providers is that now is the time for the DHSC guidance to pull back from the centralised approach that characterised the last two years and to move into a more mutual and negotiated space within which there is trust and confidence in the willingness, ability and energy of the providers to do a great job.
ARC England has worked hard to help its members to understand why guidance has sometimes been unhelpful to them, to understand that it was not the intention of the DHSC to be unhelpful and to understand and support the learning journey that departmental colleagues were on.
We want to play our part as we negotiate the ways in which the relationship with the DHSC will evolve in the coming months and years so I will offer one final thought about how we could do this.
We know that between 2009 and 2019, spending in the most deprived council areas on non-education services fell by an astonishing 31% but in affluent areas, the spending reduction was just half that with a fall of only 16% meaning that austerity has caused the most harm to those communities that can least cope with it.
Thinking about what we know about and can learn from care which is provided to older people, we also know that there are fewer older people who pay for their own care in deprived areas and that lower numbers of self-funders is linked to lower quality of care (see figures six and eight in this Office for National Statistics report).
Fully 1900 additional people joined the Department between March 2019 and March 2021, 1589 through redeployment from other departments and, presumably, 320 (or 20%) of these being new recruits.
If, as the demands related to the pandemic start to ease, some of these folk are now looking for something else to do, perhaps they could work with providers and their representative bodies to properly level up the disparities in both delivery and quality that exist across Local Authority areas?
ARC England Director