How Community Care Co-operatives can deliver better care for the mutual benefit of all

Introduction: Crisis and Co-operation

Welcome to the first section of our toolkit, which sets out the benefits of a community based co-operative approach to delivering social care. New approaches are certainly needed and there is a general consensus that the current system is broken. The fact that you are reading this shows you get this too and are looking for viable, practical alternatives to the current mess. So it is hardly worth starting with a detailed discussion of why the adult social care system is in crisis. A better question would be ‘Why might co-operation offer a better way?’ The answer to that lies in the main features of the current crisis:

An ageing population and fuller recognition of the rights of vulnerable people to decent care have exponentially driven demand
Inadequate public funding, especially since 2010 and the shift to austerity, mean the system is chronically under-resourced.
The Care Act (2014) aimed to put care recipients and carers in control of buying services. However, the amount of support available for those who could not contribute themselves has not matched that paid in by individuals who can. There is growing inequality between those who have enough money and those who don’t.
Meanwhile as Local Authorities cut costs they seek ever cheaper care, creating a ‘race to the bottom’ effect and private companies now dominate the market.
But margins are tight and there are many instances of insolvency among private social care companies. To maintain profitability private providers have inevitably sought to cut labour costs. This in turn has led to exploitation, very high staff turnover, low pay, lack of loyalty, limited training and career progression opportunities and low morale.
Predictably in such a person-centred sector, declining staff pay and conditions have led to issues with the quality of the service. In some cases criminal cases of abuse surfaced. The state responded by creating an often vigorous regulatory machinery enforced by the Care Quality Commission (QCC), although there is too-often a gap between ideal standards and reality on the ground.
Above all care has become commodified; based on markets, competitive pricing, strict contracts and narrow expectations, so that the person receiving care becomes a consumer and the business provider is careful to restrict their commitments and liabilities. Although care workers and many private companies wish otherwise, the logic of the system inevitably promotes a ‘time and task’ culture that downplays the individual needs of the care receiver.

So it’s clear that we are witnessing a market failure on a vast scale. It’s tempting to say that more money and/or a wholesale return to publicly owned and controlled provision will fix the problem - and both these are certainly going to be part of any solution. But the reality is that this is unlikely to be forthcoming in the near future and would not address all the issues in any case. As important is the way care is delivered, by whom and for what purpose?

The original co-operative movement in the 19th century was also the child of market failure, as communities struggled to deal with the exploitation and problems thrown up by the Industrial Revolution. The main thrust then was around retail and services, although a co-operative approach also came to be applied to many other aspects of society, including insurance, funerals and housing. The key motivation was an understanding that co-operative businesses, competing within a market, would offer real and tangible benefits to individuals and communities. The co-operative movement then was very much ‘bottom-up’, deriving its leadership and energy from the communities it sought to serve.

The purpose of this chapter is to show how we too can take a co-operative approach to tackling the crisis in social care. At the core of the argument lies some simple and well-tested principles concerning the value of co-operation and the nature of co-operative organisations. In particular, it argues for the roll out of the Community Care Co-operative model, as developed in countries like Italy, Japan, Canada and France. However, we need to adapt this to fit with current UK realities, an individualised market culture, and the needs of the key stakeholders groups involved in receiving and delivering social care:

Service users and their families
Staff
Members of the wider community in which any co-op will operate, including statutory agencies, community groups and local councils, as well as individuals

It follows that if a co-operative approach has any validity it must meet the needs of these stakeholders better than the private, for profit companies that currently dominate. There are solid grounds for optimism. In Japan, Italy and other parts of Europe there is already a well established social care co-operative sector. We believe that now is the time to build a social movement for co-operative care in the UK as well.

Finally, a few of points of clarification.

Firstly, the chapter (and tool-kit) looks only at adult domiciliary social care in the knowledge that residential care and Children’s Services operate in a completely different (and rightly) more demanding legal and regulatory framework. It has also been written particularly with older citizens in mind – 2/3rds of adults receiving social care are aged 65 or over - but the principles outlined would apply to any person in need of care.

Secondly, readers will find numerous references to ‘regulated’ and ‘unregulated’ care. The regulation is conducted by the Care Quality Commission and the care refers to specific types of support delivered by paid care staff, including lifting, handling, mobility, medicines, continence support etc. This of course excludes a host of other care needs which are ‘unregulated’ and tend to fall outside the money system. This will become clear when the needs of people receiving care and their families are considered more fully.

Thirdly,‘Community Care Co-operative’ model is used throughout as shorthand for a multi-stakeholder form of membership and governance that includes service users and family, staff and community members.

Our vision is for all these groups to co-operate together to deliver care in their community for the mutual benefit of all.

The Community Care Co-operative model

There are many forms of co-operative enterprise, including consumer, worker and community co-ops. But at the heart of each are the basic principles of co-operation established by the pioneers of the movement in the 19th century. These assume that co-operative enterprises will:

Be comprised of a voluntary and open membership
Be democratic and controlled by the members
Members will participate economically - whether as consumers, share-holders or producers - and will receive a benefit from doing so
Each co-op will enjoy organisational autonomy and independence so it can better meet the needs of its members
Promote education, training and information among both its members and the wider community
Co-operate with other co-operatives to the benefit of all the members of each
Be motivated by concern for the community.

These principles boil down to the idea that both individual members and the wider community will benefit from a co-operative approach. For example, in Co-op retail stores this took the form of a regular cash ‘dividend’ based on a % return on the money spent by each member, ethical trading practices and help to the wider community. The community and individual benefits of our vision of a ‘Colne Valley Co-operative Care Store’ is explained in a separate section of the Toolkit . The aim of this section is to set out the main features of our proposed Community Care Co-operative model and potential benefits for each of the major stakeholder groups, plus some comment on the advantages for external statutory agencies as well. But it’s always important to recognise that while the various parties will have shared needs and interests – otherwise co-operation would be impossible – there will also be differences and even potential conflicts. The trick then is to build in approaches, ethos and systems that will balance needs and interests to the ultimate benefit of all.

Summary of key features

Inclusive - voluntary and open membership
Personalised, holistic care packages
Expanded remit, aims and ethos
Place based and ‘just big enough’
Empowered staff members
Community involvement
Not for profit and community financed
Federation and co-operation with sister care co-ops
Democratic multi-stakeholder governance
Able to fully utilise IT and social media to develop beneficial networks
Co-operates with other community groups and statutory agencies

Voluntary and Open membership

By definition a multi-stakeholder Community Care Co-operative implies a voluntary membership open to everybody involved in delivering social care. But sometimes communities can exclude people as well as include them. So building on a clear progressive ethos and approach, Community Care Co-operatives must take an inclusive view of ‘community’, encompassing the members of the co-op itself and local statutory agencies, community and faith groups. All these stakeholder groups would be represented on the Managing Board and a strong Equal Opportunities policies and practice must prevail.

However, this in itself won’t guarantee access, especially in a class based society and a marketised care system. Social care is means-tested. Around a quarter of people who approach their local authority for social care receive short term or long term care. Increasingly, the emphasis is on people paying for their own care (‘self-funding’) with or without ‘top ups’ from the local authority. (source The Kings Fund)

These economic realities potentially pose a real problem for the principle of open membership. There are no easy answers to this if Community Care Co-ops are to remain viable businesses under the current system, and it’s clear that service user membership will be divided between those getting public help and self funders. The challenge then is to turn this negative into a positive by using co-operation and community volunteering to widen access and forge a social alliance in favour of better care.

Personalised, holistic care for service user and family members

Ultimately the whole point is to deliver a better sort of care for vulnerable adults in need. These needs will vary according to age, family resources, health, chronic conditions, economic resources, housing situation and so on. The modern social care system and legislative framework rightly recognises the importance of personalisation - that individual service users, carers and families have unique circumstances and are usually better placed to make key decisions about their care. However, the reality often falls far short of this due to the nature of the current system. It’s also important to recognise that especially for many older people receiving care, it is usually impossible to separate themselves (and the choices they make) from their families, who will rightly remain an important part and resource in any care package. That’s why our multi-stakeholder model tends to look at service user members and their families together.

People have a wide range of needs that will have to be met if they are to remain independent, well and living in their own home. Co-operative Care Colne Valley seeks to apply a wider vision of ‘need’ that distinguishes between four key elements of a person’s daily life that impacts on their sense of health and well-being. These are set out in table 1:

Elements of independence and well-being	Examples encountered in daily life
My Life	Attending appointments, Tenancy Support, Using IT, Managing Finances, Family and Relationships, Faith and Culture, Bereavement Support
My Home	Shopping, Cleaning and Laundry, Cooking, Property Maintenance, Garden Maintenance
My Community	Sense of belonging, Friendships, Social Outings and Events, Plus One Arrangements, Holiday Support, Sitting Service
My Care	Hygiene and grooming, Medication, Mobility, Nutrition, Continence Support, Emotional Wellbeing, Health

The key feature of the Community Care Co-operative model then from a service user member perspective is that the service seeks to integrate ‘regulated’ personal services (‘My Care above’) with community based operations delivered by volunteers and others delivered through a Co-operative Care Store. This will allow a holistic, truly personalised approach to develop that moves away from a ‘four visits a day’, ‘time and task’ approach encouraged by the current marketised system.

The vision and practicalities of developing a ‘Co-operative Care Store’ are fully explained here

Expanded ethos, aims and remit

We are not here to demonise all private care providers and many companies do try, within the limits of a broken system, to provide a quality service. But despite their worthy mission statements, the fact remains that their ethos is ultimately driven by the bottom line. In contrast this is the vision statement of Co-operatve Care Colne Valley:

Our vision…

We believe that people who need care in the Colne Valley deserve the best quality care. Support that enables them to lead fulfilling and independent lives.

We will:

Treat the people we care for as valued individuals and strive to provide them with the best quality care possible
Involve the people we care for and their families in making decisions about their care
As a co-operative, ensure that all members have a real stake and a real say in how the service is run
Work to ensure older members remain active members of the community through our innovative volunteer scheme
Ensure our staff are well motivated, trained and don’t come and go. We will reward, value and support staff members properly with favourable working terms and conditions, quality training and the opportunity to contribute to decision making

An ethical co-operative business operating on a not-for-profit basis. Any financial surplus will be used to improve our services by investing in our staff and volunteers who support the people we care for. People needing care and support, their families, care workers and community volunteers, respected as equal members of a dynamic and democratic enterprise.

A community based, small scale caring co-operative who put people before profit to deliver to those who deserve more.

We believe the Community Care Co-op model is the vehicle most likely to achieve this wider vision and best suited to delivering a more humanistic and holistic service that respects the rights, needs and interests of all the relevant stake-holder groups. So while direct care provision to vulnerable adults lies at its heart, other complementary aims can be pursued. These would include:

Promoting social and economic justice with care staff
Involving members of the community to promote the sorts of preventative, befriending and health prevention strategies employed by Japanese Han groups but in a less formal way (see below for more on this).
Co-ordinating and working constructively with other community groups and initiatives
Networking individuals to address loneliness and isolation using both traditional means and new digital technology
Promoting local economic growth and resilience

An expanded ethos beyond making a profit, combined with an inclusive co-operative vision, promises to benefit the whole community and not just the people receiving care.

Place based and ‘just big enough’

Every community has its own character and needs. In the case of CCCV our ‘place’ is therefore the Colne Valley, which includes a number of different villages, townships and suburbs adjoining Huddersfield - a real mixture of urban and rural, social classes and ethnic groups. But in a highly individualised, competitive market society with care companies and state agencies operating across large geographical areas these can easily be lost sight of. So the ideal would be for leaders, staff and volunteer co-op members to both live within and fully understand the communities they serve. Logically, this will encourage better accountability, communication and above all standards of care. Tight, place-based teams of staff members, working in co-operation with family and neighbours within specific local areas are more likely to see those receiving care as individuals, with individual needs. There are also practical benefits, with reduced travelling time between visits, costs and environmental impact.

All this in turn implies that the size of any Care Co-op will be a factor. While only lived experience will show what’s ‘just big enough’, there are some obvious potential advantages to co-ops with a smaller number of service user members. Ultimately, human care relies on quality human relationships that can better flourish within more intimate,local settings.

Empowered and motivated staff members

The bulk of day-to-day regulated care will and must be delivered by qualified care professionals. But as we have seen, these are usually underpaid, under-valued, often poorly trained, on zero-hours contracts with very little autonomy or say in their work. Small wonder there is a massive staff turnover, shortages of staff and problems with motivation and quality of provision. This last point is crucial, as service users rightly want and expect continuity of staff that allow trust and better relationships to develop over time.

The obvious starting point is to direct any financial surplus towards bread and butter improvements in key terms and conditions, such as ending zero hour contracts, higher wages and being paid for travel time. As a not for profit enterprise that aims to have as flat management structures as possible Community Care Co-op’s are better placed to do that. However, the economic reality of the current care market means that there are limits any care business, whether co-operative or not, can deliver in terms of pay and conditions.

But there are other forms of compensation that can make work more rewarding. From our conversations with care professionals involved in establishing CCCV it’s clear that problems around demoralisation and concerns about the quality of service they deliver are just as important to frontline care workers. So more resources can be put into providing better training and extending the times of visits to improve the quality of interactions between staff and service users.

Needless to say, trade union rights and fair, equal opportunity based employment policies and procedures are a must. Care co-ops can also empower staff as a stakeholder group through representation on the Management Board that will offer a genuine say in how the enterprise is managed. Similarly, by operating with flatter management structures and tight team working in local areas, there is scope for developing more autonomous working practices and skill sharing. For example, the Dutch Buurtzorg Neighbourhood Care System uses an internal social network to link up with a colleague with specific expertise. Nurses can post questions on a Facebook-like platform and share knowledge in a bottom up decentralised way and it is well-used by staff. Finally, team based working in specific locations, rather than having to travel distances between calls, will encourage a sense of community connection, especially when combined with family/volunteer provision. Our ideal is to give staff members a chance to work close to where they live.

More detail on how these operational and staffing principles can be rolled out in practical terms are provided separately in the tool kit

Community involvement

The key feature that sets the Community Care Co-op model apart from other service providers is the ambition to build a culture of highly organised good ‘neighbourliness’. This assumes that while paid staff members are responsible for delivering quality regulated care, many of the other things that make life worth living can only be realistically accessible to people receiving care if the wider community gets involved. This will also help take the pressure off often-hard pressed family members. There are 6.3 million unpaid carers in the UK, many of whom are isolated. Families and carers of service user members would welcome the opportunity offered by the co-op to share worries and help each other out in a safe, organised setting. But all this requires resourcing so staff tasked with organising community based care and other associated costs, such as DBS checks, will need to be built into budgets.

There are precedents from other countries that we can learn from. The Japanese model of co-operative social care may offer some features that could be applied here. The co-operative movement in Japan operates large scale health co-ops across all aspects of the sector covering 3 million household members through 120 coops with 1300 branches. Interestingly, it also mobilises volunteers in over 26,000 Han Groups. Each Han group has 10-20 members and promotes mutual aid, self help and healthy lifestyles. These often highlight issues like food and exercise. Thus care users are part of and supported by networks within the wider community.

But it’s important that any form of mutual aid cuts with the grain of dominant British cultural norms and expectations as they actually exist. Decades of marketisation, austerity and consumer culture have left communities more fragmented and peoples’ outlook more individualistic. In particular we are encouraged to think any form of ‘legitimate’ work has to be validated by money payment and that care can be commodified like any other consumer good. So moral appeals alone are not enough and Community Care Co-operatives can incentivise community participation by providing tangible benefits to individual volunteers, family members and local businesses to work together.

It’s clear that the potential for community support is vast. Indeed, many local organisations, faith groups and charities already deliver these sorts of services and a genuine co-operative approach is to work effectively in partnership with them. However, the gaps are obvious and Community Care Co-ops (alongside paid staff members) are well placed to both deliver their own services and act as co-ordinators to link service user members and families with existing provision. While the ‘My Care’ element (see table will be more ‘regulated’ and the responsibility of the staff members there are many other opportunities where staff, volunteers, family members and groups operating in the community can contribute to promoting independence and well-being. Some of these are set out here in table 2:

Elements of independence and well-being	Examples where service users and families can actively participate with staff and volunteers so it's being done by/with them, rather than to them
My Life	Helping someone else with an aspect of their life Sharing responsibilities/time spent in return for respite for yourself or a family member later on
My Home	Participating in joint shopping trips and maybe a meal out with a few others Shared meal at home, facilitated by the Co-op
My Community	Participating in social outings and events facilitated by the Co-op Visiting people who can’t get out The Co-op acting as a befriender that can bring people together with shared interests, such as sport, hobbies etc Help with technology – internet shopping, skype and telephone conversations Participating in community and democratic decision making
My Care	Through actively engaging with others receiving a boost in mobility, health and a sense of mental well-being

Our principled, innovative ideas around creating a Colne Valley Co-operative Care Store and operating model to Community Care provision is fully explored in a separate chapter of the toolkit

Not for profit and progressive community financing

Community Care Co-ops have to operate as a successful business, generate income, hold reserves and make a surplus. As we have seen this, together with savings gained by having flatter management structures, will allow them to direct surpluses into resourcing key aspects of the service for the benefit of staff and service user members.

But a better service, ethical sourcing of equipment and PPE and a responsible attitude to reserves means bigger start-up costs. Given the progressive nature of the project Care Co-ops are in an excellent position to secure grant funding for the start-up and then bid for contracts around elements of their work from local Councils and other statutory agencies.

However, a key source of capital to underpin development is to secure community buy-in and support through a Community Share offer. Precedents of share offers undertaken by co-op start-ups in this are other sectors are very encouraging.

But as importantly, the whole process of actively engaging with the community in a share offer recruits co-op members, encourage more volunteering and raise the profile of the project in the vital early stages.

The practicalities around these different aspects of Co-op financing are explained here

Federating with other care co-ops

While small-scale, locally rooted co-ops are envisaged that operate autonomously day-to-day, every coop would be expected to assist in setting up at least one other and work together with each other within Federations. In Northern Italy each co-op undertakes to put out ‘runners’ in their locality to encourage the growth of new sister co-ops - the ‘strawberry patch principle’.This will benefit individual co-ops in a number of ways:

Enjoy economies of scale on key back office functions such as recruitment, IT, training, advertising, research and development, procurement etc
Seek and secure external funding and contracting more efficiently
Speak with one single voice when negotiating and interacting with the local authority and other external agencies
Facilitate best practice, advice sharing and foster a horizontal, more democratic culture of knowledge sharing

More detailed discussion and ideas around how Care Co-ops can federate and ‘co-operate with other co-operators’ will be a future chapter of this toolkit

Democratic governance and accountability

Community Care Co-ops are democratic member organisations that annually elect Boards to manage their day to day business. The multi-stakeholder model ensures that all the relevant types of members involved in the delivery of social care - service users and their families, staff and community volunteers - are represented.

This poses potential governance challenges as multi-stakeholder co-ops have different interests represented at Board level and it is unrealistic to expect clashes not to occur from time-to-time. Clearly, a well-developed co-operative ethos that permeates all levels of the organisation is vital here. So too will getting the balance of representation right on the Board, so that professionally skilled members work alongside service user/community member representatives without either wholly dominating. There are several models that could be considered from existing examples from the UK and other countries. For example, in Italy Type A coops can have no more than 50% of board volunteer members, while in Canada it is a third. Italian Type B co-ops take positive action to employ workers from disadvantaged groups (minimum of 30% of total workforce), such as people with disabilities. Over 60% of all social care co-ops in Italy involve volunteers in decision making.

More detail on multi-stakeholder governance is covered here

Networking and the importance of digital

Extensive use of IT by care companies is already common-place in terms of rostering, billing, communications, monitoring and quality control systems. However, Community Care Co-ops are well placed to fully benefit from the opportunities offered by social media and digital technology right across the piece. In particular, co-operation requires good, structured communication and more inclusive ways of working. IT can aid democratic governance, including online voting systems. There are many social media options to help tackle isolation in online forums and get conversations going between members. Co-ops can incentivise active membership through providing a ‘dividend’ through social digital currencies and time banks. This could be especially useful for family and carer members – a sort of solidarity swap-shop.

Similarly, IT can play a key role in Community operations, facilitating better care for individual service user members. For example, ‘Care circles’ around the person receiving care, comprised of family members, relevant staff and community volunteers, can be facilitated and use encrypted social media platforms like WhatsApp or Telegram. So information and alerts to members of the care circle could prompt assistance, whether it be to help change a light-bulb, go and have a brew with the service user member, get a bit of shopping or in more serious emergencies. This would help family members, keep staff fully up to date and crucially, spread the time required to support individuals, making volunteering less burdensome.

Our approach and practical examples are explored here

Co-operating in partnership with other groups and access agencies

The modern public sector is complicated and multi-layered, with many different sorts of private companies, agencies, charities, community groups and statutory providers providing inter-lapping services. Funding systems based on bids, fixed term contracts and grants can lead to competition and tension. So if Community Care Co-operatives are to deliver care effectively and be financially viable they have to build up positive relationships with external agencies. The public sector landscape varies and if co-ops are genuinely ‘place based’ the relationships will vary accordingly. However some relationships are inevitably going to be more important than others and just to highlight two:

Mutual benefits for local councils and Co-ops

From the outset the steering group of Co-operative Care Colne Valley took a principled decision to remain autonomous and separate from the Council in terms of governance and our operational and business models. This was because autonomy would allow us to innovate and connect more fully with the communities we serve. Nevertheless, progressive leadership within the council at a senior officer and political level recognised the potential for the Community Co-operative model to achieve some key objectives, such as addressing gaps in provision caused by market failure, promoting personalised care, encouraging place-based approaches and community solutions and local wealth building. As a result the nascent co-op received valuable help from Kirklees Council in terms of start-up funding, advice and in kind. This relationship has already been beneficial to the community, Council and Co-op as shown during the Covid 19 crisis as CCCV was able to step up and operate as an ‘Anchor Institution’ taking referrals from the Council for those in need and co-ordinating food supplies and volunteer work in local Mutual Aid groups. There is every reason to believe that positive partnership will continue as the Co-op rolls out the regulated and unregulated care services.

Local voluntary, community groups

In engagement events people receiving and delivering care, family members and active citizens in the community and Council Officers all emphasised a number of points. Firstly, wheels should not be reinvented - a number of local voluntary and faith groups working in the community already exist providing services. Secondly, a key problem is that ordinary people often find it hard to access services due to the complexity of the different services and organisations on offer. Taking this on board, our co-operative approach is based around creating a ‘Colne Valley Co-operative Care Store’ which works in partnership with existing voluntary, community and faith groups for the mutual benefit of all. So for example, information sharing, coordination and systems of referral can place the co-op at the heart of a vibrant web of community support.

Summary

There is no ‘magic bullet’ to solve the deep seated problems in the UK care sector. But one thing is clear: doing nothing is no longer a serious option. Co-operation in the 19th century arose as a practical community response to market failure and that approach remains as relevant today. The Community Care Co-operative summarised here and fully explained in the Toolkit sets out viable, progressive and principled means of tackling the crisis in social care at a local level. It cannot of course solve it. That requires national solutions. But in the meantime collective action at a community level, working in a positive partnership with existing public sector and voluntary groups, can not only help those in need here and now, empowering us all.

Co-operating to care