Nick Kempe: The crisis of leadership in the social care system

“Social work should have been at the forefront of defending the rights of those who have needed care during the Covid crisis, from asylum seekers to older people in care homes denied contact with their families.”

LAST WEEK, in response to a question from Labour MSP Neil Findlay MSP, Nicola Sturgeon argued in the Scottish Parliament that the decision to discharge infected people from hospital to care homes was a clinical one which could be justified in certain circumstances. This was wrong on two counts and provides an insight into the leadership crisis in social care. 

While it is up to doctors to decide whether someone needs ongoing medical treatment in hospital, it is not up to them to decide what care might be appropriate when a person is fit for discharge.  That is a care decision, not a clinical decision and a matter for families, assisted where necessary by social workers, not for doctors. Part of that care decision should include ensuring that any proposed care arrangements are suitable to meet a person’s needs and are safe. Since the Carers (Scotland) Act 2016, Health Boards have had a legal duty to involve patients’ families in decisions about hospital discharges. That duty was not suspended by the Coronavirus Act but appears to have been overridden by the general legal indemnity granted to Health Boards for actions taken during the emergency.  The duty of local authorities to undertake full care assessments was, however, suspended by the Act until quietly reinstated earlier this week.

What Nicola Sturgeon failed to explain, when rightly arguing clinical decisions about the need for treatment are up to doctors, is why her government has overridden normal care decision-making processes. 

This brings me to the second reason why the first minister was wrong to argue as she did. Decisions about care can have serious consequences and not just for the person concerned. In the case of an infectious person discharged from hospital, for example, at present the government’s own guidance requires care homes to stop visits from relatives, except where someone is dying, for 28 days after the last positive Covid test. Even if a care home is able to care for the person with Covid safely – and we still have no means to determine which care homes might be able to do that and which not – the consequences of a new or extended visiting ban for other residents and their relatives would be immensely serious.  The First Minister appeared oblivious to the repercussions of her argument.

This example helps illustrate the structural leadership problems afflicting social care. Sturgeon and her government are over-involved in trying to manage systems and services which they do not fully understand. This has resulted in one blunder after another in the last eight months, starting with the decision the discharge hundreds of people from hospital to care homes unprepared to cope. No-one in the leadership echelons of health and of social care appears to have been to warn the Scottish Government of the disastrous consequences of these decisions. This is not an accident but a consequence of a long history of increasing centralisation, in which independent leadership within social care based on social work values has been subsumed to political imperatives and top down management.

Back in 1984, Fred Edwards, then-Director of Strathclyde Region Social Work Department, authorised loans of £121,000 to striking miners who had been denied benefits. This was against the law, but he did so because he thought no-one should starve because of their beliefs. It is almost impossible to imagine any Chief Social Work Officer, as the heads of social work are now called, taking any such action. Indeed, the opposite is happening. Last month Glasgow Health and Care Partnership, which manages homeless services for Glasgow City Council, was found to have failed to meet its legal obligation to house homeless people. Why did nobody in social work speak out?

Part of the answer may lie in the bullying scandals that have also been in the news. A local inquiry into bullying in East Dunbartonshire Social Work Department had been dragging on for 15 months before, at the beginning of November, Scotland’s Chief Social Work Officer was asked to investigate.  At the start of November it was also revealed  that at Argyll and Bute Council staff, including social workers, “have lost faith in the systems that are meant to be in place to protect them from bullying and harassment in the workplace…” 

Both these scandals have taken place in health and social care organisations whose professional social work leads are governed by Codes of Practice that are supposed to value people and preclude bullying.  

The Sturrock Report into bullying in NHS Highland, which recommended a further inquiry was needed in Argyll and Bute, had some interesting things to say about the causes of bullying:

“Within NHS Highland and particularly in Argyll and Bute the message coming from senior management has changed as the financial savings targets have increased. The message of changing services to save money but maintaining quality has subtly changed over the past few years so that frontline staff now hear only ‘save money’ with decisions made arbitrarily and opportunistically which clearly do not fit with the Highland Quality Approach – wholesale cuts to services for more vulnerable patient groups such as mental health are becoming more common.

Concerns raised about such cuts are deflected with assurances that services have simply been ‘redesigned’. The lack of openness and denial services have been cut without significant consultation or risk assessment is contributing to the disconnect between staff and senior managers and leaving the staff feeling that cost saving is the only priority of the Health and Social Care Partnership in Argyll and Bute.”

Put bluntly, the driving force behind all management in social care is now money. That some so-called leaders abandon social work values and turn to bullying is the almost inevitable consequence. 

Another graphic, but rather different illustration of the loss of social work values, is provided by what happened by Drumbrae Care Home operated by Edinburgh City Council.  Care Inspection reports show that from late 2016 there was a steady deterioration in the quality of care at what had been a very good care home. This appears to be have caused by staff shortages – poor pay is an issue now even in Local Authority run services – and changing managers. 

In February 2018 the Care Inspectorate issued ten Requirements to the City of Edinburgh Council. Eighteen months later, none of these instructions to improve had been met and as a result, in December 2018, the Care Inspectorate issued an Improvement Notice threatening to close the care home down.  

Ten years ago when I was at Glasgow City Council, a single Requirement issued by the Care Inspectorate would have resulted in an internal inquiry into what had gone wrong, an action plan and a report to councillors. Such practices, designed ultimately to protect people who use services, were common across Councils, Edinburgh included. While there is always a risk of things going wrong in care services, it would have been almost inconceivable that even one Requirement would not be addressed with six months, let alone ten for eighteen months.

In March this year, an Edinburgh councillor – a Tory as it happens – asked a question about what had gone wrong at Drumbrae and was promised a report in June. That never appeared and I have learned now through a Freedom of Information request that it won’t until next February.  Although Drumbrae has now improved slightly, with grades of “adequate”, with the continued risks of Covid-19 one might have expected that managers would have wanted to explain the issues and take the opportunity to obtain additional resources if necessary. 

That expectation, however, is built on two assumptions.  The first that the City of Edinburgh Council and the Health and Social Care Partnership that manages services on its behalf, still has some leadership capacity in its services for Older People. And the second is that somewhere in the council there are spare resources that could be invested in services like Drumbrae if requested. 

In 2016, the Care Inspectorate, which oversees social work departments as well as individual services like care homes, conducted an inspection of Edinburgh’s services for Older People. The report highlighted serious failing so in 2018  the Care Inspectorate went back and reviewed progress. Among its findings:  

“There were ongoing and significant challenges in local supply, capacity and quality in areas such as care homes, care at home services, day care, respite care and self-directed support market segments”

“Many older people and carers were unable to get help even when their needs were critical or substantial. It was not uncommon for older people to wait for lengthy periods before getting the support they needed.”

“At the time of the inspection the senior leadership provided by the partnership was evaluated as weak. When we reviewed the partnership’s progress we found leadership weaknesses had continued following the inspection”

The picture portrayed is of a department that still had many people trying to do the right thing but had been overwhelmed with being asked to do ever more with less and leaders who could see no way out.  The appallingly low standards of care at Drumbrae, which should never have been tolerated, appears to have been just one consequence of that wider system failure.

Last month, Audit Scotland published a Best Value Assurance Report into the services provided by the City of Edinburgh Council. It showed that over the last five years that the council has made annual “savings” of £35-£75 milion. Amazingly, it also found council performance had improved in most areas, with the notable exception of care services. It appears, however, that the Council has now reached the very edge of a financial cliff, with nowhere else to turn. Despite this, Audit Scotland says the council must do more. The pressure is relentless and the leadership failures in social care need to be seen within this much wider context.

The Covid crisis has exposed the failings of the social care system, and alongside that its leadership, as never before. Throughout the crisis the silence in response to public concern has been deafening, with no-one prepared or able to speak about what has really been going on. This is not just about care homes or the provision of community services.  Where was social work, for example, when the Mears Group forcibly moved asylum seekers into six hotels in Glasgow that resulted in the tragic consequences at the Park Hotel in June?

Just when it seemed all hope in anyone in social care showing any leadership was lost, Social Work Scotland, made a hard hitting submission  to the Feeley Review on Adult Social Care. It explains many of the background issues that resulted in the current crisis.

The need to manage insufficient and finite budgets requires local authorities and Health and Social Care Partnerships to impose eligibility criteria that render the concepts of choice and control meaningless to a great extent”.

In other words, despite all the policy initiatives and spin about empowering people who need care the opposite has happened.

The financial reality is described in an appendix to the submission which estimates that “expenditure in 2018-19 was over £700m less than what would have been required to maintain services at their pre-austerity levels compared to the needs of Scotland’s adult population.”

And even then, services were only provided to those with high levels needs.  This has had the consequence that:

The provision of only critical level services presumes that intervention for anything less can be picked up by family or local community, and that the person has the capacity to organise and manage sometimes complex support arrangements”.

Instead of supporting families and communities to provide care, responsibility for care has been offloaded onto them.

“Social care – indeed all social services – should not just respect human rights, but proactively work to give human rights meaning and effect. That is only possible when people working in the social care system (and in particular social workers, who have statutory responsibilities to balance rights and risks in complex circumstances) feel empowered and incentivised to act in the defence or promotion of an individual’s human rights.”

This is absolutely right. It is an implicit acknowledgement that social work should have been at the forefront of defending the rights of those who have needed care during the Covid crisis, from asylum seekers to older people in care homes denied contact with their families. It can also be read as a plea for help and for public and political support.

The current leadership of Social Work Scotland clearly don’t feel empowered and incentivised to act in defence of human rights, they know things are wrong but the system prevents them from speaking out. he only people who appear able to do so are people like myself who no longer work in the system.

Rather than trying to assign blame to individuals for the multiple failures of the social care system, to move forward, we need fundamental reform based on a public understanding of what has gone wrong. If that is to be achieved, social work leaders need to be empowered to speak out about the very real constraints under which they operate and the way that they continue to be silenced. A National Care Service could offer an opportunity for real change. But it will only work if power is devolved and the people who work in it are able to prioritise care before money.