Why we need to mutualise social care

By pooling their budgets, care users can have greater purchasing power to influence the market.

Britain is an ageing society, with healthier lifestyles and medical advances meaning that our older population will continue to grow. Many older people have lived their lives proud of their independence, and they value the control they have over their life choices. For these people it can be a frightening as well as a deeply disempowering experience to find themselves subject to decisions made by others. Some older and disabled people are told which day centre they will attend, who will come into their home to care for them, when and what they will eat, when they can socialise, sleep, bathe or even go to the toilet. In a time of austerity, with cuts to basic local services, it remains vital to meet the wider challenge of ensuring that people using care services preserve their power over what happens to them.

There are two changes already under way that start to address these problems: integration and personalisation. Integration seeks to remove the artificial barriers between services which are preventative or home-based (often commissioned using council funds) and acute services, such as hospital services provided by the NHS. By integrating the preventative with the acute, there is a clearer financial incentive to stop low-level health problems escalating.

Personalisation is an approach that gives the person using care services more control over what care they receive, who provides it, and what they want to achieve with the rest of their life. By giving the individual more control over what is done with the budget allocated for their care, with appropriate professional advice, they are in the driving seat.

Take-up of personal budgets, particularly of those taken as a cash Direct Payment, although growing, is still low, particularly for older people. There are barriers that need to be overcome to extend personalisation more widely, including better advice, guidance and facilitation for the service user and their carers, and a wider range of flexible services to meet new and changing needs.

Integration is a structural change; personalisation is based on empowerment. That principle of empowerment is key to improving a wide range of public services by making them more responsive to the real and self-defined needs of the people who use them. A logical next step for personalised care budgets is to expand its power to influence the market by encouraging the creation of clusters of budget holders. The cluster would be self-defined as far as possible, and would pool the budgets of a number of service users who have something in common that affects the service they want to receive. This might be as simple as living in the same neighbourhood, or it might be a shared ethnic or faith background, type of disability, or care objective.

By pooling their budgets, care users can have greater purchasing power to influence the market to provide appropriate services. If a group of Somali Muslim elders want to receive home care that is sensitive to their specific cultural needs, they may be able to commission such a service through pooling their individual allocations.

For optimum effectiveness, clusters need to be small enough for individual service users to know and care about each other; stable enough to deliver the outcomes required over a sustained period of time; and flexible enough to adapt as needs change or individuals need to move in and out. They require the full engagement of professionals at every stage so that individuals are supported in understanding their problems, agreeing a care plan that addresses their needs, and moving on when necessary.

This will inevitably lead to demands being identified that are not currently being met. As well as influencing existing service providers in the third, public or private sector, councils are well-placed to help develop new start-up enterprises to meet new needs and to provide the necessary oversight. Local authorities have access to office space; back-office systems including HR, IT and finance systems; and legal advice. They can facilitate mentoring from more established service providers, as well as holding budgets on behalf of users that could provide financing to new providers. By bringing these supply-side interventions together, councils can help develop new community-based services including social enterprises to meet changing demand. In some cases, this would also create new employment opportunities in communities experiencing high levels of social exclusion.

Pooling personalised care budgets is a model of mutualising care services so they become more responsive to the needs of the people they serve. If people don't like the services they are receiving, they can change them. If they want services that don't exist, they can help create them. This is not a panacea that can magic away the pain of funding cuts, but whatever level of resource is available, we will generate better value for money if public funds are used to deliver outcomes that service users want. 

Read RSA's new pamphlet The New Social Care: Strength based approaches

Steve Reed MP for was elected as member for Croydon North in November 2012, having previously been leader of Lambeth Council

Actor Tony Robinson joins campaigners protesting in support of social care opposite Parliament. Photograph: Getty Images.
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What happens when a president refuses to step down?

An approaching constitutional crisis has triggered deep political unrest in the Congo.

Franck Diongo reached his party’s headquarters shortly after 10am and stepped out of a Range Rover. Staff and hangers-on rose from plastic chairs to greet the president of the Mouvement Lumumbiste Progressiste (MLP), named after the first elected leader of the Democratic Republic of Congo.

Diongo, a compact and powerfully built man, was so tightly wound that his teeth ground as he talked. When agitated, he slammed his palms on the table and his speech became shrill. “We live under a dictatorial regime, so it used the security forces to kill us with live rounds to prevent our demonstration,” he said.

The MLP is part of a coalition of opposition parties known as the Rassemblement. Its aim is to ensure that the Congolese president, Joseph Kabila, who has been president since 2001, leaves office on 19 December, at the end of his second and supposedly final term.

Yet the elections that were meant to take place late last month have not been organised. The government has blamed logistical and financial difficulties, but Kabila’s opponents claim that the president has hamstrung the electoral commission in the hope that he can use his extended mandate to change the rules. “Mr Kabila doesn’t want to quit power,” said Diongo, expressing a widespread belief here.

On 19 September, the Rassemblement planned a march in Kinshasa, the capital, to protest the failure to deliver elections and to remind the president that his departure from office was imminent. But the demonstration never took place. At sunrise, clashes broke out between police and protesters in opposition strongholds. The military was deployed. By the time peace was restored 36 hours later, dozens had died. Kabila’s interior minister, claiming that the government had faced down an insurrection, acknowledged the deaths of 32 people but said that they were killed by criminals during looting.

Subsequent inquiries by the United Nations and Human Rights Watch (HRW) told a different story. They recorded more fatalities – at least 53 and 56, respectively – and said that the state had been responsible for most of the deaths. They claimed that the Congolese authorities had obstructed the investigators, and the true number of casualties was likely higher. According to HRW, security forces had seized and removed bodies “in an apparent effort to hide the evidence”.

The UN found that the lethal response was directed from a “central command centre. . . jointly managed” by officials from the police, army, presidential bodyguard and intelligence agency that “authorised the use of force, including firearms”.

The reports validated claims made by the Rassemblement that it was soldiers who had set fire to several opposition parties’ headquarters on 20 September. Six men were killed when the compound of the UDPS party was attacked.

On 1 November, their funerals took place where they fell. White coffins, each draped in a UDPS flag, were shielded from the midday sun by a gazebo, while mourners found shade inside the charred building. Pierrot Tshibangu lost his younger sibling, Evariste, in the attack. “When we arrived, we found my brother’s body covered in stab marks and bullet wounds,” he recalled.

Once the government had suppressed the demonstration, the attorney general compiled a list of influential figures in the Rassemblement – including Diongo – and forbade them from leaving the capital. Kinshasa’s governor then outlawed all political protest.

It was easy to understand why Diongo felt embattled, even paranoid. Midway through our conversation, his staff apprehended a man loitering in the courtyard. Several minutes of mayhem ensued before he was restrained and confined under suspicion of spying for the government.

Kabila is seldom seen in public and almost never addresses the nation. His long-term intentions are unclear, but the president’s chief diplomatic adviser maintains that his boss has no designs on altering the constitution or securing a third term. He insists that Kabila will happily step down once the country is ready for the polls.

Most refuse to believe such assurances. On 18 October, Kabila’s ruling alliance struck a deal with a different, smaller opposition faction. It allows Kabila to stay in office until the next election, which has been postponed until April 2018. A rickety government of national unity is being put in place but discord is already rife.

Jean-Lucien Bussa of the CDER party helped to negotiate the deal and is now a front-runner for a ministerial portfolio. At a corner table in the national assembly’s restaurant, he told me that the Rassemblement was guilty of “a lack of realism”, and that its fears were misplaced because Kabila won’t be able to prolong his presidency any further.

“On 29 April 2018, the Congolese will go to the ballot box to vote for their next president,” he said. “There is no other alternative for democrats than to find a negotiated solution, and this accord has given us one.”

Diongo was scathing of the pact (he called it “a farce intended to deceive”) and he excommunicated its adherents from his faction. “They are Mr Kabila’s collaborators, who came to divide the opposition,” he told me. “What kind of oppositionist can give Mr Kabila the power to violate the constitution beyond 19 December?”

Diongo is convinced that the president has no intention of walking away from power in April 2018. “Kabila will never organise elections if he cannot change the constitution,” he warned.

Diongo’s anger peaked at the suggestion that it will be an uphill struggle to dislodge a head of state who has control of the security forces. “What you need to consider,” he said, “is that no army can defy a people determined to take control of their destiny . . . The Congolese people will have the last word!”

A recent poll suggested that the president would win less than 8 per cent of the vote if an election were held this year. One can only assume that Kabila is hoping that the population will have no say at all.

This article first appeared in the 01 December 2016 issue of the New Statesman, Age of outrage