Child Protection for the Autistic Child - A Resource
THE MARKET IN CARE AND HEALTH SERVICES.
When I grew up the state provided health, care and education services. Now the state purchases many of these services from providers and private providers play an ever increasing role in service delivery.
How does this work?
Using one example and looking at what is needed to ensure good health and social care provision for learning disabled/autistic teens/adults. ( I've omitted education to 'keep it simple' Funding of SEND provision is explained in a blog by Matt Kerrhere)
Policymakers set the policy agenda at a national level by making law and setting budgets/providing funding. Delivery of the policy may involve a number of Government Departments each with different cultures, structures, policy priorities and budgets. In the case of autistic teens the Departments most involved are the Departments of Education, Justice and Health. The Department of Communities and Local Government also has as its over-arching remit ''to create great places to live and work, and to give more power to local people to shape what happens in their area" These departments need to work with each other to ensure 'joined- up' delivery.
There must be an over-arching strategy at a national level (Autism Act) and local level (Autism Strategy) and this strategy ( for this group, my own 'back of the envelope' list) must set out to deliver the following :-
·pathways for late diagnosis although the goal should be early diagnosis, even if we are not there yet. ·support for teens/adults and their families around diagnosis and management of expected difficulties. ·diversion pathways ( behaviour management teams/crash pad resource/respite?) for people in crisis to prevent the need to enter hospital/care/secure accommodation. ·secure learning disability/autism beds, ·‘step down’ pathways ( behaviour management outreach teams?) and ·community provision – suitable housing, shared lives, care support, work/meaningful activity/education, social interaction, choice.
Delivery The big challenge is to deliver the strategy. To make it a success there needs to be the right level of funding and and the right type of expertise including clinical, procurement, leadership, care, education and enough of everything/capacity for example enough expertise, secure beds, supported living etc - this is not just about money because if there is nothing to buy, more money will not help.
There also has to be clarity about who is responsible for which element of service delivery. Most strategies start from the position that the service should be responsive to local need. (what is 'local' though? - more about that below under ' budgets') This is where working with private providers comes in - seeing which bit of the strategy a provider can specialize in delivering and, of course to some extent, how much they can charge.
Over-riding issues of probity i.e. ensuring public funds are spent transparently and in the public interest, mean there must be competition between private providers.This principle also applies to delivery of many health services between Hospital Trusts - something the public may not be aware of. Providers who are good at competition are not necessarily the best to provide care and health services for lots of reasons around values, skill-sets and objectives and there are also potential problems about 'cherry-picking' of lucrative work. These are problems that cannot be solved with good procurement (purchasing at a large scale), brokerage ( purchasing on the level of one bed for one patient) skills, but it does take sector knowledge, long-term planning, capacity-building and experience. (a big lie-detector might be invaluable too.?)
Fragmentation Fragmentation between 'various bits' of the system is a considerable barrier to getting any strategy to work. To explain the problem, I recently heard a NHS clinician set out how the greatest pressures on ‘secure learning disability/autism beds’ in his area (land values relatively low beside an urban area where land values are relatively high) is currently coming from privately owned learning disability provider homes.
Features of these homes are :- ·They promote themselves as having skills and capacities they do not have (often because they fail to understand the needs of the people they are caring for or the costs associated with meeting their needs?) ·take children and adults from ‘out of area’, ·form no links with the local NHS. ·and when there is a crisis (often because they cannot deliver what they promised ) the person needs to enter a local NHS secure bed.
.....so for effective delivery there has to be an awareness of inter-dependence between all the bits of the system and all have to put the overall objective (meet the needs of autistic/learning disabled teens/adults) ahead of their individual objectives (make/not spend money) That is so unrealistic as to be dangerously naive so somehow the 'system' has to be configured to penalise providers who are not 'team players' and so on. These are 'market mechanisms' or 'market interference' depending on your perspective. There are also issues around information sharing - more fragmentation means that no-one can see the full picture, have the information they need to make informed decisions. This also touches on how risks are shared out as in 'if something goes wrong what happens?' or 'who can I complain to?'
Budgets One of the biggest problems concerns budgets. Not just how much is in the budget but who controls it. Local area budgets are meant to be addressing local need. All social care footprints (LAs) are relatively small. In some areas key decisions eg around housing are made at a semi-regional level. NHS footprints (CCGs) are different to those of the LA’s but also meant to be addressing local need just slightly different idea about what 'local' is - different footprints. NHS footprints are in flux because a number of initiatives around delivery of local health services for local people has proved all but unworkable in practice. Many areas, as in the example above, are providing a regional service in the public interest and the NHS is underwriting failure by private providers without recognition that this is causing difficulties for the NHS both locally and nationally. ( recognition of risk and who ultimately pays..)
All these 'local' bodies have different budgets. Pooling them takes commitment and negotiation practically on a patient by patent basis as things stand. That is where a strategy falls apart even if every other bit of it is working effectively. People just get stuck somewhere in this system.
Replication of the Model and its associated difficulties I think this model is largely being replicated in the youth justice system where the police are called into some children’s homes because these do not have the skills to address the problem behaviours of teens within these, even though they hold themselves out as having these skills. Children then enter the Justice system and may enter the Secure Estate. where it is unimaginably unsafe for them. Obviously this does not happen in all homes but it does happen.
Are there good private providers? Of course. In the learning disability / autism world they are often charities/enterprises set up and owned by parents of learning disabled/autistic children. Many of these find the process of ‘competition’ really difficult – they may only offer homes for very small numbers of people (is this not a good thing?) and they need help negotiating the ‘market/procurement’ maze that favours big providers. Medium and long-term relationship and capacity building by service commissioners is essential for these providers. There is also a risk that these will be 'sold on' to large providers once their owners come to retirement age and these larger organisations do not share the same values.
What cost and to whom? I've met many parent/patient representatives that have an unparalleled grasp of 'the system' if you can call it that. Many have been working on behalf of their children/ patients for decades. They are often in what is known as the 'third sector'.
I'm just not sure what is so wrong with directly commissioned services with pooled budgets where this is cheapest and simplest for those who really need health and services to work and for those with the job of delivering them. There is obviously a place for private providers too.