Social care for frail elderly and severely disabled people is in the news for all the worst reasons. The revelations on the BBC1 TV Panorama programme about abuse of patients in a private hospital for people with learning disabilities and autism followed the equally disturbing news that a mega-provider of care for older people, Southern Cross, is in serious financial trouble. Both the organisation of care and its practice are under critical media and political scrutiny.
The obvious link between the two stories is that both involve for-profit enterprises, wholly or mainly paid for out of public funds. The principle of contracting for care, which is supposed to improve quality and efficiency, is clearly unreliable. We cannot trust the business models of large firms like Southern Cross not to collapse, with serious costs to taxpayers, nor can we depend on companies earning huge fees for their supposed expertise in specialised care like Castlebeck to supply even the basics of dignity and protection for those entrusted to them.
But nor can we trust the inspection and regulation body, the Care Quality Commission, to provide an adequate regime of supervision, even when they are tipped off about abuse. Generating paperwork and ticking boxes is no substitute for a genuine, qualitative assessment of how such institutions are functioning.
These problems are not new ones. The 30 years after the Second World War, when most such care was provided by the NHS and local authorities, were punctuated by scandals over abuse and neglect, especially in what were then called 'subnormality hospitals'. These Victorian institutions, often in remote places, were at best deadening and impersonal, at worst cruel and oppressive. So the state did not do this work well either.
The aims of the reforms set in motion in the late 1970s were laudable. Residents and patients were to have more individual personal care, and be more involved in local communities. They and their carers were to exercise more choice, partly by access to a market in providers, encouraging innovative approaches.
But the policy-makers and regulators were always in danger of forgetting the grim reality of the task. As researchers had pointed out for decades, after all those who can live an 'independent' life in the community have received the necessary financial and practical support, there will always be some who are left outside the mainstream of social life, because of the severity of their impairment, or because of sheer old age and infirmity.
Staff who care for them must overcome an atavistic tendency to devalue and demean all who cannot earn the esteem and status given through work, family and civic interactions. To do their job well, staff must create their own culture, through which residents are given value simply for their humanity. This requires leadership, example and mutual support; without these, the tendency is to revert to indifference or cruelty.
Individual care plans can be faked, activities fabricated and management goals invented. No checklist can capture whether a regime has the ingredients to treat residents and patients with dignity and respect, or create a sense of belonging to a community of hope and purpose. Managers and inspectors who lack a feel for these things are of little use.
If the public culture of a society is one of individual achievement and self-reliance, all this becomes even more difficult. Depending on others, needing to be looked after, are seen as discreditable. Care is counter-cultural in such a social context.
This problem is not confined to the private sector. Recent reports on NHS care for elderly hospital patients have been highly critical of nurses, grudging about giving time, callous about distress, careless over nutrition. Here again, it is a challenge for professional leadership to reject a purely technical approach, and create an environment of sensitivity, concern and empathy.
But the Southern Cross story really is about the shortcomings of treating care as a business. It exposes the myths of choice for residents and efficiency of private provision. Block contracts which have given Southern Cross 31,000 residents in 750 homes do not give choice, and the strategy of selling its stock and leasing it back has left the business with annual losses of £300 million, all underwritten by council taxpayers. And guess who owns Southern Cross and devised the stategy. A private equity company, of course.