Reforming social care
by Paul Gosling
“Doing nothing is not an option.” The warning to local authorities came from the Department of Health in its recent ‘Transforming Social Care’ circular. Radical restructuring of adults’ and children’s services is obligatory.
Just why is easy to see. While local government settlements are bearing down painfully, social care demands are relentlessly upward. Councils are squeezed in the middle.
By 2036, the number of people in England over 85 will rise from a little over a million today to three million. Those with dementia will double in the same period, to over a million. Life expectancy for people with Down’s Syndrome doubled in the last 20 years.
As the health service becomes more effective in enabling people to live longer, so the demand on councils’ care services is expanding rapidly. Yet the funds are simply not there to meet those demands. The solution is not simply to improve efficiency, but to fundamentally reshape the provision of services and to change service users’ expectations.
The blueprint for care service restructuring – reform is an inadequate word for the scale of the change process – is spelled out in last December’s ‘Putting People First’ concordat between central and local government and in January’s ‘Transforming Social Care’ circular. The scale of the task lying ahead for councils can be gleaned from the concordat’s passing comment that “there is now an urgent need to begin the development of a new adult care system”. In doing so, local and central government are burying the Community Care framework, which “was well intentioned” but “over complex and too often fails to respond to people’s needs and expectations”, according to the concordat.
In return for doing things differently, all social care councils now have access to Social Care Reform Grant of £520m to assist them in creating that different basis for care provision. The three pillars of the new system are fundamental reform, a values-based approach (treating people with respect, not as receivers of production-line services) and a personalised service. Behind those personalised and value-based services sit personal budgets, to give service users more control over the type of services they receive, how they are delivered and by whom.
The good news is that there is some common ground between what service users want and what local authorities can afford to provide. Old style residential care accommodation was not just very expensive for councils, it was also, generally speaking, not what residents wanted. Surveys consistently demonstrate that elderly people want to live as long as possible in their own homes, supported to live independently. In doing so, the financial demands on local authorities reduce.
But the reshaping of council provision goes far beyond simply reducing the provision of residential care, replacing it with more home help support. The real challenge is for local authorities to operate proactively to actually enable people to live more healthy lives, so that they are better able to look after themselves. Not only should they live longer, but also more independently and more happily.
One of the most radical change programmes is taking place in Birmingham, where the council has faced widespread criticism – but which will achieve major savings for the council. Twenty nine of the councils’ residential care homes have been authorised for closure, requiring large numbers of residents to move. In their place Birmingham City Council is developing multi-purpose care centres and supported community living. The first of this new generation of care homes opens next month.
Savings from Birmingham’s closure of residential care facilities are being spent on extra care support – housing schemes where residents live within individual properties, but benefit from communal facilities and care. Increasingly, people will live on their own, but with access to necessary support. Like many other councils, Birmingham has also changed the character of its domiciliary care services, away from providing services for the elderly and infirm at home, to now supporting people’s capacity to live in their own homes. Day care has been reshaped to focus on rehabilitation and respite support.
Other councils are investing heavily in facilities that are more cost-effective than was traditionally the case. An example – adopted by Leicestershire and many other councils – is for smaller children’s homes, providing higher quality support and care, hopefully supplying better preparation for healthy and mature adulthood. Several London councils are placing more children in new, high quality, homes within their own boroughs and in adopted and foster care, avoiding the need to send children to more expensive residential homes outside the capital.
Many councils are financing their social care reforms using ‘invest to save’ budgets. The character of those investments vary widely in different councils. Some, such as Hampshire, are increasing the capacity of the voluntary sector to provide greater support for people to prevent them needing to be admitted to residential care. Many are using invest to save budgets to fund extra care housing. And, of course, most councils have made major savings by externalising domiciliary care services.
St Helens, has an ‘active ageing’ strategy, aimed at improving health and wellbeing of citizens as they get older, reducing their need for longer-term support, which include fitness programmes for the elderly. The council’s invest to save budget was used to provide intensive support – including home adaptations, extra domiciliary care, physiotherapy – for patients upon hospital discharge, on the principle that if their capacity to look after themselves was improved at this point they were less likely to need to be readmitted or to need residential care, were better able to look after themselves on a long-term basis and were more likely to return to work.
Such use of ‘invest to save’ budgets to pump prime preventative schemes is “pretty widespread” now, says Andrew Cozens, strategic adviser for children, adults and health services at the Improvement and Development Agency. Cozens believes that the integration of care and other services – for example, adult care with housing – has provided additional scope for driving greater efficiencies and preventative action. “Lots of directors have much wider responsibilities, which allows them to implement these strategies,” he says.
Cozens suggests that the best guide to how councils will deliver social care more innovatively and more efficiently in the future can be obtained from the experience of the 29 POPPS – Partnerships for Older People Projects – pilot schemes. The projects have used a variety of ways to establish early contacts and interventions with people who might, traditionally, have been expected to become highly dependent on local authority support. By promoting greater social links, putting elderly people into contact with ‘handyperson’ schemes and providing occupational therapy support, for example, there is evidence of lower rates of readmissions to hospitals and reduced need for residential care. There has also been particular effort by the projects at improving contacts with hard to reach groups, including marginalised ethnic minority groups, travellers and people in remote rural environments.
But the speed with which councils are adopting new arrangements for care means that it is difficult to evaluate how effective they are. “Some of the reforms are still quite new,” says Anne Williams, president of the Association of Directors of Adult Social Services and Salford City Council’s strategic director of community, health and social care. “The three seams for Putting People First are about getting better about giving people information; second, about early intervention and prevention services; and third about the personalisation of services,” she explains. “Everyone is at different stages on this.”
The personalisation reform are producing better outcomes for users, with authorities becoming more creative and treating service users as individuals with individual needs, says Williams. “But it is still small numbers compared with the numbers coming through the social care system.” The big, unanswered, question is whether it is realistic to expect this small scale pilot experience to evolve into what she calls the “industrial scale” of support through which service users can be “up-skilled” to improve their own capacity to look after themselves. This is one of the great challenges now facing local authorities.
“In terms of efficiencies, there is now good evidence that a ‘re-ablement focus’ gets better outcomes for people,” adds Williams. “So someone comes out of hospital and needs home care and if it is focused on real re-ablement it can get people confident, rather than doing things for them. There is growing evidence that people do get more confidence and can go back into employment.” This ‘recovery reablement model’ is now being widely adopted in place of the traditional ‘dependency model’, she says.
“Other reforms are starting to take effect, but it is early days,” says Williams. She is particularly excited about telecare, especially for people with dementia, who perhaps live alone and have habits of wondering about in a confused state. A call centre can know if someone has got out of bed in the middle of night, but not returned, or has left water or gas on, or even gone out the front door for a walk during the night. In each of these circumstances the call centre can trigger an alert and provide a personal safety net. “A lot of this is quite inexpensive,” points out Williams.
But even radical reforms and service reshaping do not of themselves resolve the budget crisis that councils face. “However efficient we get, however we reform services, we can’t cope with the demographics without more money in the system,” argues Williams. The ultimate question remains, she says, “How much is the family going to pay, how much is the individual going to pay, how much is the state going to pay.”
For Andrew Cozens, the central dilemma is also about money, but he puts the issue slightly differently. “The dichotomy,” he says, “is between innovative responses and the reality of living within reduced budgets.”