18. Evidence submitted by the Commission
for Social Care Inspection (PPI 144)
1. INTRODUCTION
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. WHY WE
ARE SUBMITTING
EVIDENCE
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. THE SOCIAL
CARE CONTEXT
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 tested | Free at point of use
|
| Social model (changing the environment around the person)
| Curative/Rehabilitative (changing the person)
|
| Mainly long term | Mainly 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. USING EXISTING
KNOWLEDGE AND
GOOD PRACTICE
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. FOCUS
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. STATUTORY POWERS
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. LINKS RELATIONSHIP
WITH INSPECTORATES,
INCLUDING CSCI AND
THE (TO
BE ESTABLISHED)
SOCIAL AND
HEALTHCARE COMMISSION
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. FORMAL AND
INFORMAL COMPLAINTS
PROCEDURES
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
REFERENCES
i The Joseph Rowntree Foundation has supported a wide range
of user-managed research, see www.jrf.org.uk
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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