Nuno Almeida, Founder and CEO of Nourish, hosted an interview with Martin Green, the Chief Executive of Care England at the LaingBuisson’s annual Social Care Conference. A flagship annual gathering for leaders of the sector, in Southbank, London last month.  

Against a backdrop of pessimism and challenges, Nuno framed the challenges of social care. Not just in the context of what the sector is dealing with now. But also, the challenges the sector faces as it looks forward 20 or 30 years into the future. How can social care remain a sustainable and vibrant sector? 

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“The reason why I started Nourish, the reason why we’re still going, is that I believe that a digitally enabled care system is a system that has better chances of delivering better outcomes for people in the day-to-day. In the process of building this business I’ve learnt so much about social care. Increasingly people invite me to events to share a little bit of what I’ve learnt. But also, perhaps a little bit of opinion and my view. And I’m going to start by setting a provocative scene: 

“I believe we are witnessing a remake of Dickens’ ‘The Tale of Two Cities‘. With inequality across society increasing, we will see this reflected in social care. 

“I often advise people in my circle of friends and local community about setting up their own businesses. Six months ago, I met someone who came from a banking background. They setup a domiciliary care business during the pandemic. She felt that care workers were underpaid by about 50%. So, she decided to offer services priced adequately for the quality of service. She decided to steer clear of local authorities’ commissioned services. Fast forward six months, she now employs 45 people – a phenomenal growth story. The opportunity is there to make a huge difference.  

“So, what I think the trends are showing is that there is a world of private pay. A world of local authority or commissioners’ pay. And these two worlds are becoming more and more divergent.  

“There is a surge in self-funding which is obviously driven by early baby boomers who have buying power and expect choice. A result of their life experience. They expect high quality. They expect highly personalised care and prices to reflect that. There are a vibrant, innovative and resilient group of providers focused on achieving positive outcomes every day. It’s out there and these stories need more sharing.

“The market is extremely responsive, if you provide quality care, by professionally trained care workers you end up with success stories. These care workers are not people who will look at the local supermarket for options out of despair on pay. They are proud professional care workers who are paid appropriately. These are people that are proud of the work they do. They will never look at the NHS as an alternative. They earn more than what they would be earning if they were working for the NHS. Accordingly, they feel more empowered to make a difference in someone’s life. 

“And then we have the other side, where there is an erosion on commissioners’ ability to understand the community needs.  Communities need resilience and commissioners are still trying to create markets without focusing on outcomes. Micro-managing care delivered as tasks paid for by the minute. They are focusing on the lowest price, encouraging a focus on efficiencies, and minutes being counted. Unfortunately, in this environment it is down to care providers again, to shape the market and educate the sector the best they can, so that commissioners can at least keep a market going with a degree of focus on quality rather than just the lowest possible price. Again, care providers are achieving this despite the headwinds, and there are a lot of examples of good care being delivered efficiently. Indeed with continuous tension on pay, and continuous engagement with the wider system to ensure people do not fall through the cracks (which still happens more regularly than it should).”

“While this is happening there is some noise in the background around how digital transformation is a once-in-a-lifetime opportunity for the entire sector. And it is.  

“If we have a digitally enabled sector, we can aspire to have a global view of how those systems support people to achieve outcomes that are important to them.  

“It is happening with some risks. Digital Social Care Records programmes are being absorbed by NHS England, while it is going through its own restructuring. The COVID urgency, that gave us a degree of clarity of purpose in driving digital transformation across the sector, is now starting to fade. ICS’s are being created with little representation from social care providers. Social care is a larger sector than the NHS by many measures. Consequently making this approach structurally wrong. With a significant risk of seeing social care being treated as an extension to the NHS and managed by boards that have several degrees of separation from care delivery. Undeniably this carries the potential to go horribly wrong.  

“My question is, isn’t what we are witnessing in social care a reflection of what society really wants from social care? The fact that our civilisation today is not clear about what we expect from social care, isn’t that our main challenge? We have two cities that are drifting apart as a result.” 

“Well, sadly, I think it is a challenge. I think part of our challenge is to travel from a tale of two cities to Shangri-la. 

“It was interesting to hear the conversations in today’s conference about how we need change but we’re not clear about a whole raft of things. Well, the first thing I think we’re not clear about is the vision for social care.  

“I don’t think we are clear enough about what social care does and how it transforms lives. And to the point you made that we’re seeing this differentiation between what public and private will pay and will expect. I think what we’ve got to do as a sector is close that gap. We’ve got to say every single citizen has a right to the best. It’s about changing people’s lives. It’s about enabling them to live well and giving them life chances and opportunities. How interventions at critical times can stop people going into higher dependency needs. I think what’s been missing is that we have not been very good at getting that message out that we have a vision for social care.

“We have had 70 years of propaganda telling us how great the NHS is. The world war created a platform where people came back and said, never again are we going to be denied access to health care. Well, I think we’ve now got to use our platform to say, people need social care because the world has changed! They’re going to expect social care that’s high quality. Care that wraps itself around their individual needs. Care that is developed in a way that responds to giving them as much choice and control as possible. 

“Accordingly, that must be our starting point for the future.” 

Martin Green (Left) & Nuno Almeida (right) share the stage

“This is inspirational. This is the vision that I wish society at large would share of social care.  

“Whenever we start talking about social care. Even in the context of COVID when we saw photos of care workers as heroes. It very quickly ends up boiling down to a conversation on capacity. Do we have beds? Can we discharge fast enough?  

“How can we change that conversation? How can we, as a sector, actually start being seen as an essential pillar of society? As much as so many other sectors are, such as fire services or police. Why are we different?”

“Well, I think we spend too much time responding to the NHS. So, it’s all about how we discharge from the NHS. Actually, within social care, we can develop a whole range of new services. Where most people don’t need to go near the NHS. Additionally, I think we need to start thinking about being creative with our business models and our models of service.  

“So, if you think about somebody who might be living with early onset dementia in a local area. The NHS has got nothing to offer them. But social care can change their world. If we start crafting a new approach to this, we can stop people needing to go into the NHS because the NHS is built on a complete myth. That myth is that you diagnose somebody, you treat them, and when you’ve intervened, they’re either dead or cured. That was the situation in 1948 and that is what people think about the NHS. So, if I talk about the NHS. People immediately have the perception that if they have a problem then the NHS will solve it. For lots of people, we know that’s not the case anymore. 

“So, what we’ve got to do is start the conversation at a different point. We’ve got to start also thinking about what we can do to make sure people don’t need to go into the NHS and think about the funding model for this. So that we’re not always dependant on going to the local authority. Or going to the NHS prevention budget.  

“We need to think about what we can do to draw down resources from various pots. Some will be personal budgets, and some might be insurance driven. But we need to start thinking differently.  

“I had a very interesting conversation with a respiratory surgeon in America. Where they are now funded for outcomes, for health interventions like we do with the NHS. But that consultant said to me that his biggest success was from installing air conditioning units in the homes of his poorer patients. Patients who couldn’t have afforded them. That was stopping them from going into respiratory failure in that smoggy New York summer. Consequently avoiding hospital admissions.  

“Now if you tried to adopt a different policy and think holistically about health and social care services. How do we tackle some of the elements that would give people a better life? I think what we can do in social care is think about how we package up a whole raft of things. Some of it might be about our service. But some of it might be about the auxiliary and support services that are available.  

“For example, for people who are doing home care. You will see it frequently that you’re just commissioned to do a specific task in a specific time. I have great respect for Jane Townsend (Chief Executive of the UK Home Care Association), who has argued for the end of time and task. It’s time to start thinking about people and outcomes across our entire system.  

“At the moment we are obsessed with process and organisations. We saw it during the pandemic. We saw endless discussion centred on the NHS. As if somehow that was the solution to all problems. We all got the image of a minister standing behind a lectern. Saying, ‘stay at home, support the NHS, save lives‘. It would be like saying, ‘stay at home, don’t spend money, keep the bank deposits high‘. It sounds silly, but that’s how we behave. 

“We are where we are. So, we’ve got to grasp the agenda as a sector. We’ve got to start thinking, creatively. About how we can change this model. How we can burst through so that people know we are going to deliver them a good life underpinned by good services. That’s where we need to start with this new vision.”  

“From my point of view, supporting people to have a good life, should be the mantra of an integrated system. After 15 years of studying social care, I still feel like an outsider. The separation between health and social care still feels profoundly artificial. 

“The reality is social care is much better at dealing with the other 95% of concerns that aren’t health related. Social care deals with the whole of a persons’ life. Not just their health conditions. And whether a person is living in a nursing home with five comorbidities or living at home receiving support from community services. Health should not be their main concern for having a good life. Social care understands that need. 

“Now the messaging opportunity for social care is to emphasise that social care has much better mechanisms and tools to tackle long-term conditions. Indeed, social care is probably the only system that can do a good job at supporting a person living with dementia in leading a good life. But social care is also better geared to deal with people who have diabetes and chronic respiratory conditions. Or cancer, which is increasingly a long-term condition. So, I think that social care has more answers that are essential for the future of healthcare. The sustainability of the system depends on healthcare understanding this. How do we communicate this? And how do we allow the NHS to step down from their pedestal and allow social care to help the NHS become more sustainable. To work as peers, not as a core health system with social care operating on the periphery?”  

“Well, it’s tough. When we’re going into ICS’s my cynical head says that I’m so old I remember joint appointments. Coterminosity, joint location, I remember Primay Care Trusts, I remember Clinical Commissioning Groups. They were all going to deliver the holy grail of integration.  

“None of them did.  

“But I don’t think that should mean that we say this won’t work. I think what we have to do now is roll up our sleeves and say how can we make this work?  

“It’s going to be tough because care providers are not engaged in ICSs. We have to have sharp elbows to push our way in. To get some of these solutions in front of the public.  

“I think one of our problems is that we often just talk to the system. We need to talk to the public. When we see that piece of news that says. ‘Mrs Gubbins had to wait for X number of months for her hip replacement‘. Let’s go out and showcase that if Mrs Gubbins was connected to a social care service, while she might not have had a hip replacement, she would have still maintained a quality of life. Because we could have supported the degradation in quality of life which is often irreversible. I think we’ve got to be much more creative about the narrative. More focused on sharing news that we can do some things which are really useful to citizens. And crucially, get citizens to understand that.  

“It’s about how we champion what we do. We’ve got 1.6 million people working in social care. They could be our ambassadors talking about social care at every available opportunity. The reality is that you go to a party, and somebody’s really delighted to tell you they work for the NHS. But they’re not so delighted to tell you that they work for social care. So, I guess we’ve got to do something around instilling pride in what we do in our workforce. But also give them some tools to present that to the world. How can we turn the party conversation around? How can we reveal that we are care workers with pride? Rather than a degree of expectation that this will be met with a negative reaction.”  

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This interview opened a wide range of discussions across the room. Discussion which continued into the late afternoon. It was inspirational to see so many care providers approaching us to discuss the topics we raised further.

How can we get better at managing our relationships with continuing health care (CHC)? How do you think we can use digital transformation to improve our relationships with commissioners and with ICS? What is the best way to use Nourish and digital transformation in the context of improving staff retention? Do you have a view on how to shape our digital transformation so we can deliver the right care to each person we support in a blended self-funder and local authority-paid environment?

If you have any questions, get in touch about any of these topics, or other topics related to care quality improvement, digital social care records and digital transformation in health and social care.