Thank you, Alison. Needless to say I agree with so much of that – especially the bit about the beneficial value of cake and bubbles. In my experience these are underestimated factors in effective multi-disciplinary team working - shamefully overlooked in the research literature.
May I add my welcome to the conference and to Bournemouth - as well as cake and fizzy drinks, most ten year olds like ice cream and 3/4 million scoops of ice cream are sold in Bournemouth every year. Of course its other great attraction for me is its close proximity with the home of a certain chef.
My working world is Gloucestershire, not so far from here as the crow flies but a little further via the A34, a road which must be a source of great amusement in the crow community. I’m hugely grateful to the Leader, Members and Chief Executive of Gloucestershire County Council for their support in enabling me to serve this year as president of the Association of Directors of Adult Social Services – especially in these challenging times for the authority. I'm also grateful to my colleagues, both in the Council and the NHS, who have been a terrific support.
Working in local government is never easy, though you still might gain that impression from parts of the media.
These are without doubt the most challenging circumstances I can recall in over 40 years in public service, and I pay tribute to all those working – sometimes battling – to keep their show on the road.
I’m conscious of being the third of three speakers and I want to try to avoid repeating what Alison and Gary have already said so well. But I do want briefly to cover four things:
- the budget pressures facing us in adult social care, and here I am able to share with you some findings from a new and worrying snapshot survey we have carried out among ADASS members;
- our ambitions for, and expectations of, the green paper consultation - which we sincerely hope will not be delayed long into the new year;
- inevitably, something about our current concerns over measures being taken to limit delayed transfers of care, and the impact this is having on relations with our NHS colleagues;
- and just in case all that risks throwing you into a pit of despair right at the outset of conference, some reasons to be cheerful about adult social care AND WHAT WE ARE GOOD AT – which is actually quite a lot.
But let me turn first to budget pressures. Gary has already painted the big picture very graphically, and it’s one we have been painting for several years now – with, I have to say, increasingly angry brush strokes. It feels as if we’re on a journey, artistically speaking, from still life to surrealism.
We were pleased, and relieved, with the announcement in the spring Budget of an extra two billion pounds in one-off central funding, half of it this year through the Improved Better Care Fund. That should help ease some of the immediate pressure in the system, assuming it reaches us, but no one is under any illusion that it’s anything more than a short-term fix. Remember that by next March we will have taken a cumulative SIX billion pounds out of our budgets since 2010, with demand for our services growing all that time.
There is no getting away from the fact that, as a nation, we are spending too little on care and support of older and disabled people. Comparisons of public expenditure on long-term care, as a percentage of GDP, put us below the average for rich nations with developed economies – that is, below Ireland, the Czech Republic and Luxembourg among others. We spend less than a third of what they do in the Netherlands.
That realisation needs to be front and centre of the green paper consultation. But before that it needs to be addressed in the autumn Budget next month. As Gary said, it is vital that the Chancellor recognises that we cannot continue without sufficient and sustainable resources.
Here’s why. About 100 of our members have just completed an ADASS snap survey – that’s two-thirds of local authorities with responsibility for adult social services – and more than half are already forecasting an overspend for the year to the end of March.
Top of their wish list is new investment money ring-fenced to adult social care. But just behind that is funding earmarked for the six years of back-pay for care workers who have done sleep-in shifts. We have welcomed the current suspension of enforcement action against providers by HMRC, but it is essential that we have a funded resolution of this issue – both back-pay and costs going forward - without further delay.
Dedicated care workers deserve recognition and reward, but without acknowledgement by government that it has changed its official line on paying the national living wage for sleep-in shifts – and without the funding to enable that payment – there could be a severe impact on the care of thousands of older and disabled people.
Meanwhile our survey tells a familiar and concerning story. Our dear colleague and friend Harold Bodmer, so cruelly taken from us during his ADASS presidential year last year, used to say it was homecare that kept him awake at night. The challenge of sustaining the increasingly fragile homecare sector gets more difficult by the day.
Almost half, 48%, of all authorities report that they have experienced homecare providers handing back contracts in the first five months of the fiscal year. That’s up sharply from just over a third, 37%, who said the same over a longer period – six months - in our main budget survey earlier this year.
More than 45% of councils say in our new snapshot survey that they are finding it difficult or very difficult to source homecare for people who need it. Just over 20% say they are struggling to find enough places in residential homes, but 52% enough places in nursing homes.
As one respondent comments: “A number of nursing care homes in the area are de-registering their nursing care element as a result of the difficulty recruiting and retaining nurses.” It’s too often forgotten that 60,000 nurses work in the social care sector – when it can find them and keep them – and any initiative to improve training, recruitment and retention of nurses must take this fully on board. That has rarely been the case in the past.
Almost on in 10 councils experienced a nursing home provider handing back a contract in the five months from April to August, and one in eight had a residential care provider do so. This simply cannot go on.
Turning to the green paper consultation, I spoke earlier of the fundamental importance of securing sustainable reform. We, too, were disappointed to hear last week at the Conservative party conference that it will now be the new year before that consultation formally gets under way.
Or should I say “on the fringe of the Conservative party conference”, because of course social care was conspicuous by its absence from the main stage. Nothing in the secretary of state’s speech; nothing in the prime minister’s. It was scarcely any more prominent as a topic at the Labour conference, other than as an add-on to promises on the NHS. Who would have thought it was only four months ago that the parties were slugging it out over social care as a key issue in the general election campaign?
But it is crucial that we get this right – so if it takes a few more weeks to put together a meaningful consultation that is going to add to the knowledge we already have from the, what, 12 white or green papers and four independent reviews of the past 19 years – thanks to Richard Humphries at the King’s Fund for keeping score – then the further wait will be worth it.
And it’s crucial that the consultation takes a broad sweep, embracing the support needs of young adults and not just older people; the quality of care and support, not just how to pay for it; and new care and support models, not just those that dominate at present.
We must come at this as an opportunity, and one we are determined to seize. And we must enlist the broadest possible alliance of people who use our services, their carers, our friends in acadaemia, providers, commissioners and regulators to help make our case. Which is why we in ADASS continue to work to try to build what we have called a “social movement” for social care, further raising its profile and leaving our politicians with no room to hide when we demand a hearing and expect answers to what we say.
In this slot last year, Ray James – stepping back into the breach after we lost Harold - spoke of the progress we were indeed making in getting our collective voice heard. That undoubtedly prompted the two billion in the spring budget and the debate in the election campaign. Just because that didn’t go so well for the government, we must not let the pressure drop. It’s been too quiet since June and there’s a danger of our progress being stalled. We can’t afford for that to happen - this is far too important an issue to be left to the politicians.
(DTOCs and NHS relations)
Let me add a few words to Gary’s comments about what has been going on in recent weeks over Better Care Fund planning requirements, the priority being given to reducing delayed transfers of care, or DTOCs, and the effect this is having in some localities on working relations with our NHS colleagues.
To be blunt (and I will be, although my friends and family tell me I am too often for my own good), this has not been the finest hour for those of us who want to see closer working across the care and health system because we know it is the only way forward.
I speak as a nurse. Not very many directors of social services, adult or children’s, have come from a nursing background, but it has given me a particular perspective on the great integration debate and, if I may say so, a bit of a right to call it as I see it.
I crossed over to local government from the NHS in the mid-90s, but subsequently held joint appointments straddling the divide right up until I became director in Gloucestershire six years ago. While I do not see all-out integration of the sectors as the answer to the challenges we face – in the end, they are two very different cultures - it is absolutely essential to align what we do much more closely. As more and more people get access to personal budgets combining health and social care monies, it is also inescapable.
So it troubles me to witness the kind of friction that has been generated over DTOC targets, not helped by unilateral changes to guidance that have undermined the collective effort we need to make. Our members have consistently prioritised discharge from hospital and our snapshot survey shows that 62 of 101 councils that responded to the question had (at that time) agreed DTOC ambitions for both social care and health in line with national expectations and all but one council had agreed ambitions locally. Many other areas have since agreed DTOC ambitions in line with national ambitions, with only a small number of councils that have not.
While that’s a much improved picture on what seemed likely a week or two previously, it’s significant that of those 62 councils who told us in our survey they had already agreed local targets in line with national expectations, only 32 considered the agreed ambitions to be realistic for both social care and health. That’s concerning. And as long as the threat of sanctions for supposed under-performance on DTOCs continues to hang over councils, tensions are unlikely to lift entirely.
Our survey has found that at least eight councils have already been fined since April for causing delayed discharges, compared to 16 fines reported by the same sample in the whole of last year, with recent penalties running up to £100,000. The idea of imposing further sanctions on already cash-strapped councils seems frankly bizarre.
It’s important to make the point that while DTOCs are a shared concern for us across the care and health system – and let me stress again that it is a concern we fully share – it is an issue largely relating to older people. Rising costs in social care are fuelled more by the growing care and support needs of working-age adults with disabilities, especially learning disabilities, living in the community.
In Gloucestershire, our evidence is that someone living with one or more long-term condition is self-managing to the extent that they come into contact with the NHS – usually primary care – on average just three times a year. I’ve no reason to suppose it’s much different anywhere else. Which is why it is vital that the voice of social care is heard loudly and clearly in the local STP, or sustainability and transformation partnership, process.
I regret to say that that has not, so far, uniformly been the case. Even where local health and wellbeing boards, and joint local commissioning arrangements, have laid excellent foundations for common thinking, planning and working, we have heard too many anecdotal examples of STPs doing their own NHS thing. That needs to change if STPs are to win public acceptance of their ambitious aims.
(Reasons to be cheerful)
And this is where I send you off to your next sessions with a spring in your step. Because our health colleagues don’t need to work with us out of politeness, or expediency, or because they have been told to, but because they need to know what we already know – and do what we already do.
We in adult social care have a great deal to be proud of. We pioneered choice and control in our public services, and ADASS has been a champion of personalisation since its inception. Despite unprecedented financial pressures, the groundwork laid by councils to enable people to make their own decisions about their care and support is still holding good, still having a positive effect.
Latest findings from the annual Adult Social Care Survey, released last week, show that almost 68% of people using long-term services are happy with the choice they have and a further 6% say that choice is not an issue for them. Sixty-five per cent say they are extremely or very satisfied with the services they receive. By any standard, that’s pretty good feedback.
And perhaps I might cite also a recent report from that excellent organisation National Voices, which lobbies for people to have control of their health and care. That report found that while we in social care have a lot of progress still to make, with 33% of users of our services reporting that they had as much control as they wanted and another 44% feeling they had adequate control, there is – and I quote – “little evidence” of personalised care and support planning in the mainstream NHS.
Whatever the way forward for the care and health system, personalisation is a non-negotiable. To use a term much in vogue at the moment, it’s one of our red lines. Witnessing its results is a big part of what makes the job worth doing and despite all the budget pressures, all the uncertainty over the green paper, all the unpleasantness over DTOCs, it’s downright exciting to see how new, strengths-based approaches to our work are reinvigorating our teams and forging new bonds across professional disciplines.
We may need to cling hard to this through what could be a tough winter ahead. But we have survived seven years of austerity so far and we in social care are still standing, still innovating, still supporting 1.1 million people every day of the week.
I want to thank each and every one of our workers – for our councils and for our care providers – for what they do so brilliantly. They don’t hear that anything like enough, which is just one of the things we need to see change for the better.
Enjoy conference. Thank you very much.