Care and the Community
A few weeks ago Dave moved his 90-year-old mother Olive into a care home in Newquay in Cornwall. It is a familiar story - his mum was about to be discharged from hospital and he urgently needed to find somewhere he could trust to look after her.
Power is moving away from central government towards local people
The council suggested a place: it had two-stars on the government rating and the leaflets looked promising. When Dave visited, all appeared well and eventually the time came when he had to let go of Olive's hand and leave her in the care of strangers.
You can guess what happened next.
"The experience she suffered was unbelievable," he told me. "She was left unattended for long periods of time, crying 24-hours a day, meals being dished up cold, no-one coming to see her and getting left in her room cold - absolutely horrendous."
Now Olive is in a home where she feels safe and happy. But Dave believes it was ongoing government changes to the system for monitoring care homes that left his mother exposed to neglect and maltreatment. Ministers are pushing ahead with plans to replace regular national inspection with a "localism" model, relying on residents and their families alerting the authorities to problems.
"Most ordinary people won't want to be the whistleblowers," Dave told me. "They will sit back and take it because they don't want to get involved, they don't want to cause a fuss and a stir. I got very upset over the care my mother was getting and the things being done to her. I had to take action. She was one person among 36 people. There are 35 other people still in that home who must be suffering the same kind of treatment."
Dave's point goes to the heart of the debate over localism. It is less an argument about whether it is sensible to give "power to the people", and more about whether people are ready and willing to use that power.
"People have become infantilised by their relationship with central government," Care Services Minister Paul Burstow told me in his office at the Department of Health this week.
"There's an assumption that somehow from behind a desk in Whitehall we can flick a switch and make things totally different and improve quality overnight. That's never been the case. The last government spent 13 years trying to run both the health service and increasingly care services from this place, from Richmond House in Whitehall. It didn't work."As the government's framework for adult social care explains:
"We can no longer rely on top-down programmes or performance management ...the balance of power is shifting dramatically - away from the centre and towards councils managing their own future, and empowered local communities holding them to account."
The Care Quality Commission (CQC) is the reformed regulator of all health and adult social care in England. Everything from dentists to cosmetic clinics must now meet a list of "essential standards" in order to be registered. Gone are the days when dedicated care home inspectors make regular visits to every facility, checking safety and issuing stars for quality.
Dave has had to put his trust in strangers to care for his mother
As the CQC explains: "We rely on people who use services and those who care for and treat them to tell us about the quality and safety of services. This feedback is a vital part of our dynamic system of regulation which places the views, experiences, health and wellbeing of people who use services at its centre."
The old system was never perfect - assessments could be out of date almost before the ink was dry on the inspection report and local authorities had been campaigning for greater control - but there are concerns that the new "dynamic" approach is untested and may be unsafe.
I went to see the Relatives and Residents Association at its headquarters in north London. The charity's helpline was ringing off the hook with worried individuals trying to get advice on how to navigate to a safe harbour for a loved-one. Chief Executive, Judy Downey, points out that national regulation was introduced after failures in local monitoring led to a string of scandals.
"We would never have had scandals in care homes or in any residential provision if the local theory had worked. Why didn't they know, why didn't they report it, why didn't we all hear about until it was much too late, until there were dead bodies or something really tragic happening to those people? We set up a national system of inspection which everyone agreed was a really good way forward, but the trouble is it has never been allowed to bed down. It has been very easy to dismiss it as not working before it was given a chance."
English councils are expected to improve their monitoring of care home standards just as they make cuts to adult social services, squeezing commissioning budgets and looking to find efficiencies in backroom quality assurance operations. The head of CQC, Dame Jo Williams, recently made the point herself: "The providers will be asking themselves: what can I do to cut corners?"
It is not just central government inspection of care homes which is being cut back. Ministers have also scrapped official assessments of how well local authorities commission care services. In future, councils' responsibility to ensure good standards will be monitored by a new local consumer champion HealthWatch, which itself relies on local authority funding. The NHS Confederation has warned of "inherent conflicts of interest" with a council funded body scrutinising its paymasters.
The coalition stress the importance of "choice" in driving up standards of public services, but in adult social care, even the CQC accepts that, with the abandonment of the star-rating system, consumers no longer have "an easy at-a-glance view" of the quality of care homes in their area. There are plans for an "excellence rating" but this will be voluntary and providers will be obliged to pay for the inspection.
The chief executive of the not-for-profit provider Anchor Housing, Jane Ashcroft, suspects the fee might be around £10,000 for a mid-sized home:
"At a time when funds are under pressure paying for assessment twice makes no sense. What we want to do is put money into services for our residents not pay for another layer of bureaucracy."
Ministers remain convinced that localism is not so much a gamble as an opportunity for the care home sector, that networks and systems will develop from the grass-roots to drive up standards and root out problems.
But just as Dave had to let go of his mother's hand and trust in strangers, so localism requires us to let go of the state's grasp and trust in our neighbours.