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A “gloriously ordinary life’’: spotlight on adult social care Contents

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Chapter 5: Equal partners, better lives: co-production in practice and policy

253.This chapter looks at how, by moving social policy from its present detached position to a new model of co-production, the benefits of better design and delivery will benefit everyone. Co-production is one of the most urgent areas already within reach of change. It is grounded in a fundamental principle: older adults drawing on care to live as full lives as possible. This underpins the greater autonomy and respect that we also seek for the unpaid carer.

254.To achieve this, social care services must move from a transactional exchange to one which explicitly values and builds on positive relationships. To enable this, our attention was frequently brought to the principles and practice of co-production—a process in which decisions are made together as equal partners—through which disabled people and older adults can make their own choices and lead chosen, ordinary lives.

255.At the individual level, co-production means that people who draw on care can make better choices when it comes to designing and delivering their own care, in a process that places power and decision making into their hands. It ensures a more sustainable and effective service for the future.

256.Co-production also makes for better social care policy. The most systemic challenge, therefore, is the need to change the way social care policy is made. People who receive care or provide it currently have little or no voice or locus in saying what works best.

Co-production in practice

257.As discussed in previous chapters, the discriminatory narrative that surrounds older adults and disabled people has a direct impact on the support that is offered. The present transactional basis of the system is designed, as one witness described it, to “keep people out”, often by telling them to “go away, get worse and come back when you are in a worse position” in order to be able to access care and support.401

258.Moreover, we heard from experts by experience that they are often presented with services that are considered by social workers to be sufficient to meet their needs but might in fact be irrelevant or inadequate. One witness told us: “I am not seen as someone who is expert in me.”402 She recounted how, as a younger woman with mental ill health, she knew that acupuncture, a gym subscription or a walk on the beach would help her to get better, but social services would only offer her a day service, which she did not find helpful. “The starting point is that they do not listen,” she said.403 The National Care Forum also emphasised that people are not “properly” listened to when it comes to understanding what they want and need from care and support services.404 The consequence is that older adults and disabled people too often receive a service that does not respond to their needs. In the long term, this is ineffective and costly.

259.There are different ways to define co-production, and there is no one agreed definition. However, the Social Care Institute of Excellence says that co-production happens when people who use services and carers work with professionals in equal partnerships towards shared goals, a definition which we endorse.405 Similarly, the Association of Directors of Adult Social Care describes co-production as a way of involving people “from the very beginning”, by listening to them when it comes to identifying problems that need to be solved or questions that need to be answered. “Co-production means that power is shared more equally between those who use services and those who provide them,” says the organisation.406

260.Co-production is not a new concept. Although co-production is not specifically referred to in the Care Act 2014, the term appears in the legislation’s statutory guidance, which offers the following definition: “‘Co-production’ is when an individual influences the support and services received or when groups of people get together to influence the way that services are designed, commissioned and delivered.”407 More specifically, the guidance recommends that local authorities “actively promote” participation in interventions that are co-produced with individuals, families, friends, carers and the community.408 The Government’s 2021 White Paper also included plans for the CQC to assess local authorities, ICSs and providers using a new assessment framework that will be based on standards of co-production.409 Personalised care and support, choice, control, independence, and principles established in the Care Act 2014 and in the White Paper will be at the heart of this framework.410

261.Policy pledges made on paper, however, must translate on the ground as a genuine understanding and implementation of what co-production is and what it entails. Co-production is not a tick-box exercise: it is a process that celebrates ambitions and desires. It sees individuals as active agents of change who can contribute to society, rather than passive recipients of basic care. In a co-produced model of care, therefore, people are resources, experts and citizens, rather than ‘patients’, ‘service users’ or a ‘drain’ on the system.

262.The process of co-production starts by enabling individuals to tell care professionals what they would like, expect, want or need, and to be listened to. It requires a genuine conversation between the individual and the professional, which also includes the individual’s family or friends if that is the person’s wish. At the heart of a co-produced model is the imperative to create a sustained and two-way relationship between the individual and the care professional.

263.While co-production is so much more than this, many witnesses highlighted that it is also a more efficient way of working, by drawing analogies to business. “If you were a business, why would you design services without thinking about the needs of customers and service users?”411 asked one witness, while another one compared co-production to supermarkets who empower their customers to do their own food shopping.412

264.We were told that co-production “is about listening, understanding the world through people’s eyes and then doing something differently with that knowledge and information, and doing it together.”.413 Les Billingham, Assistant Director for Adult Social Care and Community Development at Thurrock Council, described it as moving away from professionals’ tendency to think that they “know best”, to the point where the person drawing on care is “in control.”414 Co-production in social care, therefore, ensures that services are personalised and tailored to individuals’ needs and desires, because support has been co-designed in a spirit of equal relationships.

265.One expert by experience explained to us what a co-produced assessment should feel like in practice:

“I would like to abandon all the forms… This is my ideal world and I would start with the person. It would just be so nice if you went and asked the person, ‘What are you hoping to achieve, and what would help you to get there’—two really simple questions. We do not need all this, ‘Tick here,’ and, ‘Tick there.’”415

This would be more aligned with the purpose of social care than current processes. In essence, it re-establishes the meaning of ‘social’ in ‘social care’.

266.Co-production works. It optimises individual resources and capacity; but it is also cost-effective because it is essentially preventative. The escalation of needs can be prevented, for example by keeping people out of institutional care. Mr Billingham, who introduced LAC’s co-produced approach to care (see Box 5) in Thurrock Council, told us that Coordinators “have had dramatic success,” for example in resolving both the symptoms and longer-term challenges faced by people hoarding—a mental disorder characterised by the accumulation of possessions due to the excessive acquisition of or difficulty to discard possessions.416 The LAC network also told us that there have been several independent academic evaluations carried out on the model since 2009, which have consistently shown reductions in: visits to GP surgeries and A&E; dependence on formal health and social services; referrals to Mental Health Teams and Adult Social Care; safeguarding concerns; evictions and costs to housing; smoking and alcohol consumption; dependence on day services; and out of area placements.417 An analysis carried out specifically in Derby City Council, who introduced LAC in 2012, found that the model is delivering “significant” social value with up to £4 of value for every £1 invested.418

Box 5: Strength-based approaches

We heard various examples of best practice demonstrating that co-production is not an abstract concept, but a viable approach that can be implemented in practice and bring about tangible benefits. Many witnesses referred to “strength-based” or “asset-based” approaches, meaning that the emphasis is placed on people’s aspirations and existing gifts and strengths, alongside their needs. One witness told us that this means “thinking about what is strong, not what is wrong.”419 These strengths could include personal resources, such as relationships, skills or experience; or resources in their community, such as people, spaces, networks or services. A ‘strength-based’ or ‘asset-based’ approach seeks to identify these strengths and enhance them, if necessary thanks to additional care and support, to enable individuals to achieve the life they would like to lead. Local Area Coordination: A strength-based model in practice Local Area Coordination (LAC) has existed in England and Wales for over 10 years, and there are now 12 local authorities across England and Wales that have implemented it. The LAC Network relies on Local Area Coordinators, who are employed by local councils and work across neighbourhoods of approximately 10,000 people. Coordinators are integrated into the local community: they have hyper-local knowledge of people, families, groups, organisations and services. Their role consists of approaching individuals who might have care and support needs, or be at risk of needing support, and to help them build their own vision for a better life, with the objective of drawing on personal, family and community resources to find pragmatic solutions to any challenges they face.420 For example, one case study in Derby City Council saw a resident get in touch with a Local Area Coordinator because she was dealing with various physical and mental health issues following the recent loss of her husband. After several conversations, an opportunity to improve her life emerged as it became clear that she had enjoyed looking after her garden with her husband but was not capable of gardening anymore due to her declining health. The Coordinator arranged for her to meet with a local resident who they had also been helping, and who had been looking for opportunities to volunteer. They agreed to help with her gardening, in an arrangement that also resulted in both residents feeling less socially isolated.421

Valuing the local community

267.In many cases, successful co-production is grounded in the local community, which is key to weaving the web of local relationships that enables people to live an independent and meaningful life. Therefore, as one expert by experience told us: “I think an essential part of the role of social care is being involved in community development, knowing what is going on in the community and being able to connect people with one another.”422 The local community can often offer support that is nearer and more adapted to people’s needs, and more likely to enable them to achieve their goals. It often emerges, during conversations between practitioners and people with care needs, that joining a local group, meeting local people, finding out about volunteering opportunities or accessing advice and information is an effective way to ensure their wellbeing. In many cases, it is more effective than being signposted to institutional services that are not tailored to their personal needs.

268.For example, Martin Samuels, the Strategic Director for Social Care and Education at Leicester City Council, told us that when the council’s meals on wheels provider gave notice on their contract, he was initially tempted to find another partner to deliver the same service; but then decided to first engage with each person who received the service to find out if they could find an appropriate alternative in the local community. From lunch clubs to local pubs running a group: “For every single one of them, we were able to identify a means by which they could engage with their local community, so that they were able to address that need and ensure that they received meals,” he told us.423 We heard that this “fine-grained” knowledge of local communities is what has been lost in social care.424

269.We were also presented with evidence that investing in the local community comes with significant benefits. Somerset City Council, for example, started a programme of change in 2014 to help people start and run small, independent enterprises offering various forms of care and support in their local area. This ‘micro-provider’ initiative has been extremely successful, and ranges from groups taking people with dementia out to give their carers a break, to peer support groups for people with mental ill health.425 There are currently 849 micro-providers registered on Somerset City Council’s community directory;426 and the additional capacity that has been created is saving the council around £2.9 million per year.427

270.The local community cannot be a replacement for regulated care. Witnesses stressed that regulated care is necessary, but that developing a local offer alongside it means that people with a lower level of need are likely to find appropriate support without drawing on formal services.428 This means that a stronger offer of support in the local community has the double benefit of better serving citizens, while protecting regulated services for those who most need them.

271.This proved to be correct when the social care system came under pressure during the COVID-19 crisis. We were told that local authorities who had been funding local micro-organisations had created an “effective safety net and support structure” that was more resilient and respondent when the pandemic suddenly hit, and institutional services found themselves overwhelmed.429 We heard that:

“For local authorities that had invested in that [micro-organisations] there were people on the ground who knew who would need prescriptions, who would need food, and so on.”430

272.The COVID-19 pandemic also saw people and communities come together to look out for each other, which was better harnessed in communities where investment in community-minded approaches was already happening.431 Gillian Keegan MP, then Minister of State for Care (2021-2022), told us that the Government is “very keen” to learn from and build on the lessons from the COVID-19 pandemic; she argued that this means commissioning and increasing the offer of local care and support to enable people to remain independent.432 We agree that this should be the direction of travel for the Government. As one witness told us: “We want more groups, clubs, associations and services that are going to be a menu of support for people who might need a bit of help to live their lives in the future.”433

273.Stronger local communities are a key part of achieving the vision of choice and control that is needed in social care. We were told that both unpaid carers and individuals who draw on social care have often chosen to use community support and activities rather than organised day services.434 Future policy must be based on this lived experience—which is also an opportunity to redefine the relationship between state intervention and citizen action, and re-establish the place of care in the social fabric.435 This will require genuine commitment from the Government and local authorities towards organising social care differently, based on co-production, and therefore focusing on community-based services that are new and transformative. This commitment must come in the form of dedicated funding to support community capacity, local people and organisations.

274.The Government should recognise the potential cost-effectiveness of co-production, and the role of local communities and micro-providers in enabling co-production, choice and control for disabled adults and older people by ringfencing funding for local authorities to dedicate to investment in building community capacity, learning from what is working well, and to connect residents to local offers for care and support that are tailored to their needs.

Co-production in social care policy

275.Co-production is a key way to enable individuals with care needs to co-design the care and support they receive at a personal level, but it can also be used at a policy level, to ensure that local and national reforms are grounded in lived experience.

276.Policy that is co-produced with people who have lived experience, like care that is co-produced with the individual, is more likely to be effective. It is more certain to lead to a system designed to respond to the needs that individuals have expressed themselves, rather than to the needs that have been identified by people who are further removed from the social care system. This also “helps inject a much-needed degree of positivity and optimism into the debate about the future of care and support”.436

277.Research undertaken by the Centre for Seldom Heard Voices at Bournemouth University with a range of diverse communities illustrates how co-produced participatory research can lead to wider social impact and awareness of those that rely on social care—for example, the experiences of LGBTQ+ citizens, older male carers, young disabled people and homeless people.437 It is vital that social care practice and research work in partnership with individuals and communities to achieve best outcomes for those who require social care support.

278.We heard from Ms Dyson at the start of our inquiry that while her definition of co-production did not reach “the high standards” set by the Committee, the Government is “really happy to learn and to do it better in the future.”438 Ms Dyson explained that while the 2021 White Paper has been produced in consultation and collaboration with more than 200 organisations and individuals, the challenge now consists of embedding co-production as the Government puts its commitments into practice.439 It is essential, therefore, that individuals with lived experience are encouraged and supported to come to the policy-making table “as equal partners,” so that their role in shaping the design of adult social care at the local and national levels becomes central to the process of policy making.440

279.Co-production is already in place in some local authorities and is making a difference. Box 6 demonstrates examples of best practice in co-production in policy making.

Box 6: Best practice in co-production

Croydon Council Croydon Council set up the Croydon Adult Social Services User Panel (CASSUP) bringing together service users, carers of service users and Croydon residents who have a strong commitment to improving adult social services. The panel meets six times a year and works in partnership with decision makers. They represent the views of the community to improve service delivery and access to social care services.441 Leicestershire County Council Leicestershire County Council have co-produced their new review form and process. It went from being a form “focussed on tasks such as washing and dressing” to one that is “largely blank and starts with ‘what matters to you?’”. This enabled people who draw on care to “feel more in control.”442 Devon County Council The Council highlights the number of ways they ensure disabled adults and older people and unpaid carers can have their say. Adult social care engagement within Devon is coordinated by Devon’s Involvement and Equality Team, based within the adult commissioning part of the Council. They work in partnership with Living Options Devon as holders of a contract to provide local engagement activities, and undertake some activities themselves. The Council also commissions Healthwatch Devon, the local statutory consumer voice organisation and works with the County Council’s independent Equality Reference Group.443

280.We have already set out evidence that unpaid carers do not feel acknowledged, let alone represented or valued in society. This is particularly the case in policy making: there is no specific plan or strategy to support unpaid carers and they are not given a voice at senior levels of Government. One witness stated that “one of the fundamental problems about social care is that it is based on kindness and this does not seem to be valued by society in general.”444

Learning from the best: the role of local authorities in generating and spreading change

281.As we have seen, some local authorities and local communities are already putting cultural change in place across social care to enable co-production, both at the level of residents’ individual care and at the level of policy design and delivery across the locality. These examples demonstrate the possibility of moving beyond policy pledges towards the effective implementation of co-production in social care. They provide avenues to explore to develop the practical tools that can lead to a genuine cultural change.

Embracing a new narrative

282.A particular example that we would like to highlight is that of Wigan, presented as a “fantastic example of co-production.”445 In 2011, Wigan Council kick-started a major project named the Wigan Deal, intended to bring a new approach to public services, and which launched initially in adult social care. Professor Hall, who was the chief executive of Wigan Council at the time, explained to us why this was the case: “We realised we were spending money on lots of things that were not very good and people did not actually enjoy them, but we thought they were the right thing for people because we had not listened,” she said.446 In reality, the services that were provided were not what people needed or wanted.

283.The Deal was introduced in an attempt to become more efficient as the council faced drastic funding cuts. The project radically shifted the narrative from looking at residents as a collection of needs and problems to be fitted into a range of services, to viewing people as individuals who have strengths and talents, and who can be enabled to live the best life they can. It meant considering the strengths of individuals when carrying out assessments, such as their environment, life stories and interests; and looking at the bigger picture of peoples’ lives to enable them to take steps to improve their health and wellbeing. Instead of letting professionals assume, often wrongly, what someone with a need for care or support might want, explained Professor Hall, the council prioritised having a conversation with the person to find out how they could be empowered to live a better life, “based on what they like doing rather than what we think they like doing.”447 This narrative reflects the vision of adult social care that we endorse, in which people are treated and valued as equals, and in which it is understood that they are best placed to know the solutions that are most effective for them.

284.To enable this change, which was both practical and cultural, Professor Hall explained that staff in front-line teams were given “absolute permission to innovate,”448 with the objective of enabling staff to rethink how they worked based on their conversations with residents. For instance, one member of the Wigan adult social care team took an older person roller-skating, in contrast to the typical trip to Marks & Spencer. While they broke their wrist, roller-skating was something that the older person had wanted to try and they made an informed decision to do so. As a result, the team member was backed by their manager. This compares with a feeling that social services often go too far to protect people from risk.449 Thanks to this new way of working, the council was able to make savings, which it reinvested into the community and voluntary sector, as well as in preventative services, particularly in reablement, to ensure that people coming out of hospital stayed in their community.

285.The Wigan Deal illustrates the point made in a recent report led by Lady Cavendish that “there is a huge prize to be won” if the commissioning and regulation of care services is transformed.450 She argues that commissioning services should be based on outcomes and truly focus on the individual, and that this can have a significant positive impact on costs and people’s wellbeing.451 Achieving this requires a new model for the regulation and oversight of services, as well as giving care staff the autonomy to adopt a new approach to the delivery of care, in which they look after a whole person instead of merely following a process. The report points to the example of the not-for-profit home care provider Buurtzorg, which is based in the Netherlands, and is known for giving staff far greater autonomy and control over their daily work. Independent studies have found that in addition to higher levels of patient satisfaction, Buurtzorg’s costs are almost 40% less overall than competitor services.452

286.A study carried out by the King’s Fund into the impact of the Wigan Deal on adult social care established that the approach has similarly had promising results in the locality, both for professionals and residents. The CQC assessments show that the quality of social services in Wigan has improved, that the healthy life expectancy of residents has increased, and that the council performs well when it comes to supporting people to leave hospital and remain in the community. Staff engagement has also improved, as professionals feel liberated to practice in a different and better way.453 Crucially, the Wigan Deal was shown to be more sustainable, including economically. Working in this innovative way meant that people’s needs were better met, that they were more able to live healthy and fulfilling lives, and that they became less likely to constitute a strain on the social care system, as well as other public services. Professor Hall told us that before the Deal, Wigan City Council was spending on average £250,000 per year on families in need without seeing any significant improvements to these families’ situations; in contrast, since the Deal was established, the council made significant savings across all public services.454

287.The King’s Fund analysis of the success of the Wigan Deal states that “above all else, the Wigan Deal is a story of profound cultural change within the council and its partners.”455 This came from a new set of “positive beliefs” about the purpose and outcomes of adult social care, and trust in the potential of staff and local residents to bring about the necessary change. The council succeeded in enabling this cultural change because it consistently embedded its new narrative across the local authority. The King’s Fund describes that “a common vision was forged early on” and “a clear narrative” was developed for all staff to refer to.456

288.The importance of having a clarity of purpose and a cohesive narrative to steer local authorities’ work in adult social care was also highlighted by Professor Tew, who argued that ensuring the “crystallisation of a vision” is key to successful change.457 He explained that local authorities rarely manage to put the changes they would like to make into a “very clear, simple vision that everybody gets.”458 Without this, however, it is challenging to ensure the success or the continuity of any reform. Professor Hall told us that “very often, people come in in a heroic leadership way, whether as a political leader or executive leader. They set out a vision; that person leaves and then there is a new version when a new person starts.”459 In contrast, the Wigan Deal was designed as a long-term, more bottom-up cultural change across the whole community.

289.For this vision to be effective and successful, it must be co-produced with carers and older adults and disabled people, as well as building on the expertise of people who work in adult social care.460 Many witnesses pointed to Think Local Act Personal’s (TLAP) framework ‘Making It Real’. This is a framework for how to do personalised care and support, for people working in health, adult social care, housing and for people who access services. TLAP described it to us as a way to take the principles and values that should underpin social care, as well as the existing policy and law, such as the Care Act 2014, and transform them into something “real and tangible”.461 Making it Real takes the form of a set of principles called ‘I’ statements, which describe what good looks like from the perspective of people with care needs; and ‘We’ statements, which describe how organisations can meet the ‘I’ statements. All of the ‘I’ statements have been co-produced, meaning that the framework can be used as a tool to frame the conversation in a way that ensures a vision, purpose and focus that are rooted in co-production.462

290.The framework is designed to help decision makers understand what their actions and priorities should be in order to achieve principles such as choice, control or person-focused care and support. The CQC is adopting it as part of its new assurance framework from 2023.463 TLAP has been working with several local authorities to implement the framework, including Leicester City Council, who told us that Making It Real has played a significant role in helping the council to work more closely with residents and to put people’s voices at the centre of reform.464

The workforce: a key to unlocking cultural change

291.Better training and upskilling for social workers was frequently described as critical to enable the success of co-production and cultural change within local authorities. Professor Hall said that bringing the workforce onboard with the project was crucial. She hired an anthropologist to retrain all of the council’s adult social care workers “to listen deeply” rather than “just assume what we knew was best for people”; and a ‘Different Conversation Toolkit’ was designed for staff.465

292.We heard from Martin Samuels, Strategic Director for Social Care and Education at Leicester City Council, who told us that the council is now undertaking work to understand the challenges to engaging with residents, in an effort to bring “user-led” voices to the centre of services. This has meant revising guidance and policy to make processes more person-centred; changing the assessment and review process; and retraining staff to ensure that they “focus on the individual.”466 For example, staff have been trained to move away from processes and towards individuals—making them accountable for the outcome of the individual rather than simply being able to say that they followed the process.

293.Mr Samuels noted that some staff found it challenging: “They have found it culturally a real threat to their position in the system and their way of thinking.”467 This was echoed by Mr Billingham, Director, Adult Social Care, Thurrock Council, who noted professional scepticism and cultural resistance when Thurrock Council introduced Local Area Coordination. This was particularly the case as budgets reduced, and LAC increasingly became perceived as a non-statutory service that could more easily be stopped. He described how concerns dissolved after people started seeing the positive outcome of the scheme.468 “We held our nerve and our ground, and I am so pleased we did, because it has been the fulcrum upon which all of our transformation since has been built,” concluded Mr Billingham.469

294.The British Association of Social Workers also highlighted that meaningful participation with people, families and carers requires “a skilled approach” or runs the risk of becoming “tokenistic”.470 Improving the assessment of local authorities’ performance regarding co-production is encouraging, therefore, and we welcome official commitments to the principles of co-production. The challenge, however, lies in enacting these principles in practice. To enable this, it is necessary to reskill the workforce, to ensure that co-produced approaches to care are embedded in professionals’ processes.

295.The Government should ensure that the definition and vision for social care that is proposed by Social Care Future, as specified previously, is endorsed in principle by all national social care bodies (such as Social Work England, the Care Quality Commission and Skills for Care) to put the best ambitions and values of the workforce into policy and practice more effectively.

296.The Government should work with local authorities, the voluntary sector and social care providers to embed the principles of co-production. This means working with social care staff to enable them to acquire the support and skills necessary to co-produce care and enable a shift in power from staff to individuals who draw on care and support.

Sharing good practice and robust data

297.The benefits of co-production are also evident in the innovative ways that have emerged in terms of developing, embedding and scaling-up good practice through, for example, informal channels of sharing information. For instance, national innovations such as the Local Area Coordination Network bring together a diverse range of stakeholders working to develop strength-based approaches. Likewise, academics at the University of Birmingham have studied practice across local authorities, examining the development of preventative and capacity building activities through a range of models.471 Just as people who draw on care and support, local authorities and their partners benefit from peer support: “There is a chance for them to compare notes, support each other, and learn from each other’s mistakes in a wider community of practice.”472

298.However, existing networks are often informal and underutilised. For instance, Shared Lives highlighted how there is a Shared Lives scheme in most local authorities, yet these are relatively unpublicised compared to traditional methods of care.473 There is also a lack of reliable data and evidence-based research that could help identify the exact costs and benefits of new approaches to social care. It can also be difficult for local authorities and other stakeholders to evaluate new ways of working and to understand the costs, benefits and limitations of new models. However, there are lots of positive examples and a growing range of support available from organisations such as the Social Care Institute for Excellence, the NIHR School for Social Care Research and IMPACT (the new UK centre for implementing evidence in adult social care).474

299.Good policy and practice have been conspicuously inhibited by a lack of data. The Government, as a priority, should invest in robust data collection to reveal the conditions and characteristics of the social care sector and inform effective practice.

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