Select Committee on Health Written Evidence

18. Evidence submitted by the Commission for Social Care Inspection (PPI 144)


  1.1  The Commission for Social Care Inspection (CSCI) is the single social care regulator for England. The Commission is a statutory body whose primary function is to promote improvements in social care—across children's and adult's services, in local councils, and in the private and voluntary sectors of social care.

  1.2  CSCI welcomes the opportunity to submit evidence to the Health Committee on the subject of patient and public involvement in the NHS. CSCI is the body set up to register, inspect and report on social care in England. Our job is to improve social care and to stamp out bad practice. We assess social services functions in 150 local councils and our inspectors visit over 26,000 registered services.


  2.1  CSCI has a strong commitment to involving people who use care services in our work and to ensuring that the bodies we inspect involve their service users as widely as possible. We were represented on the Expert Panel on the future direction of PPI. The panel's work formed the basis of A Stronger Local Voice, which sets out proposals for LINks. Some of our evidence draws on information considered by the panel. In particular we endorse the panel's advocacy of a commitment to develop and build public involvement in more flexible and creative ways, rather taking an over-prescriptive approach.

  2.2  In line with the policy set out in the White Paper, Our health our care our say, the recommendations in A Stronger Local Voice apply to social care as well as to health services. So at CSCI we thinks it is vital that plans for LINks take full account of the particular context of social care. We believe that you cannot make recommendations on patient and public involvement in the NHS without understanding how involvement works, and needs to work, in social care. Our comments are mainly related to adult social care, as most of CSCI's responsibility for services for children will be moving to the new Ofsted before LINks come into being. However, as LINks will be concerned with services for people of all ages, we have referred to our experience of working with young people where we think it is relevant.


  3.1  There are some obvious links between health and social care, not least the overlap in the population of regular users (older people, disabled people). However, there are significant differences:

Social Care Health Care
Rationed (based on "eligible" need) Universal (based on clinical need)
Means testedFree at point of use
Social model (changing the environment around the person) Curative/Rehabilitative (changing the person)
Mainly long termMainly short term
Cash available in lieu of services (direct payments) Cash in lieu of services not allowed
Main adult user groups relate to disability and age Main user groups include those relating to disability and age but also many others eg maternity, accident and emergency

  Current thinking in social care is driven by the social model of disability. This is about enabling people to be active players in society, fulfilling their potential by removing the barriers that might prevent this.

  3.2  Within social care there are many good examples of user-designed, user-managed services, which can provide a model for devolving power to users. There is also more experience of user designed and user managed researchi than is the case in health care, and some creative examples of involvement for children and young people.

  3.3  Current initiatives are giving individuals the capacity to purchase their own care and design their own structures of support outside the health and social care professions, a different but significant form of "involvement".

  3.4  Most people want involvement at a local or even personal level. In the new landscape of "personalised" services, user involvement needs to include user control of the services closest to them. It is important that LINks take account of these developments.


  4.1  There is significant body of research on user involvement in social care (for both adults and children), which has been collated and evaluated by the Social Care Institute for Excellence. ii

  4.2  One of their overall findings was that people who are social care users are often marginalised in more general community involvement work (for example people with learning difficulties or very frail older people are often left out of general consultations and deliberative events). But good, tested models for their involvement exist.

  4.3  One of the repeated findings of research is how certain groups remain marginalised in wider involvement activity. There is a need to pay particular attention to people with minority communication requirements such as BSL or people with non-standard communication requirements, such as people with multiple impairments who do not communicate in words. "Not everyone is equipped to speak up. Everyone wants to know their views are taken into account" as one user told CSCI recently. iii

  4.4  LiNks need to be inclusive in their working methods, and to use of good practice from previous involvement activity in both health and social care. They need to be set up and to operate in ways that empower people who use services.


  5.1  A major focus of the work of the LINks will be on commissioning. The Overview and Scrutiny Committee (OSC) will need to work with the LINk to assess the quality of local commissioning. Ideally, work on service change and improvement will be collaborative; the involvement of people who use services will start from the belief that they have as much expertise to contribute as any other participant in the process.

  5.2  The best person to comment on whether a service is good is the person using it. This is especially true for people with long-term conditions, and this includes most people who use social care services. This basic premise should be upheld when designing any system where people might make judgements on behalf of the people who are using the service.

  5.3  The person who uses the service needs to be involved, and needs to be supported in ways that let them demonstrate their expertise. In practical terms this means things like providing planning information in accessible ways. In process terms it means involving people who use services at a sufficiently early stage that their input can make a real difference, including whole-scale redesign if required. It means developing specific opportunities for involvement for young people. There needs to be a developmental model, enabling individuals to gain as well as share knowledge, and enabling organisations to be sustainable. User-led organisations need a lot of support and investment to enable them to play an equal role in partnerships with commissioners and providers.

  5.4  LINks have a vital role to play in making sure that this support and investment takes place. LINks should provide a flexible vehicle for communities and groups to engage with health and social care organisations, will support and promote voluntary and community organisations locally and will promote public accountability in health and social care through open and transparent communication with commissioners and providers.


  6.1  CSCI welcomes the proposals in the Local Government and Public Information in Health Bill to give service providers a duty to respond to requests for information, reports and recommendations from LINks. (clause 155)

  6.2  We also welcome the power set out in the Bill to give LINks powers to refer social care matters to OSCs and the duty on the OSC to respond. (clause 157)

  6.3  CSCI is concerned at the proposals set out in the Bill to give LINks rights of entry to premises, notwithstanding the conditions that will accompany this right. Clause 156 allows the Secretary of State to make regulations imposing a duty on service providers to allow authorised representatives to enter and view, and observe the carrying-on of activities on, premises owned or controlled by the services-provider. We feel that this proposal does not take account of the difference between a health setting such as a hospital or clinic and a social care setting such as a care home.

    —  Care homes are just that—the homes of the people who live in them. Many are small, catering to only three or four people.

    —  Although the proposals are for representatives to observe activities not to inspect them, we feel that in practice this difference will not be clear to the provider.

    —  We believe that it is important that people living in care homes have as much say as possible about who comes into their home. We can see a value in residents inviting a representative of the local LINk to visit.

    —  But we remain concerned that LINk representatives would view their role as quasi-inspection and that it would be experienced as quasi-inspection. We think that the proposal runs counter to the current drive to reduce the volume of inspection experienced by providers.

  6.4  CSCI recognises the benefits of having non-professional input to the inspection process. We have worked extensively with people who use social care (including younger people) to find out what type of inspection they want. We have developed various methods to gather the views of individual care users, through surveys, one to one discussion and other direct communication. In addition, we employ "experts by experience", people who use social care services who join the inspectors on site visits to give a view of the service. All these methods have been piloted and evaluated, and people who use services have been integrally involved in their design and in their implementation. For example, our picture based communication kit was developed by Bristol and South Gloucester People First, a self-advocacy organisation of people with learning difficulties.

  6.5  Although CSCI's existing work on experts by experience was recognised by the Government in their response to the consultation on A Stronger Local Voice, we do not feel that the relationship between existing inspection work and the proposed visits by LINks have been sufficiently thought through. There is nothing in the current Bill that guarantees that visits to premises will be focused on giving people who use services a direct voice; instead they read as if they will reproduce older models of public involvement, where people speak on behalf of those who use services.


  7.1  We welcome the setting up of LINks as a co-ordinator of local involvement. We endorse the view that LINks should have the right to be involved and to be consulted by NHS and social care organisations. Equally, they should expect transparent and public communication with NHS and social care organisations. This includes the regulator, and CSCI will be committed to building working relationships with LINks, including receiving information about services from them. We see LINks as an important co-ordinator of local knowledge about service quality and an important conduit for the voices of people who use services locally. We welcome their role in bringing issues about social care to our attention and hope we will be able to work with them in gathering and checking evidence about services locally.


  8.1  It is already open to any member of the public to refer a concern about a social care service to CSCI. We expect that LINks will have a role in facilitating this sort of referral. We would also expect that their position as co-ordinators of involvement across an entire area would enable them to identify patterns of complaint and to draw relevant bodies' attention to these.

Dan Murphy

Commission for Social Care Inspection

January 2007


i  The Joseph Rowntree Foundation has supported a wide range of user-managed research, see

 ii  Has service user participation made a difference to social care services Sarah Carr SCIE 2004.

iii  Real Voices, Real Choices, CSCI, 2006.

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