Four Seasons, Private Equity and the Care Sector

Money Talks - Do you listen?

Both the Guardian and the Financial Times report on the possible imminent buy out of Four Seasons by ‘Terra Firma’ – a private equity company. Guy Hands, who chairs the company is described by the Guardian as

the tax exile and private-equity baron best known for his disastrous debt-fuelled takeover of EMI

Comforting.

Four Seasons Healthcare is a large provider of nursing and residential care homes in across the UK. As it says on the front page of their website

We are the leading independent healthcare provider in the UK. We own and operate over 500 care centres and nursing homes, employing around 30,000 people. Our care homes and nursing homes are unique and we’re proud to offer consistently high standards of service and care.

Seems like a perfect investment opportunity for a.. er.. private equity company, right?

Maybe I’m being a little disingenuous. Having an A level in Economics doesn’t give me a significant understanding in financial models of support however what is blatantly obvious is that the sector as a whole (and we’ll push Southern Cross into the mix here as well) have over borrowed on assets which haven’t produced the intended profits.

The further link with Southern Cross is the irony (or maybe it isn’t) that Four Seasons took over a number of Southern Cross homes when they went under.

The Financial Times explains that Four Seasons is looking to refinance a £780 million debt and is ‘likely to raise £525 million of new debt’.

These kinds of fantasy figures have little in the way of substance to me. But that’s a lot of money and I do wonder at the amounts of money knocking around in these health and social care sectors.

Last month Terra Firma bought a Gardening Centre group for over £200 million.

The type of business is of little interest to the company putting the money in. It is purely and simply a business opportunity. This is one of the reasons I shudder at the leaking of health and social care into the private markets. The reality of financing, refinancing and profit making can be cut throat but for the people who live in these nursing homes it’s worth remembering that they are possibly the last years of the lives of people at stake rather than lilies and tomato plants.

Four Seasons has a deadline of September 2012 to refinance the debt it has. It is currently owned by a consortium of banks. A private equity company will be no worse nor better than what exists now unless it is able to offer the company more financial security (which I presume it is) but the interesting part, for me, as an outsider to the world of equity and financing is that this is not the first very large healthcare company to be switching hands and talking in terms of millions regarding profit in health care.

The Matlock Mercury (in the East Midlands) has a story which raises concerns by the GMB union when Southern Cross staff were transferred to Four Seasons and they asked for a response from the CQC. They write

Recently the Care Quality Commission said as follows: “The large health and care organisations are not overseen financially by anyone.

“The Care Quality Commission (CQC) require that a provider is financially stable, but it is outside of our remit to carry out financial audits or financially background checking of any service provider.

I can appreciate that. The CQC is pushed but isn’t it worrying that there is no-one at all overseeing whether service providers are ‘financially viable’? It doesn’t need to be the CQC – but perhaps – as we move towards a situation where more and more health care services are moving into private hands – it should be someone..

This is the future of the NHS. It is already here. Profits will be pushed to shareholders and companies are accountable to those shareholders rather than the people who use and need the services provided.

Tomorrow, this will be the hospitals.

picture by w4nd3rl0st at Flickr

To vote or not to vote?

To be (vote), or not to be (vote): that is the question:
Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,

Next week the local elections in the UK will be held and many people will not even bother to vote suggests a report in the Independent Newspaper today . Despite the open discontent with current political and social changes I am amazed that people do not see that voting is their only way of showing their concern?  This is the only time that every person truly has a voice and is more authentic than any consultative/listening exercise is ever going to be. With an introduction by Shakespeare (from Hamlet) no less I will try to persuade you why you must vote this week 

  1. People have fought for your right to vote don’t waste their efforts and suffering
  2. Political parties will be watching very closely to see if they have the ear of society
  3. Not voting is a passive and not very effective way of showing your concern
  4. Local elections mean local changes that will have more effect on our personal circumstances like council tax etc.
  5. You cannot complain about a political party that you did not vote for
  6. Political parties develop ways of controlling and managing society do you really want to leave them to it?
  7. If you have children their future is at stake
  8. If you have older or disabled relatives their dignity and quality of life is at stake
  9. If you have beliefs about a fair and just society they are at risk of being ignored
  10. we should encourage everyone to use their vote, don’t leave it to others to decide your future

I personally do not think it is nobler in the mind to suffer and so will take arms ( literally not actually) wherever I can and always within reason of course. Politics (and using our vote) is one way we can all get involved in making choices about our future. Therefore our democracy depends on  each and every one of us, not just the politicians. 

Shine A Light

What would Not So Big Society do without the Daily Mail? It’s the unfailing inspiration behind many articles as we take to our keyboards in umbrage at the latest affront perpetrated on our profession and especially on the vulnerable people we in our different fields all work with.

Last week they published a piece by a columnist with a long history of antagonism towards social services. It trumpeted the scandal that children are being needlessly removed from their families. It’s familiar fare but not without its dark humour.  Googleads’ faithful algorithm  pops up at the bottom with two ads for companies offering child protection training. This time, though, there’s one difference: the author may have a point.

It’s made with a numbing, naive disregard for the reality not only of professionals but also for the children and young people who desperately need help before their lives are scarred permanently and who need the best possible services. Social workers first round up children who are then corralled into care by a legion of staunch experts (sorry, that should read “experts”).  The middle-classes are now being targeted by a new weapon of unsubstantiated non-scientific jargon. You would call it neglect. Minister Tim Loughton was moved to publicly discredit the piece.

Remove the bile, invective and unsubstantiated assertions (there won’t be much left) and a key question remains: are too many children being taken into care? There is no denying the large increase in care admissions, well-documented since the tremors of the baby Peter effect caused an upsurge in care proceedings. The aftershocks are still being felt and I’m not sure this is necessarily a good thing.

At least the growing debate is breaking out of the confines of the sector into the mainstream, including the political arena. In 2010 Barnardos commissioned a report from the thinktank Demos that concluded more children should be taken into care and at an earlier age. Their CEO at the time, Martin Narey, is now the adoption czar. The influential head of Kids Company Camila Batmanghelidjh feels the state should step in. In another piece from last week, Anthony Douglas, head of CAFCASS the over-worked court social work and mediation service, argues that taking more children into care can be beneficial.

Whichever viewpoint you take, it’s imperative that this is talked about as widely as possible. As Douglas says, “These children need as strong a light as possible shone on their lives.” Yet the context of this debate has still to be established and without it, we can’t progress. The balance between the intervention of the state and the freedom of the individual in regard to child care is fundamental to every household with children. Until this is clarified, social work will flounder at the mercy of shifting tides of opinion and will not be able to protect the children who need to be safe. Never mind the controversy in the Mail or elsewhere about where the threshold lies, we need to know that a threshold exists.

The boundaries are being established not by evidence, policy or government initiative but by the reactions of local authorities to two developments: baby Peter and the cuts. As a professional this makes me profoundly uneasy. I want to know what to do, how to apply the law together with my training and expertise. This has diminished value if  the threshold for care is dictated primarily by factors that have nothing to do with these fundamentals, let alone the actual level of need.

Good social work with children and families depends upon the practitioner having a variety of solutions available in any given situation. These resources range from preventive provision in the community through to the intervention skills of the worker and different types of placement. Hold on to your hats for the revelation that every child, every family, each situation is different so the professional needs to be able to choose what method works for this child, this family at this time. Steady yourselves, there’s more. Things change over time, so different resources might be needed further own the road.

The basic premise, as with so much of good care, is obvious. The problem is, those resources at one end of the spectrum have crumbled under a quake of a different kind, the spending review. Preventative services for children and families are fast disappearing as local authorities consolidate their precious scant resources around statutory duties. Surestart, parenting groups, family centres, section 17 money, therapy – slipping through the cracks into bottomless chasms of oblivion.

Fewer resources mean that children come into care later therefore their problems are more entrenched. Also, there’s more weight given to the option of care because there are fewer alternatives. It becomes a self-fulfilling prophesy.

Then, once in care, we come across another element of the debate, the crisis in foster care as we struggle to  find enough high quality placements to address complex need.  To borrow Ermintrude’s recent remarks in regard to adult care, there isn’t a crisis in foster care. Rather, “there is a well foreseen and ignored gap in the funding and provisioning of needs in the sector.” And so care doesn’t work,. the system is failing children and we are trapped in a cycle of failure of our own making.

The Mail is the amongst the first to criticise social workers for not acting when children have been abused but this is more than the classic ‘damned if you do damned if you don’t’ bind that blights our profession. Social workers act on behalf of our society. We are public servants. If society isn’t sure what we should be doing, then neither are we and that is no good to anyone.

Panorama and Ash Court – Towards Improvements

I watched Panorama last night. The programme, as explained yesterday, focused on the abuse by care workers at Ash Court of an older woman with dementia whose daughter filmed her secretly on a hidden camera in the home.

The footage of the abuse was sickening and involved both physical and psychological (neglectful) abuse by those employed to care for her. Most indicative was the lack of regard that the care workers had for Mrs Jane Worroll as a human being as we saw the treatment dehumanising her.

It was clearly uncomfortable viewing and links are being made with Winterbourne View but there are vast differences and this time, although I almost surprise myself, I think it’s important to defend the role of the Care Quality Commission in this case.

With the Winterbourne View Panorama expose there were whistle blowers and the regulator should have taken action as a result. With the situation at Ash Court, there was a hidden camera and while some of the cultures could have been known to exist within the home itself, it’s clear that the regulator did not have a way of knowing what was happening before it happened.

As they say in the statement that they make on the programme that what they (the CQC)

cannot do is to identify and stamp out deliberately concealed abuse. By its very nature, concealed abuse takes place away from the eyes of managers and inspectors and can even take place, as in this case, in a well run care home. Abuse of vulnerable people is a criminal matter, and is rightly handled by the police and the courts.

That’s the big difference between Ash Court and Winterbourne View. The disappointment in Panorama is that it tried to merge the agendas of both and while there is a common narrative to both programmes about abuse of those who have power of those who do not, the solutions and causes are different.

I mentioned on Twitter during the programme about the discrepancies of procedures and powers for adult safeguarding and safeguarding of children.

Personally I see ‘safeguarding’ and ‘abuse’ as the use of power by someone against another person who has no power. That might be as a result of physical ability, mental capacity or understanding or just some of the institutional structures in place. Whether the person who is abused is 6, 65 or 85 shouldn’t have any sway within the processes. What I’d like to see is a unified process that deals with the effects of abuse and the power differentials – rather than provide so many more hoops to jump through and weaker processes when the person to whom the abuse happens is over 18.

The effects may be different according to the stage in the life cycle but they may not be. The criminal act is around the abuse of power and the abuse within the relationship that takes place along with the eventual effect.

I’m sure those with more knowledge than me will come back to attack my somewhat simplistic judgements and thoughts on this but it’s frustrating working within an adult safeguarding process that lacks so many of the potential teeth when we see some of the abuses that take place and see so few taken to court due to unreliable witnesses or lack of scope for action.

Another disappointment of Panorama (although unsurprising as they wanted to squeeze out all the ‘abuse’ footage for shock value and only had 30 minutes) was the lack of attention to some of the systemic problems that have led to warehousing of older adults in institutions when they need residential care. The pay of the staff was mentioned but pay is not the only consideration.

I worked quite happily at a very low wage as a care worker myself for a number of years but what matters as much as pay (although pay helps) is the value placed on the members of staff. Staff who are not respected and who are treated as expendable and with little respect are more likely to pass that feeling of powerlessness on to others. It isn’t an inevitable link – you get good staff in bad homes and bad staff in good homes – but it’s more likely that if staff feel linked to and attached to those whom they care for and those for whom they work – they are more likely not only to pass on that feeling of respect but to feel vested in the organisation for whom they work.

Too often care work is seen as ‘easy’ and care workers are seen as ‘replaceable’. Organisations like Forest Care (and many others I know) bring staff over from the Philippines en masse to carry out these roles or put staff on zero hour contracts and push out unionisation. Organisations have to regard staff better – and pay is one of those aspects but not the only one – in order to create cultures of care and compassion. The other aspects are good and robust supervision, including peer supervision and giving staff responsibilities and a stake or voice into the organisation they are working for. Whistleblowing has to be easier and better regarded. Complaints improve care and processes and they should not be feared.

Local authorities and the government needs to be willing to pay more for care and for monitoring inspections which don’t need to simply come from the Care Quality Commission. If LAs push prices down to rock bottom quality will suffer. Some people do need 24 hour residential or nursing care and it shouldn’t be accepted as being ‘sub-standard’ as default. It doesn’t have to be.

Panorama didn’t shock me, unfortunately. It saddened me. I hope it doesn’t become just another blip in the process of change. I want the processes and structures to be pushed to positive change. Blaming the CQC won’t do that – changing the expectations and systems might.

As for hidden cameras in residential care homes and in people’s own homes – I see it increasing and have a sense of discomfort about some of the rights to privacy that are impeded however finding and challenging abuse is important. Would Mrs Worroll’s abuse have been discovered without them? Unlikely unless one of the care staff attending her raised concerns with their own manager. I may be tempted to use hidden cameras myself if I had a family member in a similar position but that’s the key – it’s only those people who have family members who will have recourse to such action – what we need to do is find the reasons these abuses happen institutionally and act on them.

Of Hidden Cameras, Care and Panorama

Tonight’s  Panorama is focusing on care of the elderly or rather, lack of care. Maria Worroll was placed by her mother in a care home in Camden which had an ‘excellent’ rating by the CQC (Care Quality Commission).

Jane Worroll, Maria’s daughter, noticing something amiss and perhaps having concerns, set up a hidden camera in her mother’s room to observe how her mother’s treatment. Mistreatment and abuse were filmed and it led to a conviction by a care worker, Jonathan Aquino, under the provisions of the Mental Capacity Act (2005) and a jail term of 18 months.

There are a few key points to take into this and to note. Prior to June 2011 (when the filming took place), the previous assessment and inspection by the CQC was in 2009. It was an unannounced inspection and as described above, the outcome found the home was excellent.

There were a couple of ‘compliance’ visits after the incidents films came to light but the important thing to note is that an excellent care home can provide appalling care if there is one abusive care worker. Similarly a care home which may have a poor inspection report can provide excellent care if there are caring and good quality care staff. Historical reports of care by regulators actually tell us little about the quality of the care today, at this moment, as staff in these care homes tend to be transient and low paid.

There is an issue about management culture of course. I have seen a switch in manager making both a very positive and very negative effect on residents in these homes. While more regular ‘spot’ inspections – perhaps by lay visitors as well as official regulatory bodies – may be one answer, it may not root out the individually abusive members of staff. A much better way to do that is to firm up whistleblowing procedures and supervision procedures for care workers – perhaps more peer discussion and supervision as well as managerial supervision.

As for the effects I see, I am no longer surprised by the increase in surveillance by family members which is a definite increased trend that I’m seeing. While there may be issues of privacy, the concerns of families are very real.

Until our care systems can provide better qualities of regulating and monitoring care – and not only from the CQC but from commissioners – whether they be local authorities or privately funded – there will always be these questions that linger at the back of the mind.

I expect I’ll be watching tonight, if I am able. I think I know what I’ll see but it is important that these incidents come to light so that changes in the systems can be made. This is one incident but it is very far from isolated. Our society needs to deliver the type of care and the methods of monitoring of care and the financial provisions for care that are not age-dependent. Until we do so, I can only infer that the systems of social care in this country are inherently ageist.

Regional pay cuts for NHS staff (Except if you’re a top exec on a commissioning body)

Sometimes I think Andrew Lansley exists purely to make me angry. I’m sure one day I’ll wake up to find him vomiting in my shoes. This morning, however, what I woke up to find was that he’s backing regional pay cuts.

Andrew Lansley, the health secretary, is threatening another controversial revolution in the NHS by proposing that its staff be paid less if they work in poorer parts of the country.

The cabinet minister is backing a plan for regional pay, which would mean that nurses, midwives, hospital porters, cleaners and paramedics would earn less if they work in the north or the Midlands rather than in the south of England.

Yep, we’re going to follow the private sector in a race to the bottom, and helping to further entrench the North-South Divide while we’re at it?

But what if it creates skills shortages? Surely there’ll need to be exemptions to make sure clinically-vital posts get filled?

Official documents reveal that the only backed by the Department of Health would be for highly paid managers working in new bodies established to deliver Lansley’s controversial NHS reform programme, widely criticised as a privatisation of the health service.

The department, according to a submission to the NHS pay review body, believes special arrangements would be necessary for this new cohort of executives to “attract and retain high-calibre leaders and staff responsible for transforming delivery”

So, the only posts for which we need to “attract and retain high-calibre leaders and staff” are for the commissioning bodies that nobody wanted in the first place?

I’ve said before and I’ll say it again. What a complete and utter Lansley.

Angle Management

In among the tributes for the centenary of the Titanic, there’s one little-known incident which didn’t get mentioned. I shall now remedy that:

On the deck of the Titanic, all the lifeboats had gone. A group of terrified children huddled together as the ship began to tilt and the stern slowly rose out of the water. Suddenly, the captain walked over to them.

The captain said, “I’ve been asked to have a word with you about your angle problem.”

“Our angle problem?” The children were confused. “Do you mean the fact the angle of the deck is starting to tilt?”

“Yes, that’s right, your angle problem. You have a problem with angle control. Your parents and teachers have gone to the lifeboats, but they feel you need some angle management.”

“Angle management? Isn’t there something wrong with the ship? We saw an iceberg earlier.”

“Never mind that. You need to understand and accept that you have an angle problem, and you need to engage with the angle management programme that your parents and teachers agree that you should undertake.”

“What are they doing in the lifeboats? Surely they can’t just leave us here!”

“Now, now, they don’t have an angle problem, but you do, and it’s your responsibility to sort it out not theirs. Anyway, let’s get to work on the angle management. We’re going to start with some preliminary sessions on how to use spirit levels, so that you can recognise when your angle is getting out of control. Then, we’ll work on some cognitive-behavioural strategies that you can use to regulate your angle.”

The children then complete the angle management work with the captain, who uses a morse lamp to signal the parents and teachers in the lifeboat, informing them that the kids have had their angle management as requested. The deck then finally floods and the children all drown.

A slightly silly tale, but is it any sillier than the constant requests I get from people who want an abused, traumatised child, often living in dysfunctional circumstances, to undergo anger management? Why do these otherwise-intelligent people believe that this will have the slightest benefit to the child or anyone else?