Yesterday after collecting both written and verbal evidence, the House of Commons Health Select Committee published their report into Social Care.
It makes very interesting reading and is written accessibly so I would highly recommend that anyone with an interest in this area reads the original but I wanted to pick up on some of the themes myself as there were such crucial issues raised.
The main theme I picked out (and you don’t have to be very astute to click with this one!) is the need for continued work towards integration – not only between health and social care which has become a bit of an old chestnut, but also with social housing.
The figures the report pulls out are that 50% of GP visits and 70% of hospital days are required by older adults as well as half housing association tenancies.
It’s not surprising but when we think about these figures, it is very important to put them in the context of need and service delivery rather than indicate that people who have additional needs, whether due to age-related disabilities or other illnesses or disabilities are not a ‘burden’ or a ‘problem to be solved’.
The problem absolutely lies in the way that these services are both funded and commissioned rather than the additional needs that exist, after all, we can hardly say, in 2012, that an ageing population with higher health and social care needs has hit society suddenly without notice.
It is a lack of political (and fiscal) will to change that creates the poor delivery of service, not merely the numbers needing additional care.
The report criticises the ‘silo thinking’ of these different agencies, particularly local authority ‘social care’ funding, NHS ‘health’ funding as well as housing and provisions of benefits. All live in their own splendid funding isolation where there is a distinct benefit to the individual budget holders to push costs from one siloed ‘pool’ to another creating a more complex, detached and poorer service for the end user.
So, the report looks to joint commissioning as an answer, particularly suggesting a single commissioner with a responsibility for older adults in particular across all these layers of services.
I understand the intention and see it as an improvement but I feel there needs to be greater innovation in this approach. I have little faith in commissioners that work within the services I have to dole out. They never seem to have any interaction with the service users/carers/professionals at the ‘front line’ and provide poorer quality services at yes, lower cost, because they are not the ones who have to receive those services.
The Committee scoffed at Burstow’s claim at there is no funding crisis in social care.
there is clear evidence of resource pressures on social care authorities. The Committee welcomes the Government’s commitment of an additional £2 billion per annum to social care by 2014-15, but recognises that even this substantial additional commitment is only sufficient to meet additional demand if social care authorities are able to deliver an unprecedented efficiency gain of 3.5 per cent per annum throughout the spending review period and does not allow for any progress in responding to unmet need.
The report also raises the joint issue of quality of care as well as cost of care as the two go hand in hand and current commissioners have to take some responsibility for that
The Committee’s response to changing the funding system is broadly in line with the Dilnot report with some caveats around the levels of the proposed ‘cap’ on payments and whether this may discriminate between areas of the country where costs (particularly housing costs) are very different and they state that while this may solve one area of the current difficulties and muddled thinking – it is by no way a panacea.
They have an interesting few paragraphs about personalisation and the roll out of personal budgets, emphasising the possibilities to make care more flexible however the realities of the levels of budget can sometimes belie expectations. There is also a warning.
A growing number of people are having their care needs quantified and converted into a sum of money through a resource allocation system (RAS). This creates a scenario in which people’s needs could be assessed less personally and could develop into an entitlement-based system which awards them a specific cash amount under a process more akin to social security than social care.
Something to be mindful of as the RAS comes under scrutiny at the Supreme Court
It’s an interesting and useful report and as I said at the start, definitely worth reading for an overview of some of the challenges that face adult social care currently.
I’d like to see more innovative approaches to building new systems. It feels as if social care is often slower than other areas to change because some of the monolithic systems within local and central government have ‘been that way’ for such a long time.
The world is changing. The Personalisation Agenda reflects the move into a post-modern climate of care delivery but the systems remained couched in the modern origins of the welfare state. Until there is more movement from commissioning and service delivery, the talk will mean nothing. While I am hopeful by some of the suggested changes, I look to the government who denies there are any problems in funding and despair.
We need to change and at least the committee recognises that although it’s hardly ground breaking. The need for joint commissioning strategies, linked in outcome measures and cross pollination of money/ideas between health and social care is hardly new.
No government wants to jump because powerful interests and lots of money is at stake. Hopefully more and more reports will finally lead to something being done differently and better.
guiltycommissioner
February 9, 2012
There ‘s loads to talk about here but I will confine myself to two comments
Integration: Always put forward as the panacea but from my experience over the last few years , sometimes things were better when people belonged to seperate organisations , felt secure within their boundaries but talked and worked together. I could never understand, as a social worker why people when on about the huge diffrences and difficulties between social care and halth, when the health staff i worked alongside – both nurses and doctors, OTs, physios, in hospitals and in community services – seemed to share all the same values as me and we got on with the job of trying to help people. In my area these have been forcibly integrated, morale is rock bottom, confusion regins, there is duplication and there are gaps. Now as a commissioner I udnerstand it all too well. The only real barrier was of course the budgets, but that doesnt seem to have improved, unless you call a total health takeover and disappearance of social care values an improvement. Sad for the casualties, the old people denied hospital treatment under the guise of ‘reablement’, the failed early discharges where people end up as emergency nursing home admissions.
Personal budgets: there is a fundamental conflict between the risk averse, quality assurance box ticking culture of commissioning and the idea of freedom, choice and control. Freedom always comes with risk attached, but it seems we must give people personal budgets to spend as they wish in the open market but at the same time must ensure that nothing can ever go wrong adn that none of the advantages of state control are lost. Hence now we have commissioners trying to force domcare providers to charge the same hourly rate to personal budget holders as they do to the council whilst ignoring the fact that a) these are independent businesses, the contract is between them and the paying customer whether paying from their own capital or from a PB and it is essentially none of the council’s damn business what they charge and b) there is a world of difference commercially between block contracts or even spots where the Council is paying and is never going to default, unlike private clients who frequently refuse to pay. You just cannot have it both ways. If Big Dave wants a world where care goes back to parish volunteers/the lady next door/the unemployed grandkids there will be consequences in a society where exploitation of the weak is increasingly embodied in national economic policy.
I am not being defensive of commissioners here as, you can tell from my screen name I have severe doubts about a lot of current commissioning culture. Recently there has been a bit of a backlash against the procurement/managerialist model and people are starting to talk about the importance of relationships with providers, and the importance of commissioners who actually have some clue about the reality of the services they are commissioning. If this grows there is hope yet for a return to sense.
ermintrude2
February 10, 2012
Thanks – I’m aware that I’m often uncharitable to our commissioners but that is partly because they are so distant from us and seem to make contracting decisions for infathomable reasons (well, we know it’s just cost but the impact of poorly commissioned services is one I have to deal with daily – not them!)
I change my mind about integration to be honest. I’ve worked in very successful integrated teams (in adult services and mental health services) where there are a great deal of opposition but this was smoothed over by personalities involved
.
The problem with PBs is not about direct payments users who can choose their own support plans but the ‘managed’ budgets which are commissioned without any vision (in my view). Yes, I know it’s about cost but it feels no different to previous provisions however the amount of work involved.
My wishlist for commissioners is for them to actually come and speak to us and to meet with us. Let us know how they make decisions and let us tell them about the feedback we get.
It’s not meant as a personal slight
)
guiltycommissioner
February 12, 2012
No offence taken Ermintrude. Some of the things I hear commissioners say make me want to weep.
Re managed budgets, well they are no different are they? In fact in my view they are worse because they make no allowance for individual needs which happen to be for more expensive services. For example a set amount is in our local RAS for carers needs, whereas under the bad old system the carer’s needs were assessed individually and high needs carers could get quite a lot in terms of sitting, respite etc. Most carers needs were seen addressed by the care package. In came a set amount which meant everyone who ticked the box marked ‘carer’ got a set amount, spreading resources far too thinly and meaning the really high end carers are now very poorly supported, in my view.
We have restricted social workers’ choices of what providers they can use in for example dom care because of the ‘need’ to contract manage all the providers we use. We dont have enough commissioners to accredit and review every little dom care agency that might have a dozen of our clients. So we insist that the social workers use a limited list of providers. This limits innovation in the area – if you were to start up a small but excellent agency you would have no chance of getting LA cases unless they client takes PB and manages it themselves, which let’s face it few elderly frail people want to do. Contract management/quality assurance is a hit and miss process, there is a time lag between accumulating information that points to bad practice and actually taking any action – personally I would prefer there were sufficient front line resources to review people more often and more carefully, which would throw up the bad providers probably far more effectively.
I agree about talking to each other. I find practitioners appreciate it when I bother to come out and see them in their teams to find out what they really need and want for their clients. I know I cannot rely, for example on my couple of years in a psychiatric team 25 years ago to guide me as to how mental health services operate now. Mind you, it is better than no experience on the front line at all. I wish the issues between practitioners and commissioners could be more openly discussed, but unfortunately there seems to be a climate of fear, resent builds up rather than being ventilated in open debate. Providers are also afraid to complain with a fear of the cconequences. Sometiems this is exaggerated, but I wish it always were. Organisation which speak up about changes to services which they see as adversely affecting their clients can be the subject of some pretty damning comments over here on the dark side of the ‘biting the hand that feeds you’ kind. .