Eleanor Roosevelt, 1958

'Where, after all, do universal human rights begin? In small places, close to home -- so close and so small that they cannot be seen on any map of the world. Yet they are the world of the individual person... Unless these rights have meaning there, they have little meaning anywhere. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world.' Eleanor Roosevelt, 1958

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Tuesday, 21 August 2012

The state isn't always better, but profit usually makes things worse

In the wake of Winterbourne View we are all looking for answers to the questions: How did this happen? How can we prevent it from happening again?  There are as many different answers to this question as there are different responders.  But there are difficulties with any one size fits all answer.  It's easy to blame it on the regulatory model, but as the Serious Case Review (SCR) showed CQC was one agency among many which failed to respond adequately to whistleblower allegations.  We could blame it on the model of care, and it was a vile model of care - storage, not support, as Neil Crowther put it.  But abuse happens in community based care homes and supported living settings as well.  Another pattern, which I want to discuss today, is to blame it on the privatisation of health and social care services.

Let me be clear, there are many many problems in social care that can be traced back to privatisation.  Drakeford has written extensively about the problems of privatisation in social policy (e.g. this book), in a more recent paper he predicts:
'Far from providing a plethora of small-scale, responsive, customer-focused services which the privatizers and marketers promised (see Drakeford, 2000 for a more extended discussion), the residential care market has displayed far more traditional tendencies to monopoly and standardization. The future of private provision is set to be one of large-scale warehousing, physically located on far fewer premises and offering little by way of choice.'
When I attended a BIHR run event on human rights in healthcare in 2010, Nigel Thompson - head of human rights and equality at CQC - expressed concern that large care providers could undermine the diversity offered by micro-providers, and questioned how CQC could protect that diversity.  I don't know that any answers are forthcoming yet.  Last year the National Development Team for Inclusion (NDTi) produced a fantastic report examining the root causes of why large, expensive private sector hospitals for people with learning disabilities continue to exist, when they secure such poor outcomes and are a discredited model of care.  The answer in one word: capitalism.  Most private providers are financed by debt. Banks must be satisfied that services are financially viable. Hospitals are easy to conceptualise with 'safe predictions of profit', whereas 'alternative service models more in line with the Mansell Report ...consisting of preventative services, sessional input and flexible contracts for support ...are more complex to cost and predict.' Consequently, 'At a time when banks are less willing to lend, and are looking for greater security from companies, a move towards untried (in business terms) models that have no recognised framework for costing and predicting profitability will be attractive to neither the provider nor the bank.'  The report concluded that only with concerted state action could services in line with the Mansell report be developed.

When care services are contracted out to the independent sector, there is a loss of transparency and accountability as key modern democratic instruments such as the Freedom of Information Act 2000 and the Human Rights Act 1998 lose their traction (yes yes, the HRA applies to care homes when people are placed under the National Assistance Act, but there are plenty of other statutes a person might receive independent sector services under, and not all services are care homes).  Revolting reverse auctions used by local authorities to secure the cheapest contractor for services drive down price at the cost of quality, and will favour providers who can operate narrower profit margins due to economies of scale.  Meanwhile commissioning authorities can distance themselves from tumbling care standards as they have merely 'purchased' the care, rather than delivered abusive and neglectful services themselves.  Rather than engage in the slow, hard and costly work of improving services, they can just shop elsewhere.  Staff typically have better working conditions in the public sector, although to my mind the issues around low pay and working conditions which plague the care sector should be addressed for everybody working anywhere.  And paradoxically, although privatisation was supposed to result in greater choice and freedoms of which services a person used, this very choice and freedom can threaten the economic viability of services themselves.  In relation to the supposed 'freedom of choice' users of supported living services are meant to enjoy over who supports then, the Voluntary Organisations Disability Group and Anthony Collins Solicitors writes (pdf):
'...CQC’s primary concern is to ensure people have freedom over their choice of care provider ...Providers [of supported living services] are left unable to link any ‘care’ services to the location of the person which prevents them from being able to plan the totality of services required in an economically viable way. This does not help to deliver this type of accommodation in the volume people need...Significant tensions exist between the rights of the individual to self determination and choice, the financial constraints on the cost of care and the regulatory framework.'
In essence, although the ideals underpinning the privatisation of care turned in no small part on freedom of choice, this turned out not to suit providers all too well as they suffered the resultant market instabilities.  That market failure might be a bigger problem in care than, say, discontinuing a line of baked beans, was evident from the panic that ensued when Southern Cross was folding, and nobody was sure week on week who - if anyone - would be supporting residents of Southern Cross care homes.

But to say that capitalism and marketisation is problematic for social care, and to say the state must take action to override the tendencies of free markets in social care to result in uncertainties, monopolies and 'care as storage' is not quite the same as saying that state run services are always better.  Would it be too easy and trite to point out that scandals in Cornwall, Sutton and Merton, the Royal Sussex County Hospital, not to mention Mid Staffordshire were all NHS run services?  I was set to thinking about this yesterday by a column written in the Telegraph by Dr Max Pemberton, entitled 'Winterbourne View: The problem with all care homes', with the byline 'Many people with severe disabilities should be cared for within the NHS, rather than in private facilities'.  Pemberton appears to be under the impression that Winterbourne View was a care home, when in fact it was a hospital.  This has been a pretty common theme in media coverage of the scandal, but in this context it's quite an important confusion as the argument he appears to be making is that Winterbourne View was caused by the care in the community reforms of the 1990's:
People with severe disabilities, such as those at Winterbourne View, would have previously been cared for in large NHS asylums. However, in the Nineties, with the widespread closure of these, the residents were moved out and cared for by the NHS in the community. While some were able to live independently with NHS mental health service input, some were too disabled and required 24-hour care. These people fell awkwardly between the criteria for NHS care and for personal care, and ultimately their welfare was placed in the hands of social services, despite them having severe and complex medical problems.
Legislation such as the 1990 National Health Service and Community Care Act, as well as the Supporting People initiative, enabled private agencies to develop and provide specialised housing. The result of this is that too many people with severe and complex needs, who were once looked after by medical staff in institutions, are now at the mercy of unqualified staff in the private sector. The issue is not just that there is abuse taking place in some of these homes, but that the level of care that residents receive in all of these homes is substandard because the staff are not medically qualified or trained to the standard expected on NHS wards.
There are several points about this argument.  Firstly, it appears (to me) to be endorsing a very medicalised view of what kind of care adults with learning disabilities should be receiving, which sits in tension with the arguments advanced by leading learning disability experts and charities that:
There is no place for specialist hospitals in the care of people with learning disabilities (outside of serious forensic issues). There is clear evidence that such hospitals provide poor outcomes, often at very high cost, and that there are better, alternative ways of supporting people that have behaviour labelled as ‘challenging’. There is a place for a small number of local assessment and treatment beds, integrated with other local community services.
These charities aren't arguing for people to be moved into NHS run hospitals, they're arguing for people to be moved out of healthcare services altogether - into community services.  To be fair to Pemberton, however, he does argue 'I wouldn’t advocate returning to the days of large institutions and asylums', but he does seem to be advocating for care services run on a healthcare model.  Secondly, it seems to be linking the abuse at Winterbourne View to the fact the services were not run by the state.  I'm probably going to lose a few friends by what I'm going to write next, but I think it's problematic to argue that the state always provides better services.  I don't mean to come over all Philip Blonde about this, but the fact is that there are many excellent and innovative forms of care that are being developed - with (hopefully) support from local authorities and the state - in the independent sector.  For example, most micro-providers - which can have excellent outcomes - are in the independent sector (see Community Catalysts); Shared Lives schemes can have excellent outcomes, and they can also be in the independent sector (although some are run by local authorities).

Pemberton's article sent me scurrying away to look up some research I did in the twilight days of the CQC using care standards ratings.  Using their old search engine (have I whinged yet about how much better it was than their new search engine?), you were able to search for the number of registered providers of different types of care (e.g. care homes, domicilliary care), of different target users (e.g. learning disabilities, 'old age', dementia, etc), and of different provider type (e.g. voluntary sector, private sector, council run, NHS).  Now, CQC did release some data back in 2011 which showed that council care was better than private sector care, but the data I unpicked showed a slightly more complex picture.

For each type of service provider (e.g. NHS, local authority, voluntary/charity or private - meaning 'for profit') I calculated the proportion of services receiving CQC ratings of 0 (poor), 1 (adequate), 2 (good) or 3 (excellent).  I broke this down by type of care being provided.  I also looked at the proportion of services offered by each type of provider.  The charts below reflect what I found.  These data were collected in April 2010.  I have shared a copy of the spreadsheet with the data in full here, which you are very welcome to use as you see fit although please note the Creative Commons license this blog is published under.  I apologise that the graphs don't quite fit on the page, but it's probably better to be able to read the text than look pretty!

Domiciliary care services

The largest proportion of domiciliary care is provided by for-profit ('private') providers, followed by local authority, then voluntary/charity, and then a small proportion of NHS providers.

Of those providers, the private sector has the largest proportion of services rated 'poor', followed by the local authority (note: not the independent sector).  The Voluntary sector had the highest proportion of its services rated 'excellent', followed by the local authority, then the NHS, with the private ('for profit') sector having the smallest proportion of its services rated 'excellent'.

Care homes

As with domiciliary care, the private sector provides the largest proportion of care homes, followed by the voluntary/charity sector, then local authorities, then the NHS.

As with domiciliary care, the private sector has the largest proportion of its services rated 'poor', followed by the voluntary sector, then the NHS, then the local authority.  However - contra Pemberton's cheerleading for the NHS - the NHS also has the smallest proportion of care homes rated 'excellent', closely followed by the private sector, then the local authority, with the voluntary/charity sector providing the largest proportion of care homes rated 'excellent'.

This pattern changes, however, if we break down care homes by the type of user.  For care homes for old age, the private sector has the largest proportion of 'poor' services, followed by the voluntary/charity sector and then the local authority.  The NHS offered the highest proportion of 'excellent' care homes for old age, followed by the voluntary/charity sector, then the local authority, then the private sector.  But before we get too excited about the NHS offering no poor or adequate services and the largest proportion of 'excellent' services, note that there were only 3 NHS run care homes catering for 'old age' in this sample.  

For dementia, again we see that the private sector has the largest proportion of 'poor' services, followed by voluntary/charity then the local authority.  The voluntary/charity sector offers the largest proportion of 'excellent' services, followed by the NHS, followed by local authorities with the private sector coming last.  Once again, however, the NHS data should be treated with caution as it only reflects a sample size of 10.

For adults with learning disabilities, the private sector had the largest proportion of 'poor' services, and the local authority the least.  The voluntary/charity sector offered the highest proportion of 'excellent' services, followed by the local authority, followed by the private sector - with the NHS offering the smallest proportion of 'excellent' care homes for people with learning disabilities (there were 157 NHS care homes for this sample).  The NHS did offer the highest proportion of 'good' care homes for adults with learning disabilities, but in terms of services rated higher than 'adequate' it only equalled the private sector and was outcompeted by both the voluntary/charity sector and the local authority services.

This last chart is not related to the type of provider, but does facilitate comparisons between how good different types of care homes are for different types of users.


These data are two years out of date now, but they do suggest that it is not an easy generalisation to make that the state offers better quality care than the independent sector.  Digging deeper into the data, there are many occasions when the voluntary/charity sector performs better, and - for care homes for adults with learning disabilities at least - the NHS doesn't seem to excel.  It might stick in your throat to acknowledge this, but the voluntary/charity sector would not be offering these kinds of care services were it not for the 'privatisation' of social care which allowed services to be commissioned from independent providers.  One pattern does stand out in these data though, that the for-profit private sector, which holds the largest share of the market, is consistently the worst.  It offers the most poor services, and the fewest excellent services.  The state isn't always better, but profit usually makes it worse.


  1. The CQC ratings were always known to not realistically reflect the ongoing quality of provision e.g. of domiciliary care providers of any sector.

    The CQC tick box approach has never been inquisitive or demanding. I know of a not for profit care agency with a history of fraud / client abuses and ongoing poor management knowledge, 'growing' determinedly and economical with the truth, given a 3 star rating which it has continued to advertise publicly long after the ratings were stopped.

    1. Hello, yes I should have included a caveat saying that. However, I can't think of any reason to think the CQC are systematically biased for the voluntary sector, against the private sector and against the NHS in learning disability services. Even if they overestimate quality and underestimate problems, I can't think why they'd systematically differ in that for different provider types. So the relative ratings may still tell us something. Open to suggestions though!

  2. Angela Catley - Community Catalysts22 August 2012 at 09:40

    This is and excellent and thought provoking piece and thanks a lot for the mention of Community Cataysts and for highlighting the potential for micro services (both regulated and unregulated) to provide high quality services. This piece raised a few thoughts for me firstly Shared Lives is an interesting model becuase it is regulated by the CQC but still remain largely invisible. The majority of Shared Lives schemes are run by local councils though some of the biggest are run by voluntary organisations or charities (St Anne's, PSS, Avalon, Ategi). I think Shared Lives Plus have done some work to compare CQC ratings for Shared Lives against other types of regulated care but don't think they (or anyone) has done the kind of public sector/independent sector comparison that you have done here. A final note on the Quality Mark which we have developed to enable micro providers to deliver high quality services and to evidence that quality to customers and other stakeholders - I think this type of approach will be key in our sector in the future as care/support becomes much more about living full lives rather than simply receiving personal care services in ways that are regulated.
    Thanks again

    1. Hi Angela, thanks very much for your comment. I've updated the article to reflect that shared lives have mixed providers. It would be interesting to look at micro-providers using an analysis like this - I was thinking of one comparing number of beds in a location, and number of locations for a provider, to quality ratings. But you couldn't do that now that CQC have disbanded their quality ratings; the closest you could get would be compliance ratings, but I'm not sure that's quite the same thing. The Quality Mark sounds interesting, I'll look out for that.

  3. Andrew Makin.Nursing Director RNHA; Independent Mental Capacity Advocate11 October 2012 at 08:44

    It conflates effects with causes to say that "profit usually makes it worse". Since the NHS & Community Care Act 1990 came into force in April 1993, local authorities have consistently used their monopsony position to drive down fees - not one has kept pace with inflation in the last 19 years - with the result that homes which rely predominantly on local authority commissioning have had to cut their cloth accordingly. In particular it has depressed wages in what is already an unpopular employment sector. This in turn means that, although good people are to be found, there are also a number of care workers who are unmotivated and lack insight, leading in turn to what Graham Stokes has called malign care - well intentioned but ill informed. Add to that the need to make a surpus (Profit is not what provides the holidays in Barbados, it is what pays the bank loan and new capital expenditure), and it is not surprising that home owners resort to satisficing. See also my letter in Nursing Standard, October 10th 2012, page 32.

    1. Hi Andrew, thanks for your comment. I don't doubt for one second that the LA's have driven down fees over the past two decades and that this has had an impact on quality. But this analysis was cross-sectional, not longitudinal, and my point is that sometimes independent sector providers offer better quality that state providers, but that for-profits rarely do.