EXCLUSIVE INTERVIEW: Care England – the watchdog bears its teeth

Professor Martin Green.

Care England CEO Professor Martin Green is not easily angered, but the failure of politicians and the NHS to work constructively with the care industry is costing lives, wasting billions of pounds, and pushing him to consider extreme measures, as Care Home Professional Editor-in-Chief Rob Corder discovers in this unguarded interview.

CHP: How do you describe the role of Care England and your key priorities?

Martin Green: Our aim is to improve the environment in which care is given. We have four key strategic priorities. The first one is funding for quality, and we have very much linked the issue of funding to the need to deliver really high quality outcomes for the people who use services.

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Our second priority is about proportionate regulation. We believe regulation should be the foundation for quality care, but it should be proportionate, outcome-based, and less adversarial. We believe in the airline model, where everything this geared towards learning from experience if mistakes are made and validating quality.

A third key priority concerns the workforce. You cannot deliver quality care unless you have a very well trained, respected and funded workforce.

Our final aim is about innovation and development. We believe that residential care has a real role to play and can diversify to deliver companion care services such as step up and step down from hospitals. We believe that care homes could become hubs of care for people living with long term conditions in their area. We want to unleash the potential of residential care.

CHP: When you talk about the airline model, do you mean its approach to crisis management?

Martin Green: I mean the sort of non-judgemental reporting of critical incidents. The problem with the system at the moment is that, if you admit that you have done something wrong, the system tends to hang you out to dry. In the airline industry, if I am a pilot coming into land at Gatwick and make a mistake, my first response is to tell the regulator so that it can do a critical path analysis of why the incident happened. It does not set out to blame somebody and leave it at that.

One of the problems with our current regulatory framework and regulatory system – not just the CQC, but everybody in the system – is that, if something goes wrong, the default position is to find somebody to blame and hang them out to dry. Of course, there can be a need to find the root of the problem and ensure they take responsibility, but there are lots of people who make mistakes. If we are going to have a system that learns from experience, we should not be thinking too much about how we apportion blame, we should be thinking about how we structure things so that mistakes do not happen again.

CHP: We will come on to talk about funding issues in a moment, but what is interesting about your view on regulation is that you are describing the need for a change in culture that would not cost anything to bring about a considerable improvement.

Martin Green: Very much so. There is a real challenge right across a number of sectors with culture. If governments spent one tenth of what they’ve spent on structural reorganisation on cultural changes, we would be in a much better position than we are.

For example, within much of the NHS, there is a hatred of the private sector. It is a sort of Animal Farm mentality: public sector ‘good’, private sector ‘bad’. We need to sweep that away. People who use health services are not that bothered about whether they are delivered by the public sector or the private sector. What we should be focused on is what those services deliver and what works best, not thinking about them in terms of structure.

CHP: One of the great challenges for the care home sector is that it is made up of so many different organisations, entrepreneurs, private equity, charities, etc. To change culture, you would need to get people to speak with one voice from across an enormous and varied landscape.

Martin Green: Yes, but all those businesses, however they are structured, have to interface with the public sector, so perhaps it would be easier to start with the public sector and try to change its culture away from the current hostility towards private sector provision.

CHP: Successive governments have spoken about better integration between social care and NHS services, but you seem to be suggesting that outright hostility from the public sector towards the private sector care providers is getting in the way.

Martin Green: I am saying that. One of the sad things about the past 10 years is that we have had rhetoric emanating from different governments about integration, but we have not seen anything happening in practice. For example, we find ourselves at the moment with the NHS saying it is facing a winter pressure crisis, but it refuses to engage with the independent care sector that could solve a lot of those problems. We have been speaking to the Department of Health year after year about how we can help, and get no response. Now we get another winter pressure problem and the secretary of state for health rewards their bad behaviour with another £900 million. So there is an incentive in the system to continue this bad behaviour.

People should not think about whether it is an NHS service, a council service or a private service. They should instead scan the horizon to find the best outcome. The challenge of winter pressure at hospitals is always about how to deal with elderly people who have finished their medical intervention; where do they go? If you look at the number of care home beds available, that could have solved about three-quarters of the problem, but the system, despite having year-on-year engagement with people like us, just does not engage with the independent sector. They just see themselves as the only show in town, and they are not.

CHP: The NHS always seems to have the ultimate weapon when it comes to lobbying for more funding, which is the threat that if the money runs out, people die. The care home sector doesn’t have the same power.

Martin Green: Absolutely. There has been a propaganda offensive since the NHS was founded about how wonderful the NHS is, and politicians respond to this. The NHS is wonderful, but it is not without fault. And it is also not always the most cost effective and best option. But politicians constantly cave into the NHS and nobody takes a more reasoned view of what is the most effective treatment and care option in any case.

I work on three measures: citizen experience, clinical or care outcomes, and effective and efficient use of money. We know that our sector can deliver on all three of those things if we were given the opportunity. But sometimes the system works not as a facilitator, but a block on getting the best outcomes.

CHP: You seem to be suggesting that if the boundary between the care sector and the NHS was shifted so that more healthcare was delivered within care homes, you would actually save money for the NHS and by extension the tax payer. Are you saying that this is not happening simply because the NHS wants to protect its turf and its funding?

Martin Green: Absolutely, they are protective of their turf, but it is also that they don’t think of anything other than NHS. Yesterday, I went to a meeting of people looking at new quality standards for dementia, and the room was absolutely chocked with NHS people. All the time they referred to everything in terms of the NHS, in the language of the NHS, using the acronyms of the NHS. They spoke about what the NHS would do for dementia in hospitals, and what the NHS would do for dementia in the community. I honestly think that about a third of that room thought that the solution for dementia care was just about making hospitals work better with GPs. The irony of course is that nobody seems to have clocked that GP practices are private businesses, yet they are quite happy to engage with them.

CHP: Maybe the NHS would only consider an integrated care and health system if they succeeded in a land grab that brought care homes under their control as well?

Martin Green: One of the things that I think is really interesting is that the care home sector is facing a real crisis of funding, and local authorities and the NHS are working out contingency plans for if there is a major breakdown of the care home sector. That contingency plan seems to be focusing on what they would do if they have to take it all over, which is ridiculously expensive. If they just provided the right amount of funding to ensure care homes are financially viable, there would not be a crisis. So, they precipitate a crisis, and then respond to it by taking things over themselves and spending more money on the same services that could have been saved in the first place.

CHP: Let’s put a radical proposal out there: Let’s say that the residential care sector needs an additional £3 billion to ensure it can deliver services. We know there is no additional money at the Treasury, so why not move the £3 billion from the NHS budget to the care sector?

Martin Green: Exactly, that is what you should do. But, interestingly, if you look at something like the Better Care Fund, which is designed to do that, what they produced was not money going to the front line of the independent care services. They produced loads of new initiatives that were in effect ways of taking people who were already working in the NHS or local authority, giving them a new role within the NHS or local authority and then paying them.

What happens is that you shuffle money around the public sector instead of saying, let’s make sure that we get the best value for this money and use it in whatever way supports citizens to live well with their conditions.

Every time you have an initiative that is supposed to reform the system, the system grabs a hold of the process and turns it around to ensure that their part of the system is still supported.

CHP: The lobbying power of the NHS is hard to match when it can effectively call on the entire population for support. The care home industry is seen as more like a grim reaper that everybody would prefer to never use, let alone pay for. Politicians feel they can safely ignore the demands of the care sector as long as they can count on the votes secured by championing the NHS.

Martin Green: I think that is right, and there are all sorts of undercurrents here. For example, when people need care and support, particularly for the elderly, they have reached a position where they can no longer take care of themselves. Nobody wants to confront that, so you get nonsense said such as local authorities saying that nobody wants to go into a care home. That may be true if you ask people when they are 40, but certainly isn’t true when they are old, suffering from dementia and unable to manage living at home.

If you asked healthy people whether they would like to spend time in a cancer unit, they would all say no, but if I had cancer I would say yes.

CHP: What you need is a much larger population of people who will put pressure on politicians to act. At the moment, you represent a care industry populated with very old or frail people that cannot put a up a fight. But when I speak to private care home operators, want to create specialist accommodation for anybody over 55 including retirement villages; housing with care; assisted living; care homes with and without nursing. If this much larger cohort spoke with one voice, it would be much stronger.

Martin Green: We put a lot of energy into that, but people do not want to engage with something which is going to be about their own demise.

CHP: But people support the NHS when it demands an extra £8 billion because they want hospitals capable of delivering the best healthcare if they develop cancer of have a stroke.

Martin Green: The issue is that people have a different view of the NHS to a care home, which is that they think the NHS will cure them. So people’s view about the NHS is that when they have a problem, it will be taken away from them. Compare that to the way they think about going into a care home, they don’t see themselves getting better. They think of it as the end so it is a different proposition.

CHP: If you were to create a SWOT report on the British independent care home industry, what would you say are its strengths?

Martin Green: The strengths are that they are delivering care to a very vulnerable group. People in residential care tend to have many conditions and have the greatest need. The care sector is good at supporting those people, giving them a good quality of life in an extremely cost-effective way. It transforms the lives of the people in care, and their families.

The weaknesses are that the residential care sector is very fragile because of its funding. It is very tough to deliver the right care, particularly for those that are publicly funded.

We are also not always a coherent group. You made the point about the different number of operators involved in the care sector, which makes it difficult to speak with one voice in the same way that the NHS does.

Another major weakness is that sometimes we are not tough enough about saying no. When you are a business and you are dependent on one customer, it is very difficult to say no to that customer, and we are exploited because of that. In our case, that one customer is the local authority.

The great opportunity for the care sector is to diversify. For example, providing step up and step down services for hospitals. We could do day care, night-sitting services for people with challenging conditions. I think operators should think about how to diversify what they offer into different markets.

The threat is that we are under-funded. And that is made more difficult because the public doesn’t value us, and value what we do in the way that they value the NHS.

CHP: The top end of the market, where residents are paying their own fees of over £1000 per week, seems to be in great health. They are still complaining about issues like the National Living Wage, but they are doing so from behind the wheels of their luxury cars.

Martin Green: This is not unique to care home operators. Just go to the car park of your local NHS hospital and see what cars the consultants are driving. I do find it perverse in this country that being successful is a negative. It is a serious point, though, because I have had government ministers say to me that they all drive these luxury cars. My reply is always: yes, and they also take all the risks.

CHP: The perception can be problematic when things go wrong. For example, if a care home group hits the headlines because of poor care, and the owners are known to travel around in a company helicopter, it will not play well in the press.

Martin Green: I do find it quite bizarre how those issues get conflated. One of the things that I tell all my members is that you cannot lose touch with the fact that you are providing services to people and the quality of that service will depend on the success of the organisation. Like any business, if you lose touch with your customer, the business fails.

I said this to a chief executive of a large operator and she said: “unfortunately, my customer is not my resident. My customer is the person in the local authority commissioning unit. If they tell me to do XYZ , that is what I will do”. This goes to show the perversity of the approach we have at the moment.

CHP: There appears to be a growing split between operators in affluent areas of the country making healthy profits and those in the poorest regions struggling to survive. This is often translated into a North/South divide. What is your view on this?

Martin Green: The shorthand is the North/South divide, but it is definitely affluent versus non-affluent. If you are in an area where there are very affluent people and property prices are high, then the choice of care homes available to you is much better than if you are in the Northeast of England and there is not a lot of money around.

CHP: How do you solve the problem of the poorer parts of the country having worse care home options? With most operators owned privately, you can’t expect funding to flow from rich areas to poor areas.

Martin Green: The government will have to decide whether it thinks that people in care are valuable. If they are, they will have to pay for them properly.

I thought it was perverse recently that we had a debate in Parliament about the right to die, and politicians were jumping up and down to say that people should not have the right to die because every life is sacred. But the same politicians come up with £2.80 per hour to pay for somebody who has complex dementia needs.

Frankly, if they are not going to put the funding in, they might as well give them the right to die.

CHP: Finally, let’s look a little bit further into the future. Where do you think the care home industry will be in 10 years time?

Martin Green: I think the business will be consolidated into smaller number of larger groups. I think it will be a much more diverse industry that will move into that space between social care and healthcare. I think also, because of the demographics creating more and more pressure, you will see much stronger operators because the supply and demand equation will be at a point where local authorities will not be able to just behave badly like they have done in previous years.

There will be more and more people, and more and more self-funders, so the local authorities will need to compete with the self-funders for beds, which gives power to the operators.

CHP: Or, the NHS will grow and grow to provide the care service beds that private operators refuse to provide on terms that the local authorities will accept.

Martin Green: Or worse, we will see local authorities decide that they will build their own care homes, and we go back to the failed policies of yesterday. I remember Norfolk went this way and had their own care homes. They then floated them off into something Norse Care, which they pretend is an independent entity, which it isn’t because it is all controlled by the local councillors. They are paying hundreds of pounds a week more for that provision, just because it is public sector. The pension provision, alone, is huge.

So, if the public sector takes over care homes, it will be appalling quality at a much higher cost. This is what happened last time they ran them and what we will go back to if we are not careful.

We don’t need them going back to try that again, we just need local authorities to fund the current care home sector properly. Even with proper funding, the current care homes are very good value and a hell of a lot cheaper and better than having people in acute hospitals.

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