The future of adult social care: ADASS President Phil Holmes on funding, reform and local government

Phil Holmes is the President of the Association of Directors of Adult Social Services (ADASS). Phil has been a Director of Adult Social Services for 11 years across two councils and has served two spells as ADASS Regional Chair for Yorkshire and the Humber. He is the Executive Director of Adult Wellbeing and Culture for the City of Doncaster Council, and a qualified social worker with a strong passion for social justice. 

Timestamps:

00:45 A rage against injustice in adult social care
05:32 The impact of the Care Act
08:03 Centrality of local government in the delivery of adult social care
09:41 Baroness Casey’s commission and its implications
13:03 Opportunities for local government in adult social care
16:15 Opportunities and collaboration in a period of significant change
19:07: Impact of wider local government reforms on adult social care
22:41 What should a sustainable funding settlement look like?
25:14 Learning from best practice in local government

You can watch the full interview on Youtube here

In your inaugural speech, you spoke about bringing rage to your presidency, a rage against injustice. What injustices do you see in the system, and therefore what do you hope to achieve in the next 12 months?

The rage comment was funny because it was made as a bit of a joke. My predecessor, Jess McGregor, the Director in Camden, used a mantra called to act is to love. So, focusing on action, which comes from a place of bringing people together. So I made a joke about maybe I should be the president of rage. But what I ended up saying in the speech was connecting people, building bridges. Working in that way was the only way to go. But, the rage thing has stuck a bit because it got misreported in one of the trade journals. And I think it’s not unhelpful to me that people understand that motivation around social justice. 

Because I think what that does is help us tell a different story about adult social care. I think maybe nationally, or the public, think about it as assessments, waiting times and care arrangements. Actually, what it is, is about making sure that people who might need care and support from whatever age they are in their life, because we know that people who are young people with special education needs and disabilities, preparing for adulthood, through to the very oldest people in our society.

They all have human rights, they all have hopes and dreams, that shouldn’t be extinguished by a medical condition, a disability or any kind of problem. Reminding ourselves that that’s what we’re there to do, and recognising that there’s still plenty of injustice around to address. In a world where people are pretty angry about being left behind, it’s not an unhelpful dynamic. But I’m really not the president of rage.

Harnessing a bit of impatience and a bit of determination to make things as right as they can be in my year of office is definitely motivating.

Where do you see that motivation leading over the next twelve months? What are your biggest aims?

For me, it’s about trying to work in the right way as president. So again, inheriting some of the ways that Jess works, as my predecessor. There’s probably three things that feel really important to me making good on the progress that Jess has made and also our many predecessors. So the first thing is getting out and about, connecting adult social care up and down the country, because if I’m in a policy bubble. I currently work in Doncaster, I’ve been there for seven years. I previously worked in Sheffield, before that in Derby and then in some London authorities. But if I’m just speaking from the basis of my experience in Doncaster now, my historical experience in other places, I’m not really providing a massively helpful lens. If I’m connecting with practice up and down the country, then I’m representing a great breadth of experience. 

My first priority is to get on my bike, get up and down the country and see adult social care working well in different places and also see some of the barriers that it’s experiencing in different places. 

The second priority is that there’s so much change going on at the moment and I think on the whole there’s good change, but everything’s happening all at once across different areas of government reform. So, my second priority is to be a good ally to that change and help it land constructively. Ensuring that nationally, people aren’t throwing any babies out with the bathwater. And they’re telling a story that makes sense because often it feels to people like there’s so much change they don’t know whether they’re coming or going. They need a narrative to land things well. 

The third thing, which probably connects a bit, is just to tell a clearer story of adult social care. It’s people understanding that adult social care is how we want to live and how we want other people to live. It’s the caring responsibilities that we might have, it’s the ageing that we will experience, and it’s also the people that we see around us living with some things that are visible and some things that are invisible. And thinking why shouldn’t they have the same opportunities that I have. 

So telling that clearer story. This is something that ADASS have been doing through our Care Can’t Wait campaign, which is getting people drawing on care and support to tell their own story and explain what’s working well and not making everything into a catastrophe. Showing that good adult social care is happening up and down the country. The failure is that we need the support to make it happen everywhere, all at once. So that good practice isn’t just spotted around in different places, but it’s something that everyone experiences everywhere.

I want to come back to the second point you were talking about with the sort of change and the pace of change. I’m just wondering, because you started as a qualified social worker and as you mentioned, you’ve been in lots of different local authorities, what sort of changes are you thinking of there over the last decade, and what, on the other hand, has stayed the same?

I think the biggest bit of positive change, over slightly longer than the last decade, would be the Care Act. The Care Act brings together adult social care legislation in a clear way, but also began with key principles, human rights, prevention and inclusion.

You don’t meet people working in adult social care who would say, “We need to rip up and start again” or “The fundamental statutory basis of adult social care is wrong.” But what people will say, and I think that’s the challenge of the Care Act hasn’t, by itself, magicked up a new way of doing adult social care. Some of the methods and the orthodoxies that the Care Act was trying to get away from, are still there and are still quite strong.

I think the idea that the Care Act was about, how can I start with the person, how can I start with the environment that they’re in, the assets, the strengths that they bring, how can I build my statutory responsibilities off the top of that. 

Going back way further, before I was a social worker, say that the Community Care Act was almost a factory model of adult social care. I’m going to assess you, I’m going to see whether they’re eligible or not. If you’re not eligible, I’m going to hold you at arm’s length.

Councils don’t just do that; councils connect really well with their communities, understand what’s going on, and are building that up. But it still feels like the dominant orthodoxy is gatekeeping, also in the context of councils having lost a lot of resources through years of austerity. 

There’s still something fundamental about the Care Act being there. But it could still feel more alive in the way that adult social care is experienced by people. Quite a lot of that is around the experience of austerity the councils have had, and maybe how they’ve retrenched a bit off the back of that. 

All the hollowing out of councils that we’ve heard about, so the preventive services, the infrastructure in communities maybe not being there, and the way that it would have been when the Care Act was first envisaged. So, you see that journey, and there’s quite a lot of variation as well, so what I’m really not seeking to do is paint all councils as the same.

Councils today are facing a different range of issues. They’re not all exposed to the same degree of challenge. Some are looking headlong into local government reorganisation; some have had elections in May that have significantly changed the politics and the people they’re working with. There’s quite a lot of variation that councils are dealing with. 

Those general challenges we’ve all got are very differently experienced in different places. What I would say, though, and I’m really glad Baroness Casey has been so strong in saying this, is that local government is the place to do adult social care, because adult social care starts with what people need to live a good life. It doesn’t start with what medical treatment they need in the NHS. It starts with how do I get out and about? What does my environment give me in terms of opportunities? How is my local economy flourishing? Adult social care sits on top of that.

And if it connects well with local authorities, then it can still do okay. But if it turns into a treatment service, a safety net treatment service, as we might experience in other parts of the NHS, then it’s probably missing a lot of opportunities.

You’ve mentioned one of the principles that you think is correctly being identified in the report of the centrality of local government in the delivery of adult social care. What are your hopes for what the report can recieve more broadly, and what other principles would you consider when considering reforming social care?

Baroness Casey is clearly exactly the right person to be leading the commission. I think she’s correctly identified that the public needs a clearer conversation about adult social care and what it means. I think she’s framed it in similar ways that I have, around, what are your rights? What rights should you have? What responsibilities should you have? What is living and ageing? What should it be like? How do we define fairness? What contribution should we make in our own lives? I think what I like about what she’s done is that she’s tried to take a lens that’s accessible for people to start to look into adult social care. 

So she’s talked about dementia. She’s talked about the experiences of people living well and not so well with dementia. That enables people to see adult social care in that way, but it also enables people to see adult social care alongside the health system in that way. I think that’s been really helpful, and she’s done the same with motor neurone disease. 

I hope she’ll want to avoid adult social care being perceived as just a response to a set of medical conditions. It’s a really good way for people to understand, “Okay, I can relate to MND. I’ve seen Rob Burrow’s heroic story and how Kevin Sinfield’s is keeping that going.” 

People are aware of dementia, and they’re aware of its impact. People are aware of other things like caring responsibilities and so on. I think the way in to those things is really helpful. 

But I suspect you’ll want to avoid a medicalised definition of adult social care. I suppose the cliche would be if you’ve met one person living with dementia, you’ve met one person living with dementia. So the focus of adult social care is on individual dignity, the strengths that individual people have, and being informed by a condition is helpful. But actually, what people are bringing is their own strengths, their own assets, the people around them, their own spirit. So we’re not seeking to try to put them in boxes via diagnosis. I think that feels like an important area to make sure that we get right. I feel pretty hopeful. 

I feel like Baroness Casey is morally driven. She’s able to describe issues in a way that resonates with the general public, but also brings high challenge as well as high support. I don’t expect her to blindly defend local government, as all was marvellous. There’s a whole bunch of stuff that we know, even without new money, that we could probably improve on. She’ll bring that objectivity. That means we’ve got a better chance of meaningful change happening. It feels like a good time, actually, to be the President of ADASS when these things are starting to land.

Well, to stay on the optimistic note for as long as we can, what other opportunities do you see that local governments have now in terms of delivering adult social care?

I think local government needs to lean in strongly to this NHS-driven agenda called Neighbourhood Health. It does feel like the Neighbourhood Health agenda is NHS-driven and probably particularly hospital-driven. I’ve heard NHS colleagues say, ” Well, hold on. It’s a really permissive framework, actually.”

Local areas can get together and make sense of what matters to them. We’re doing nothing to stop that. I think that’s theoretically true. But actually, all the metrics, the high-level measures that are set out as arbiters of success, are NHS measures and specifically measures about protecting hospitals. So I think that’s problematic, but the job for local government and adult social care within government is to step into that space. I think the opportunity and the challenge are around our health and wellbeing boards and the role that they are expected to have. 

There will be variation, there’ll be great health and wellbeing boards up and down the country. But there might be some that are moribund committees that are still very technical. Where people don’t really see them as a compelling place to have a public conversation about what good health and care should mean, or the difference that it should make. So I think because within the health bill, where the various bits of local government influence on the NHS have been watered down, and we’re feeling a bit challenged, that needs to be challenged in terms of the role of local government – for example, on integrative care boards. 

At the same time as pushing for the government not to throw that baby out with the bath water, I do think we need to make sure we rise to the challenge about health and wellbeing boards being everything that they should be. I think a member of the public would see that as the place where there should be public accountability for health and care working together, making a difference in the interests of the local population and the voice of local people coming through in those spaces. As well as it should be, by the way, an overview and scrutiny mechanism. So I think there are opportunities for local government to think about the mechanisms that we’ve got. 

Also, I suppose what I’d see as a retrograde step around Healthwatch being abolished, what space do we need to get ourselves into in local government around commissioning the voice of local people, especially around social care and associated services? 

Because if we’re not directly listening to people who have the experience of care and support, we’re going to be commissioning the wrong things, doing things in our own bubble, things that don’t make sense.

So we also have substantial reforms to children’s services across social care and SEND, and significant reforms to integrated care boards. We see reforms to police, reforms across the public sector and the NHS. As president of ADASS, where do you see the opportunities among all of these changes? And how would you want to join up the dots between them?

So we do periodically meet. So the first one’s meeting’s coming up. So, the President of the Association of Directors of Children’s Services, the President of the Association of Directors of Public Health and the place directors in councils who have a massively important role in that prevention space, by the way in terms of that, that infrastructure that actually often children’s social care and adult social care costs eat away at the infrastructure and councils to help people live good lives. So us connecting and being in that space is important. 

Actually, the previous Secretary of State in the Department of Health and Social Care, we ended up having written to him about health reforms in a meeting, all of us together, and it was really helpful for us, and I think it was helpful for him to see that local government could talk with one voice across a range of health and care issues.

We’ve got a new Secretary of State at the moment. We don’t know what the state of the government will be in a few weeks’ time, but I think with the new Secretary of State, we need to try to cement some of those relationships. I like to be in adult social care, maybe more than I would like to be a DCS, or I’d like to be maybe someone who works in an ICB, because I think there’s a lot of command and control in those environments, say from Ofsted, from NHS England or those kinds of health orthodoxies. I think that can be a real problem in terms of effective working, which makes sense because people feel so strongly mandated by regulators or by kind of command structures that they find it hard to do the right thing in terms of collaboration. I think we need to try to push at that. I feel like the Care Quality Commission Regulation of Adult Social Care is pretty enlightened and permissive, is holding us to account around maintaining good standards.

Having that assessment framework has been helpful. Phase two, I think, will get even more helpful as they kind of fine-tune their orthodoxy, but there’s no perverse incentives to do the wrong thing in the CQC arrangement. So I think that can sometimes get in the way of joint working with some other professions, but the individuals in those leadership roles are people who feel that they’re easy to work with. We can put up a united front without it looking forced. We’ve got the same motivations around people’s rights, good outcomes and evidence-driven practice, whatever the age of people and whatever their background. I think we need to do a bit more in that space because we’ve got a lot in common.

In your view, as the President of ADASS, what impact does the wider local government reforms, and there I’m talking about reorganisation and devolution, what impact do they have on the adult services across the country?

I mean, there’s devil in the detail, right? 

All parts of this reform agenda make sense as individual parts. The theory behind them is sound. It’s hard to argue that there aren’t things that should be done and will be helpful. 

There’s a lot of devil in the detail around implementation and some of the feelings about goalposts moving that I think are really challenging for councils on the ground that are embroiled in particular issues. There’s a sense that they consume a great deal of bandwidth in relation to managing the change. 

But the thing for us to try and do as a point of principle, I think, is hold our nerve on navigating through that period of time and trying to give the government of the day a strong challenge, but also strong support where we can, so that things can land without there being kind of perverse outcomes. There’s something about it all needing to make sense to people. What I perceive from the national government is that they sometimes see local government objecting to everything while saying that everything can’t stay as it is. I don’t think we can stay in that pattern.

If I were embroiled in a particular local authority at the moment, facing the sharp end of local government reorganisation and feeling like things felt very different from how they were presented a year or two ago, I might have a very different perspective just because I was so involved in it personally. But seeing it as a whole and a logical set of things to happen, how can we manage the implementation? How can we get the balance right? And how can we help people see their way through this period? 

What it means for adult social care reform is that the people working in these areas are not going to have much bandwidth for other aspects of reform. The other thing that it means, the very practical thing that it means, is that we’ve already got an issue with investment in a pipeline of Directors of Adult Social Services, a pipeline of Principal Social Workers, of Principal OTs, and of key roles that each new unitary council will need. We’ve already got an issue with that because there in investment from DfE, for example, in children’s services, that we do not have in adults from government departments. So that is only going to magnify the risk for the national government, for new councils standing up without good quality, supported and developed, DAFs, principal social workers and so on. 

For me and from an adult social care perspective, it’s really important that they take the opportunity to invest in the pipeline of leaders that these new councils will need because there are going to be more unitary councils – although there’ll be fewer councils overall – there’ll be more councils with social services responsibilities, and we can’t magic these leaders out of thin air. So we really need focused attention on that. 

As I say, in some ways, DfE have helpfully backed DCS development, in terms of the differential approach. We’ve probably not had that experience from a DASS perspective, and it’s overdue now, and it’ll get business critical if it’s not invested in.

In your view, what do you believe a sustainable and equitable funding settlement for adult social care should look like?

The first thing I’d say is that it’s manifestly wrong for adult social care to be propped up by social care precepts added to the council tax basis. We already know that council tax is an inequitable way of raising local revenue, so the idea of layering a social care precept on top of that is unhelpful in itself, and it also runs contrary to the national government flow about the idea of a national care service. That’s a whole other conversation, you might want to unpack that, but if you’re talking about a national care service, one of your fundamentals ought to be that each constituent geography, each council has sufficient transparent funding to reasonably make a fist of it in their area, and anything that’s dependent on local council tax raising – obviously alongside the local politics that go with that. Especially in the current volatile climate, we’re setting adult social care up to fail, so every year we don’t address that we are leaving councils further and further short. It’s a little bit disingenuous, isn’t it, that we’ve given the councils this amount of money, with an asterisk if they max out on council tax. So we need to make sure that adult social care addresses that.

I’ve seen some thinking from the Fabian Society suggesting there should be a pretty much ring-fenced allocation of adult social care funding for councils that explicitly relates to evidence of need in that area, and then it’s reasonable to performance manage the council against that amount and the outcomes that it delivers. There’s definitely a devil in that detail, but it’s a much more transparent position than the one we have at the moment, and we know at the moment, in every council, people aren’t quite clear about adult social care, hence the Casey Commission. 

People are super clear about potholes, though. They’re super clear about when their bins will be collected. They see that that area of council activity is being eaten away at by increased children’s and adult social care spend that’s being raised locally. So that just doesn’t feel sustainable.

Where and how do you think councils across England can learn from each other? And if we move even wider, do you think there are any lessons that English councils can learn from international council best practice?

ADASS is a charity, but we’re also a member organisation. There are 153 councils up and down the country in England, and there’ll probably be more with local government reorganisation. Probably one thing that will annoy people who are looking at things nationally, will be, well, why there is so much variation in the sense that something which manifestly works over here is not being practised over there? And there are local variations that are understandable in terms of local conditions and local strengths, so you don’t want one-size-fits-all adult social care. That’s probably something else that the Casey Commission should watch out for, prescriptions that look logical on paper, but actually will strangle some of the innovation, and some of the individual strengths and individual councils. It needs to get the balance between that and an appropriate level of consistency.

So the job of ADASS, alongside other organisations, let’s say the Social Care Institute for Excellence, Skills for Care, is having a look across our councils, having a look across practice, across providers as well and saying, How has this area made this particular area work? What will this particular area of activity work? What are the lessons? 

It’s not just  lifting and shifting it or a PowerPoint presentation, that’s sort of magically doing it. But what were the lessons of implementation? How did they get to where they got to? 

Some of the good examples are Wigam, best EQC rating in the country. Known really well for the Wigan Deal going back a few years. Also, we’re doing some really good work from Barking and Dagenham around neighbourhood health, which is based on authentic relationships in communities. We’ve been hearing really good feedback about hospital discharge as well in the West Midlands. 

The success factor has been good local relationships that have lasted for a number of years. So it’s not the magical, wow, I’ce seen the project plan, I’m just going to replicate that and get it done next year, because the budget savings say I’ve got to do that. The success is around the right people with the right values in health and care, working together over a number of years. When I went to Wigan a few years ago about the Wigan Deal, I said, ” What’s the best way of getting to where you are?” and they said, “Start eight years ago.” 

So it’s about understanding that we have to lay the conditions for long-term relationships rather than all this flurrying about. It’s values-driven, authentic leadership, connecting with local people, being driven by a good life for them, and having partners with the same approaches. That’s what’s given us those successful examples up and down the country. It’s not implementation via a project plan.

I think that angle is really important. As I was saying earlier me going up and down the country is part of telling that story. I think ADASS, as well, has hugely strengthened its approach around international research. I still think it’s relatively early days for us demonstrating an impact from that.

It’s really easy to go abroad and say, “Look at that amazing outcome in that system” and then realise that a lot of the conditions are not particularly transferable to the English system.

But we’re really upping our game in ADASS. We’ve got a specific research network with some brilliant leadership and good people engaged with it. We’ve got connections with universities, and we’re connecting that with some of the international work that’s had consistent leadership for a while in terms of international research. So I don’t think there are any glib answers. But I think ADASS, in terms of both national and international evidence, is starting to get into a stronger position to put it together.