Social Care Reform: A Fair Deal in Social Care?
It is a huge privilege for me to commence this year, serving you as your President.
My first priority is to thank Sandie on our behalf.
Sandie has spoken at 43 conferences, issued 38 press releases and given 31 radio and TV interviews. She has travelled the length and breadth of England and beyond, clocking up 16,887 miles in the interests of social care. An abiding image for me will be of her gracing BBC’s breakfast news - occupying the sofa at Salford, following a 5am dash to the studio.
I have worked closely with Sandie since becoming Vice President in September, and regard the opportunity to work closely with her, albeit for a few months, as a real highlight. I have observed her qualities. She is a woman of enormous depth, who has very strong values, cares immensely about our collective responsibilities and has an amazing capacity to cover a huge range of issues with clarity at any one time. She is a shrewd and wise judge (apart from the spurious contention that all good things and people emanate from Yorkshire!). She seems to have the ability to be in several places at once. She has profiled our achievements, defended us when necessary and encouraged us to raise our ambition when needed. She has enhanced our standing and reputation with a wide range of stakeholders and partners. It is no coincidence that during her leadership we have become partners with government in the delivery of the Care Bill, she has a natural way of bringing people together and inspiring confidence. She is a tough, but inspiring act to follow.
I know her Chief Executive has plans for her back in Leeds and she will have more time with Ralph. Sandie, we owe a huge debt of gratitude to Leeds for lending you to us, but particularly to you, for all that you have led and achieved over the last year.
I would also like to extend a warm welcome to the extended membership to the Seminar and hope that the next two days is useful and stimulating. It is very good that you have made the time to come and I hope you will contribute and gain from the sessions and the informal discussions with colleagues.
Our roles get broader. We have approximately 30% of Directors who are also responsible for children’s services whilst the rest of us have a range of responsibilities across local government and increasingly health. It becomes difficult to find the time to consider the opportunities and solutions to our challenges, but of course these are the very things that sustain us and help us to step up and create collective ways forward on the key issues. So, it is fantastic that you are all here.
ADASS is a very small organisation and we owe our success to the energy and commitment of Directors, senior colleagues and associates who participate in regional work and the networks. We are supported by a small team and thank you to Mary, Drew, Jonathan, Catherine and Andriana in London and Amanda, Dani and other colleagues in North Yorkshire. We have been respected because of this commitment and because we are not only interested in shaping policy, but also in implementation of new policy or legislation with partner organisations. The desire to support each other and local authorities with the challenges we face is in the ADASS dna. Personally, I have learnt a huge amount from colleagues who have been willing to share their knowledge, expertise and experience. I hope that those of you who are new or have yet to get involved, can be encouraged to contribute in whatever way is possible for you.
It was in July 1982 that I turned up at the Social Services office in Nottinghamshire with my long shaggy beard and Citroen 2CV. I started as a community social worker covering child care and working on a range of initiatives, community activities, employment and welfare provision. The passion I had then was to make a difference to the people that I worked with. I was a little naive about the challenges, but this passion remains through the various roles I have occupied, including 9 years as Director of Social Services and Director of Adult Social Care. I am very grateful to Nottinghamshire for agreeing to support me and my brilliant senior team, who I can’t speak highly enough of. During the next year, as I spend a little less time with them, they are going to make sure that everything is going superbly well in Nottinghamshire. I am sure they regard this as a very good “development opportunity”.
The theme of my presentation is Social Care Reform: A Fair deal in Social Care?
In posing this question I want to acknowledge our successes, consider the key priorities and suggest the things we have to do.
The difficulty with the question is that what is fair is subjective but it does have at its root the values to which we aspire. There are some values that need little debate as there is a broad agreement in the sector, amongst politicians and with the public. Of course, within Councils there are inevitably debates about the relative priority of social care compared with other essential and valued services, whether this is children’s services, roads, libraries, the cultural offer or economic development. However, there is that consensus around
Treating people with dignity and respect
Personalisation, enabling people to have choice and control
Making sure that there is a greater opportunity for people to have a good life
Providing funding to enable these things where people do not have the means to pay for the necessary services themselves.
In fact these are the very things that brought me into social work and social care in the first place. My grandmother spent thirty years of her life in a psychiatric institution and my mother’s earliest memory was of her mother being taken away in a straight jacket to the Psychiatric hospital. I say this not to bear my soul or to embarrass anyone, but to point out that things have changed dramatically. A combination of medical technology and the care system means that if my grandmother were alive today, she would not have spent anything like this huge proportion of her life ostracised from her family and community.
It was whilst with Dame Phillipa Russell, Chair of the Standing Committee on Carers recently at a conference that we reflected on how far things had come since my grandmother spent so much of her life in hospital or Dame Phillipa’s disabled son was a young man.
The reason for this is that those values have been promulgated and owned by enough people to make the sort of changes which mean that we are contemplating a system enshrined in law that espouses the wellbeing of the individual.
This question brings to the fore an understanding of the vision and priorities for social care, nationally and locally. It brings into focus the responsibilities of the Government, Local authorities, Directors and senior colleagues in ADASS. It also involves our major public sector partners in health and housing providers of care services, the communities, carers and Service users, in a complex system. The success of care services depends more than ever before on the contribution of all the partners. Our role is to harness these contributions.
The vision for social care
The vision for social care is clear.
This is a care system which seeks through prevention to keep people as independent as possible with good advice and information, preventative approaches such as reablement and enablement before personal budgets provide as much choice and control as possible for service users and carers. There is a strong momentum for joining up commissioning, and where appropriate, provision with health and other services such as housing. Last year, Sandie set out a vision of building community capacity using the strengths of communities, the voluntary sector and corporate responsibility of business in sharing responsibility and balancing the responsibilities of the state, communities and individuals.
Given the consensus, its easy then!
The Care Bill
The Care Bill is one vehicle for delivering this vision. It is a difficult time to introduce legislation which increases responsibilities for care services and also extends the remit of state support for meeting care costs.
The debate about who should pay for care and the balance of responsibility between the state and the individual for the costs will continue. Yesterday we heard about this in the conclusions of the Barker Commission, there is a broad consensus on the principles underpinning the Bill.
There are points of principle and practical issues, particularly as we are trying to join up social care with the health service, largely free at the point of delivery. Views of what constitutes a fair deal will vary, but any changes in responsibility for social care services which result in a spreading of the resources more thinly - by extending the offer without funding it - cannot be a fair deal.
There is now greater awareness amongst the public. The evidence is that as more people are carers of people with long term conditions, they are rightly indignant when the system fails. The voices of the user and carers have been growing stronger. Often concerns have been about an uncoordinated, fragmented and unresponsive system. The fact is that as the number of people who experience health and social care services as carers increases, a more powerful lobby for change has emerged.
For the first time in my experience, this year in Nottinghamshire the top three issues from the budget consultation were about social care. We have shot up the agenda, in ways that do not always feel comfortable, but demonstrate that there is interest and concern.
The first aspect of the Bill to be discussed is paying for care and this can overshadow the other changes. It is vitally important that we understand the costs of paying for care under the new arrangements. We are collaborating with the Department of Health in this area in modelling the financial impact. John Jackson outlined the progress on this at our AGM. It is very important that we are able to reach a reasonable understanding of the costs so that we can have the discussion about either mitigating them or ensuring that new responsibilities are funded.
Many thanks to those authorities who have undertaken the detailed modelling work and the intention is that all authorities will benefit from the follow up to this work.
At the same time, we must not lose sight of the fact that we would all support the principles of the bill, as importantly do users and carers and the rest of the sector – that this is a once in a lifetime opportunity to build a platform, albeit in tough times, for the future. It is right that the need for services to carers, a clear safeguarding framework, prevention and appropriate advice and information are included in legislation.
There are concerns about timescales and readiness. There is much to do and ADASS is now contributing to all 38 work streams. A number of Associates are helping to bolster capacity as we seek to help shape the regulations and the statutory guidance. The collective agreement to share responsibility for the reform set out in the Bill gives us an opportunity to shape the implementation. It also means that, to an extent, the success of this will depend on how much we contribute to shaping the detail of how this will work. We have a few months and there are many opportunities for you to get involved in particular workstreams. There is funding of £2.7m for regional work and the possibility of funding for each Authority is being considered. There are many opportunities to work across regions, for local collaboration between Councils to plan and implement the changes. We can make much faster and more certain progress by collaborating in this way.
There are regional events being planned by the programme office for June to consider the regulations and guidance, review progress on planning and the support required.
The success of the next year depends on a number of things. But I would like to highlight four things – firstly, that we continue to build trusting partnerships in delivering the reform; secondly that we understand the resources required to meet the aspirations of the bill; thirdly, that there are strong arrangements at a national, regional and local level and finally there is good communication across the sector and with service users, carers and the public about the changes.
Integrating health and social care
It is worth reflecting the pace at which things have changed and momentum has built in the moves towards integrating health and social care. At our Spring Seminar last year integration was on the agenda, but since then there has been seismic shift in momentum.
111 Pioneer bids alone showed the level of ambition in health and social care communities. We have 14 pioneers, who are developing our understanding of what works, and breaking down the barriers to help us all progress more quickly. Despite the strong drive towards integration on a national scale, the emphasis has been on local solutions based around the needs of the individual and carers. This has the strength of recognising that there are different ways of integrating. This cannot be led by structures, but by focussing on outcomes.
The health service has moved increasingly towards a service where a large area of activity and cost is in meeting the needs of older people with a number of long term conditions.
There is strong evidence that 30% of those occupying hospital beds are older people who could be cared for in the community if the right kind of proactive multidisciplinary community care is in place. Clearly, shifting the resources and the care is still a huge challenge and there are still many who doubt that this can be done. In an area such as Nottinghamshire if this was to be realised it would release £200 million of expenditure. We need to understand the configuration of transformed services in the community and the way in which costs and funding change to support it.
GPs are now in a crucial position in the Health Service as Commissioners and they have a greater appreciation of the ingredients of successful community care and the significance of social care. Social care has a very long history of considering the whole person and their needs (rather than a condition or a series of conditions) and successfully supporting very vulnerable people to be as independent as possible. This is an essential part of our contribution, as highlighted by the work published this year on the role of social care in integration by the four nations.
The introduction of Health and Wellbeing Boards was greeted with mixed views three years ago when they were introduced. But now they have acquired some substantial responsibilities with most arguing for an even stronger role in any future architecture for health and social care. Whatever the pros and cons of the Better Care Fund, it was inconceivable even a year ago that Health and Wellbeing Boards would be responsible for an amount which equates to over 30% of the adult social care budget.
The Better Care Fund is a further catalyst for integration. The real value in the Better Care Fund is not the decision about how 3% of health and social care funding is spent but to provide a basis upon which more ambitious plans for prioritising spend across health and social care and transforming services can take place.
We all know the challenges. These include the current pressures on the acute system and that the evidence base for integration is mixed. Common sense tells us that it must improve co-ordination, create seamless service responses and save money. Where it works well, in clearly focussed areas, with specified outcomes it can deliver these benefits. There are, however, examples where this is not the case. We have to plan and focus with care.
The task becomes more complex as the number of organisations increase. In some areas, such as London there is only one CCG but several acute providers. In large Counties there are both numerous CCGs and Trusts. It is possible to integrate in all these circumstances, but the work to galvanise around a common vision and objectives requires relentless determination and very strong, trusting relationships.
Financial incentives have been perverse. The tariff system and the funding model for Foundation Trusts can work against our objectives to transform the way that services are delivered. There is an increasing recognition of the need to align incentives by Monitor and NHS England.
There has been considerable focus on information sharing as an essential pre requisite for effective integration. My personal experience in Nottinghamshire of being part of a national pilot on leadership in integrated care, leads me to conclude that much that can be done by local leaders to break down the barriers to information sharing. There are continuing discussions about whether some moderate changes to legislation or regulations are required.
The funding reductions in local government and the profile of expenditure create some differences in priorities. The financial pressure for the health service is the increasing numbers of older people. Whilst this is important in social care, the fact is that the funding pressure for younger adults with complex needs is greater. The proportion of social care expenditure directly related to learning disability services has risen from 23% in 2007/8 to over 30% in 2013/14.
The continuing challenge of ensuring that the needs of adults with the most complex needs are met appropriately is highlighted by the continuing work following the uncovering of the shocking treatment of people at Winterbourne View. Some progress has been made towards more appropriate arrangements for those identified in local plans, but we have to do much more across the country to ensure that strong commissioning arrangements and local services are in place to avoid simply repeating the previous pattern of commissioning. We need to ensure not just a fair deal for older people who need to have better care closer to home, but also for younger adults who are growing in number and whose needs stand in danger of being squeezed. We are best placed to ensure that the principles of personalisation are embedded in commissioning for younger adults.
There is no doubt that integration requires changes in culture at all levels of health and social care. Equally responses of the public to changing the balance of care presents the challenge of convincing local people that there is an alternative to buildings based models of care.
The power of local government in achieving change has never been better demonstrated than over the last few years as local government has been at the forefront in responding to reductions in funding with some significant new responsibilities such as Public Health and Health and Wellbeing Boards.
We have to be strong partners in building new integrated commissioning and services, focussing on using the whole of the budget in local areas to transform services, concentrating on the evidence of where this works. There will be different solutions in different places. There are some common themes, but local social care leaders have a key role in driving the scale and pace of change.
Commissioning for better outcomes
This year has been a very active on the issue of commissioning and procurement. The Leonard Cheshire campaign on 15 minute calls, the Human Rights Commission, the Low Pay Commission, a Guardian survey, regular national and local publicity on the quality of care, and the groups representing providers have all called into question the commissioning by local government. For residential and nursing care we are still vulnerable to provider failure and poor quality. Andrea Sutcliffe is energetically leading the work of the Care Quality Commission to reform the regulatory system and respond to their new responsibilities in addressing the risks of market failure.
As Directors and senior managers, we are caught between stretching the public purse as far as it will, whilst meeting increasing need.
In the short term, we published Top Tips as a suggested way of Directors and senior colleagues satisfying ourselves that our commissioning and procurement practice is appropriate; that we understand how the market is working in practice and its impact on the quality of the care received by service users and carers. We will be working with our partners and service users and carers to develop guidance on Better Commissioning by the autumn.
There are some key messages from our procurement survey:-
- The need to ensure transparency in Councils and with the public as we seek to balance seeking savings from procurement with the impact on quality
- There is a large consensus in favour of outcome based commissioning. So the task is to find ways to do this whilst having confidence about the cost implications and the impact on service users and carers
- We have an increasingly clear responsibility as Councils to understand the actual costs of care and take this into account in setting our prices. A stark example is that we are right to believe that it is provider’s responsibility to ensure that such basics as paying the minimum wage for travel time and meeting travel costs in home care are in place. At the same time we need to ensure that we are making this possible and we have ways of knowing that providers are fulfilling their responsibilities. Again ensuring transparency is crucial.
- The impetus of Personalisation is to ensure that we are as far as possible co-producing the solutions and commissioning. In Nottinghamshire 33% of all service users have Direct Payments. This means that the commissioners are the service users and carers and our job is to ensure that the market is available to meet their choices and needs at a cost that can be afforded from the public purse.
Turning to money, I did not expect to be a Director in charge of a programme of cost reduction in Nottinghamshire of over a £100 million in a seven year period. It is the case that some of this has been recycled to deal with increasing cost and need, but this is an enormous sum of money.
I concluded that my personal responsibility was to make every penny count and, as far as possible make sure that vital and essential services are in place and that great care is taken of how we manage the changes. Like my colleagues up and down the country we have benchmarked our costs and used as many of the best ideas from across the country that we can find. We have stretched every pound we that we can lay our hands on and continue to do so.
In the last few weeks there have been three reports published by the Nuffield Trust, the Barker Commission and the National Audit Office, all of which have highlighted the continuing funding challenge facing social care.
The National Audit Office report into the State of Social Care in England states:-
“Pressures on the care system are increasing. Providing adequate social care poses a significant public service challenge and there are no easy answers... Need for care is rising while public spending is falling and there is unmet need”
Caroline Abrahams representing Age UK at the Public Accounts Committee likened this to “running up the escalator the wrong way”.
How can we work towards a fair deal in social care, one in which the vision is realised in a sustainable social care system as needs are increasing?
As social care leaders and as public servants we have a responsibility to make the public purse go as far as it can, to ensure that we use every appropriate means at our proposal. Our achievements in reducing spend by £2.68 billion whilst progressing personalisation preserving the level of commissioned or provided services that we have is extraordinary. We have provided better advice and information; implemented reablement and intermediate care; supported carers; tendered or re-tendered services; joined up services with health; created innovative cost effective personalised services; developed extra care and supported living; implemented new technology; joined up services across and between Councils; reduced the costs of infrastructure; compared and reduced our costs in line with those of other Councils and explored ways of building community capacity enabling service users, carers, families, neighbours and communities to provide informal care and support.
As an Association we must continue to promote ways in which we can make savings but deliver services that are consistent with our responsibilities and the vision of the Care Bill. It has never been more important to ensure that we use every tool available. We must continue to strive to balance choice and control, with quality and cost effectiveness.
As individual Directors and as an Association we have to keep under review the impact of the steps we are taking so that we are working with elected members about the level and quality of service and performance. A key tool for us is the budget survey and thank you to all of you for continuing to support this crucial piece of work.
Our responsibility is to ensure that we have used all these tools and are transparent with our politicians, locally and nationally about our achievements, as well as being clear about the impact. We need to continue to evaluate whether our objectives have been met and whether our actions are appropriate.
There must be serious doubt about whether the level of funding reductions envisaged over the next few years can be delivered without compromising the vision and expectations upon the care system. Since Sir Andrew Dilnot highlighted the growing gap between need and funding in 2011, the relative spend from the public expenditure has reduced from just over 2% to just under 1.8%. Integration with health and best practice in the use of resources are both routes to more cost effective provision and better outcomes, but we have to continue to have a national discussion about the need to ensure a sustainable financial future for adult social care.
Sector led improvement
Sector led Improvement has provided us with an opportunity to take responsibility for our own progress and performance. There is now strong activity in all regions, with self assessment, peer reviews and challenges, benchmarking and monitoring of performance. 93% of Councils have published local accounts
Having been the subject of a peer review and recently part of a review team, I think the opportunities for mutual learning are enormous.
There are question marks for some about sector led Improvement.
The questions that remain are
- Is it now embraced by all Councils?
- What has the impact been?
- How transparent are we about our performance?
The Care Bill does remove the provision for general assessments of local authorities by CQC. There are calls for consideration by CQC of Local authority commissioning and the Bill does enable specific inspections where there is an identified need. We should not be concerned about this, but we need to be prepared.
Having been involved with various inspection regimes over time I can see that if embraced with commitment, sector led improvement can have huge benefits, both in helping to focus on areas for development and celebrating success. It also means that when we are held to account by our local politicians or by inspections, we are aware of our strengths and actively addressing our challenges.
This year, we need to continue with the programme in each region, ensure that we are being transparent about our local performance and collecting evidence about the impact of our work.
The social care workforce
There is a huge job of work to do across all organisations to ensure that social care workers roles are valued and supported. It is the case that when I visit particular services I always feel both encouraged and humbled by the energy, commitment, care, determination and pride demonstrated by the people who work in the sector.
In this context it is very good to welcome Lyn Romeo to her first Spring Seminar as the Chief Social Worker. Social Workers are a key part of building the future, whether it is in integrated teams, in leading safeguarding investigations, or working alongside service users and in developing self directed support. I know that Lyn is very keen to meet with and talk to as many of you as possible about the social work role.
Creativity, innovation and leadership
As we look up and down the country at what has been achieved there is a huge amount of creativity and innovation in response to the need to change. Mentioning examples is invidious, because for every example there are others doing equally creative things. However, in the last few weeks I have heard mention of:-
- Work with carers in Bristol
- Team Doncaster in achieving transfers of care
- Local Area co-ordinators in Derby
- Community interest companies in Oldham and Norfolk
- Outcome based commissioning in Wiltshire
- Work on Winterbourne View in Sunderland
- The MJC award to Lincolnshire for co produced prevention in mental health
- The social investment bond in Leeds to create new models of care
- Progress on integrated care in North West London
There have been many more. I would like to collect more of these examples and ensure that I am communicating about them, partly because it shows just what we can do with a determined and creative approach. It is also necessary to counter balance the image of social care with a wide range of our stakeholders and the public. Yes, we need to be authentic about our challenges but to balance this with the many examples of creativity, innovation and partnership that we will need to be in plentiful supply to demonstrate that we have done everything we can in our stewardship of the public purse.
What is clear is that the leadership skills we demonstrated in making progress will be required in abundance in leading change in the future.
As leaders this will require us to be brave and discerning, to be clear with our citizens what we can and cannot do and the role that individuals and communities can take in promoting their own wellbeing.
Finally, I return to that young social worker in Nottinghamshire in 1982 with a passion for making a difference. This passion is undiminished and I intend to channel this in doing my utmost to work with you and represent you, whilst helping to lead us as we work with others to ensure a fair deal in social care services, for those who need them and use them. Unlike that young man I am conscious of the challenges we face, but at the same time I am excited about the opportunities ahead.