I read through the Berwick Report “A promise to learn – A commitment to to act” which was published yesterday. While I have experience working in both health and social care settings over the years, I read it very much with my ‘social care’ hat on. The lessons are geared towards health settings. I wondered and still do whether they can be transferred into a social care specific setting – accepting (and I understand this better than ever) that while ‘health’ and ‘social care’ aren’t isolated entities – there are different pressures and cultures that exist although there is a lot that is transferable. In a sense, the sadness is that some of the most fundamental recommendations needed to be told.
Berwick identifies seven ‘problems’ and ten ‘recommendations”.
The problems he identifies are
1. Patient safety problems exist throughout the NHS
While Berwick highlights poor care evidenced in Mid-Staffordshire, there are many other ones we can all recall in the public consciousness. Similarly with social care there is no room for complacency. Winterbourne View was very much a hospital but it shows where the boundaries between health and social care blur. We have seen Panorama programmes which specify poor care in particular care homes or home care agencies. I’ve possibly seen more than most due to my work in safeguarding adults over the years but the important lesson is not that abuse goes on in services that should be providing care – unfortunately – but that no service can afford complacency. While we don’t talk of ‘patient safety’ in social care – we can look at a basic expectation of care provision which provides the basics to people.
2. NHS staff are not to blame
Berwick is big on looking at systemic rather than individual failings. Social care is far more fragmented than health – although the NHS is going the same way. There is so many different models/structures/sizes involved. I’m not sure I’d necessarily go with the ‘no blame’ approach but I’m not as fine a person as Berwick. I think accountability for decisions and actions taken needs to remain. However, most people want to do a good job and that has to be a starting point.
3. Incorrect priorities do damage
Targets. Oh, targets. I think this is definitely transferable. I’m not inherently against targets but targets are gamed and twisted until the outcomes are meaningless to the people whom we are supposed to be serving – just look at the way local authorities have warped personalisation from positive progress towards people getting more choice to a tick box exercise which favours those who are most able to manage their own budgets but ignores the needs of those on ‘council-managed personal budgets’ (which are EXACTLY the same as they were before but allow councils to tick the ‘done’ box and give no incentive to do anything differently – with the collusion of central government who just want to prove they have ‘done’ something).
4, Warning signals abounded which weren’t heeded
Perhaps this is where we diverge – the health and social care agendas. While I can tell many anecdotal tales of the changes in quality of provision since the onward march of the purchaser/provider split after the 1990 NHS and Community Care Act, we don’t have the same data tools (or I’m not aware of them – which may actually well be the case!) to evidence falling quality in social care provision. I’d like to think the warning signs have been evident though – thought more qualitative research and reports. It’s just harder to pin down.
5. Responsibility is diffused and not owned.
I can definitely relate to this. We have a myriad of small providers in social care from single operations – but then we have the large organisations like the Castlebeck/Southern Crosses. There are public sector commissioners from local authorities and CCGs and there are individuals who do not qualify for funding purchasing care individually. Where is the responsibility for quality? Well, with the providers but commissioners (and regulators) have a role. With more people buying their own care, the commissioner role becomes more removed and where is the responsibility or accountability? It’s not the same as NHS responsibility but it echoes.
6. Improvement requires a system of support
Berwick emphasises the importance of building a learning organisation which constantly learns. In social care we are left with building strings of systems in organisations both public, private, third sector – all and nothing – so where does that support and what is that ‘system’. I suspect this might be the biggest challenge in social care.
7, Fear is toxic to both safety and improvement
Without any doubt this is something the social care sector has to embrace. We have to recognise our failures and faults and drop any hint of defensiveness.
So looking at Berwick’s recommendations through the same social-care tinted spectacles, I wonder where we can find the improvements to the ‘system’.
His first recommendation is
1. The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning
While Berwick focuses on patient safety as the goal – we can’t detach social care from quality of life questions which are beyond ‘safety’ alone. We have to continually strive for the best care than can be delivered. He does mention the balance between minimising harm and allocation of resources and that’s always going to be the key. We can look at the care homes that are presented in the Guardian in brochure-like appeal (where prices are FROM £1200 per week) but that’s not where we need to start. We need to start at the minimum wage, zero hour contracted home care workers going into people’s homes for 15 min ‘visits’. How do we improve quality and assure standards without impacting resources? We do need a change in culture, understanding and appreciation of social care and the skills needed to do the job well.
Meanwhile, Norman Lamb suggested Neighbourhood Watch can provide personal care – we are not providing the same amount of respect for social care work that Berwick clearly expresses towards NHS staff. ‘The ethic of learning’ is important too – but not in the same way. Organisations need to learn – providers and commissioners. They need to be unafraid of criticism but there’s too much money in the ‘business’ for improvement to be pushed for its own benefit alone. Am I too cynical? I hope so. I’d like to see this transfer to the social care sector.
2. All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.
Now let’s replace ‘NHS healthcare’ with ‘social care’ and it’s even more depressing to read because we are so far away from having cohesive and strong social care leadership. We see many faces who talk to each other and pat each other on the back – but I see little inspiration to those who are doing the job every day directly with people who use social care services. I’m thinking of the Department of Health too – while Berwick says
“Leaders need first-hand knowledge of the reality of the system at the
front line, and they need to learn directly from and remain connected with those for whom they are responsible. “ We have a ‘Director-General of Social Care who doesn’t have previous experience in social care and the Department of Health seem to think this is acceptable as leadership for the sector – oh, he’s local government, that’s good enough – seems to be the thinking. Berwick says ‘first-hand knowledge’. Hmm.
Ministers seem to think it’s fine to denigrate social care because it isn’t as ‘political’ as healthcare and make statements about any neighbourhood watch volunteer being able to do it. Is that political leadership?
Social care has a long way to go on this. I hope that the new Chief Social Worker can pick up on this a little bit but social care is so disparate – we can have many leaders but they need to lead more. They need to lead people who are doing the job at the grassroots – rather than existing in self-referential circles which seems to be the case at the moment.
3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.
4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well supported.
This could relate within residential settings as a responsibility however it already existed – less clear in home care settings but we do need to ensure that community teams are well-resourced – however that costs money – something that everyone seems to want to avoid admitting.
5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals including managers and executives.
6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS
These come together in the report as a part of learning as individuals and as organisations. Personally, I’ve found that the NHS has been better at promoting learning than the local authority I worked for but that doesn’t mean there’s no room for improvement in both.
Social care needs to appreciate the value of learning and training. That doesn’t mean giving care staff 10 e-learning modules on everything from health and safety to safeguarding to do at home in their own (unpaid) time. I think we need to focus on learning across the levels of people who deliver social care. I’m less concerned about the ‘managers and executives’ than Berwick as they are paid good money and have power. I think we need to look at the support for training and career progression for people who are care workers and often working with low pay and low status.
As for organisations learning, it’s absolutely the way to go. We need to actively welcome complaints as a positive opportunity for learning and not as a personal attack to be swept under the carpet. I think that may take a while.
7. Transparency should be complete, timely and unequivocal. All non-personal data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.
8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.
I’m a great believer in transparency as is Berwick. There are different challenges within social care as there are so many different organisations collecting different information in different ways but there may be ways for local authorities to share information between them and most importantly with us, the local residents, to understand more about the quality of social care provisions locally.
As for seeking the patient and carer voice in monitoring quality of care, I hope we will see an increasingly substantial place for Healthwatch in this process. I’d like to see users and carers involved more in local authority monitoring and commissioning decisions. These are all ways that progress can be made. We need to know how commissioning happens in a much more open way. I’d love to see a council explain what, how and why they make the decisions they do about choosing providers and being held to account for it.
9. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.
The regulatory model is currently similar across health and social care with the CQC taking charge of both. Hopefully the current changes which are in progress will point towards ‘simple and clear’ in social care as well as in health systems.
10. We support responsive regulation of organisations, with a hierarchy of responses. recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment
Personally, if I were rewriting regulation, I’d come down a lot harder on social care providers who do practice wilful or reckless neglect or mistreatment. I think we are not strong enough on that as things stand. I don’t see why this cannot be transferred wholly into the social care regulation system
The report was written for the NHS and for patient safety. I’m supposing that some of the tenets would be transferable but I’m not convinced (unfortunately) it’s possible. I wish we could see similar interest in the social care system and its failings as we see in health though but in the absence of that, we take and adapt what we can.
I hope we can see some movement in some of these areas in social care as well as health though because it’s equally important and equally needed.