It is my great pleasure to welcome you to Manchester to the 2014 - National Adults and Children's Conference. Also speaking at this session will be Alan Wood, and Cllr David Sparks.
I am excited by the programme this year and I look forward to the opportunity to learn from the sessions and catch up with colleagues to hear about your challenges, plans and achievements.
I would like to take this
opportunity to thank Members and colleagues of Nottinghamshire County Council
for supporting me in having the enormous privilege of being the President of
ADASS. I would particularly like to thank Muriel Weisz, the Chair of our Adult
Social Care Committee. It is with mixed emotions that I realise just how well Jon
Wilson and members of the senior team in Nottinghamshire are doing without me!
I will cover three things in the next 20 minutes – the key issues so far this year, a vision for 2020 and our collective leadership.
The priorities for ADASS this year reflect the size of the agenda and are covered in detail in sessions at this conference. I will cover just some of the current themes.
The final regulations and guidance for the Care Act changes from next April were published last week. Credit is due to the Minister, Norman Lamb and colleagues in the Department of Health for the collaborative way with which they have engaged with the sector. The strength of this approach has been exemplified by the joint programme between the Department of Health, the Local Government Association and ADASS. The contribution of a range of organisations representing providers, users and carers has also made a qualitative difference to the content of the Act. This is the most important legislation for the care and support of adults in 60 years. There is widespread support for its main principles of wellbeing, personalised approaches and integrating health, care and other organisations.
From this point on, the balance shifts towards local implementation working closely with our partners. In the most recent stocktake, 97% of councils were very or fairly confident that they will be able to deliver the Care Act Reforms from April 2015.
One of the main concerns is whether there is sufficient funding to cover the costs of the new responsibilities. It is very difficult to extract the debate about money for the Care Act, from the impact of overall reductions in local government finance.
In preparation for the 2015 changes, 120 authorities returned a survey at the end of August on projected costs. This suggested that the funding for carers assessments and services needed to increase, whilst further analysis indicates that it is reasonable to make some adjustments to the level of funding for deferred payments and early assessments. Of course, the level of demand for new services is difficult to assess as we cannot know precisely how many people will come forward. These judgements involve a balance of risk.
The survey results have been taken seriously by government and led to an increase in funding for carers. The National Audit Office in their excellent report on “Adult Social Care” in England published in March reminded us that the financial value of informal caring is at least £55 billion in this country. The recent report by Carers UK called “Carers at Breaking Point” emphasises the pressure that informal carers can be under including that 1 in 5 of those surveyed had given up jobs to care. Allied to new responsibilities for carers’ services councils will need to work with health, other public services, employers and the wider voluntary sector to galvanise the support to carers.
The government’s analysis identifies that an additional allocation of £35m in year one translates into £90m after five years. This reduces the financial risk for local government as well as making a difference to the quality of life of carers and service users.
There is still much more work to be done to get to a better understanding about the costs of changes to the financial thresholds and the setting of a cap on care costs in 2016. This includes the initial costs and how steeply they will rise. This work will continue in the coming months.
I believe this is a once in a lifetime opportunity to create a care system that truly reflects the changing balance of need in the population. It is important that we find the capacity to manage present challenges and to lift our heads to create the platform for the future. Of course, as part of this, we need to ensure that there is sufficient funding to not only fund the Act, but to achieve its aspirations.
Commissioning for Better Outcomes
A key section of the Care Act is enhanced and clearer responsibilities for local authority commissioning. This conference sees the launch of the standards for Commissioning for Better Outcomes - a piece of joint work across the sector with Birmingham University, led by Sandie Keene. We will need to ensure that commissioning reflects the need for a diverse, sustainable and improving market and one in which the terms and conditions of staff are compatible with quality care. The CQC report published ten days ago highlights how far we have to go, with the level of turnover of nursing staff in care homes at 32% and care staff at over 25%. We do need care to be a career choice to improve the quality of care in this country.
The need to save money is balanced with the need to make sure that service provision is at least of an acceptable quantity and quality. This lies at the heart of the legal responsibilities of Directors and lead Members.
For a master class in making every local authority penny count I recommend John Bolton's work for the LGA on adult social care efficiency. This work highlights the creativity and innovation by Members and colleagues up and down the country in using every principled method of saving money.
It also profiles innovative practices including transforming the model of delivery in Shropshire: advice, information and initial response in Calderdale, increased use of telecare in Hampshire and reducing admissions in South Tyneside and Tameside.
It was the National Audit Office who highlighted the extent of the financial challenge now and in the future. The report concluded that:-
“People are living longer and with some long term and complex health conditions that require managing through care. Need for care is rising while public spending is falling, and there is unmet need.”
They also posed the question as to whether we are reaching the end of our capacity to absorb the pressures. The ADASS budget survey published in July showed that 26% budget savings, £3.5bn had been required over four years -12% cash reductions and 14% due to increasing need. Directors reported a range of concerns including that some people who need services may not be able to access them and that the quality of life and care may deteriorate.
We came to the conclusion that the situation is unsustainable. Any savings will be outstripped by the doubling of the over 85’s in the next two decades and the increasing numbers of working age adults who will need care. This includes the number of adults with learning disabilities needing care, which will increase by 25% between now and 2026. The Barker Commission is very persuasive, too, in identifying the fact that integration is absolutely the right thing to do; but that any greater levels of cost effectiveness which may result cannot meet the growing need that will be experienced in the future.
In the NHS Five Year Forward View launched last week a £30 billion gap for the health service was reviewed. It is increasingly being accepted as a problem that requires a mix of measures to resolve. For this conference we have published our paper on Adult Social Care Funding with the Local Government Association. This highlights the equivalent gap by the end of the decade in social care is £4.3 billion, or 29% of the budget. It is notable that the NHS Forward View also calls for sustainable social care services.
As we approach the general election, the focus on social care is rising with increasing public awareness. The Alzheimer’s Disease Society has reported that 21 million people in this country are in touch with people with dementia. A recent YouGov poll commissioned by the Care and Support Alliance of over 4,500 people has indicated that one in three people rely on or have a close family member that relies on the care system. Also, after the NHS, social care support is the biggest priority where the electorate want the government to increase expenditure.
We must continue to share and advocate for the best and most cost effective ways to deliver a good social care system, balanced with sufficient investment for a sustainable service.
Deprivation of Liberty Safeguards
During this year we have seen the impact of the Supreme Court Judgement on Deprivation of Liberty Safeguards, the assessment of people’s Best Interests either through local authorities or for people in community settings, the Court of Protection. Our survey indicated a tenfold increase in the number of Best Interest Assessments and referrals to the Court. ADASS supported by the LGA made a joint submission to a hearing of the Court of Protection considering the implications of the judgment. Our Mental Health network has led a task force on behalf of the government to streamline as many of the processes as possible. Our view is that the law commission review of the Mental Capacity Act should consider transferring assessments of people in community settings to local authorities.
We believe that the scale of the change requires a joint approach between central and local government to address both the legal and financial issues as quickly as possible. Our first priority in this discussion is to ensure that those people who lack capacity and are in need of continual supervision have their Best Interests assessed and their needs met in a timely manner.
The last six months have also involved significant activity to join up health, care and other services.
The purpose behind the Better Care Fund is widely supported; it has to be right that we try to join up services around the need to shift the balance of care to prevent many people from spending time in hospital if this can be avoided. A number of directors have spoken to me about the experience of the Better Care Fund as one whose intentions they can entirely support notwithstanding the complexity of its formulas. But they also suggest that bringing forward 3 per cent of health and care spend to the table is probably not enough as a basis for shifting the balance of provision and transforming services. It is also clear that we need to invest in changing cultures and transforming approaches - and this is as great a priority as pooling money and building structures.
One of the most significant initiatives in the longer term may prove to be the joint prospectus launched in September between NHS England, ADASS, Think Local, Act Personal and the LGA of Integrated Personal Commissioning with the ambition of joining up personal health and care budgets. Simon Stevens the NHS Chief Executive stated that the ambition is for “North of 5 million people to be on a personal budget”. He went on to say:-
“We need to stop treating people as a collection of health problems and treatments. We need to treat them as individuals whose needs and preferences should be seen in the round and whose choices shape services, not the other way round”
Before I move on to the future I would like to pay tribute to our partners at a challenging and exciting time for the sector. Over the last six months we have worked closely with Government and regulators, other public service leadership organisations and through partnerships such as Think Local, Act Personal. We have also worked with a range of care providers, the voluntary organisations and interest groups. Across the sector I have continually met people with different interests and perspectives that are united in the one ambition of creating care services that everyone can be proud of - particularly those who use them. So much of what we can achieve locally and nationally depends on this collaboration.
As new responsibilities arise, new relationships emerge. One of these is the Care and Custody Alliance reflecting our clearer responsibilities for people who offend whether they are in prison or living in the community.
A vision for 2020
Turning to the future, what could care and health services look like in 2020?
I continue to be struck very powerfully by the National Voices definition of integrated care
“My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes”
Any future vision has to be rooted in the experience of the people who need or use services not in terms of the systems or organisations.
The NHS Five Year Forward View highlights that long “term health conditions rather than illnesses susceptible to a one off cure now take 70% of the health service budget” – prompting the need for a radical re- think about prevention and breaking down the barriers between primary and secondary care and between health and social care.
For the whole population there is a need for us to take take better care of our health and wellbeing by encouraging patterns of behaviour and investment that will keep us well, active and healthy for as long as possible.
What could a good health and care system look like in 2020 which is person centred, co-ordinated and enhances independence, choice and control?
- We will have the best advice and information – not just a directory or menu of services. The information will help us to understand and manage our circumstances and conditions, as well as navigate the system. The focus will be on what we can do as well as our needs.
- There will be help to manage crises and for recuperation, reablement or rehabilitation. Housing options are available that are better suited to changing needs. There will be earlier diagnosis and support for people with dementia and other long term conditions, with public health initiatives designed to prevent or delay the need for health, care and support. The health service is better geared to promoting the physical health of adults with disabilities, reducing the current level of inequality.
- There will be joint assessments of needs. There will be simple electronic health and care records which make it easier to share information so that we only have to tell our story once. It is updated as needs change. At least 3 million people are utilising personal health and care budgets.
- By 2020 public services, neighbourhoods and communities are more sensitive to the needs of disabled people of all ages. There is intolerance of disability hate crime and a supportive environment in local communities. This includes a doubling of the number of dementia friends, an increasing number of businesses who are adopting policies encouraging employment of disabled people and flexible schemes to assist carers.
- By 2020, we will have a care workforce which has greater parity of esteem with the health workforce. The turnover rates are below 10% in care settings because the structure of pay, training, accreditation and qualification means that care is genuinely a career choice for many people.
- Social Workers and other care professionals are recognised for their skills in supporting people in crisis, identifying and reducing risk in safeguarding and helping to co-ordinate and plan for meeting people’s best outcomes through their personal budgets. All organisations are deemed to be meeting the employee standards with a vibrant national group of principal social workers in all areas.
health and care funding and commissioning arrangements are overseen and
co-ordinated by Health and Wellbeing Boards – a place where local politicians,
clinicians, providers and experts by experience can genuinely shape services.
This is supported by clear policy and performance priorities from national
government. Financial and other incentives are aligned.
The compact between national government and organisations recognises that as Joel Klein pointed out:-
“You cannot mandate greatness, you have to unleash it”
LeadershipThis brings me finally to leadership and my hopes for this conference.
There has been no more challenging time to be a leader in local government and indeed, in organisations who are dependent on contracts with local government, as we seek to grapple with making savings and changing the way in which we commission or deliver services. However, there is evidence of how well we have responded to the challenge by wrestling with the financial circumstances, changing services and engaging with new national policy and legislation. I have attended new Directors and aspiring Directors leadership courses and have been impressed with the commitment and potential of our new leaders. As the pressure mounts continuing to set an example both internally and in our work across organisations requires resilience. We need an ever increasing ability to work across systems in situations where no one person or organisation holds the key. As we lead systems and organisations at times of great change I am reminded of David Behan’s comment when he said at the ADASS Spring Seminar this year that people thrive in a “high challenge, high support environment.” We need to ensure that challenge is balanced with support and that our behaviours serve to bring the best out of each other.Earlier this year as chair of the national sector led improvement board for adult social care I outlined six key priorities, including the need for transparency through local accounts, the publication of peer reviews and a clearer offer of support. The message is that there is support for Councils and leaders brave enough to seek it.
My hopes for this conference are that by Friday we are all clearer about the national policy direction and how this can be delivered at a local level and we are all in a position to implement the best ideas across the country, with our motivation and confidence enhanced.The energy of local political leaders, senior colleagues from across the country, advocacy organisations and providers will be directed as ever towards making this work for the local communities we serve.
Min Kyu Choi a designer said:
My hope for this conference is that by the end of this week all of our lists of things that we cannot change will be “surprisingly short”.Thank you.