- Posted:Thursday 15 September 2016
Okay. Well we are really pleased to welcome the report today. We haven’t had much chance to scan all the pages in detail. It is a stark report I think, but it’s helpful in reinforcing the evidence of the real pressures on adult social care finance and the impact particularly if you link it to the Richmond Group findings. Some of the figures that Richard brought out, 81% of councils spending less, 26% fewer people receiving care, also 6.2% fall in fee rates since 2011, and significant and rising unmet need, and also figures on delayed transfers of care which are not all social care related but the proportion has certainly increased, so all those things are indicators of a system in difficulty.
Councils I would say have used every tool at their disposal to manage reducing budgets and to continue to deliver services and meet their statutory responsibilities in the face of rising demand, and rising levels of need which is important too. And as Richard said also there is some good news within the gloomy stats, some really proper efficiencies, things we should have done, efficiencies we should have made. Improving workflow, reducing the cost of agency staff, and sickness management, all those sorts of good managerial things have been happening. And there are some good things that have improved outcomes for people as well, so that less formal care is needed. Enablement, prevention, engaging communities better, partnerships with the voluntary sector, those things have impacted in our local areas.
But even with some evidentially successful approaches, those are sometimes lost as social care departments struggle to meet savings targets. Councils have a statutory duty to meet eligible need, but what meets the need is harder to define. They also have a statutory duty to balance their budgets, which is quite a significant difference to their colleagues in the NHS. So in many ways what councils have achieved in the face of austerity is remarkable. They have delivered the savings needed, and so far have avoided...I have to touch wood here, major collapse or disaster, but how they have done this is through some effective and beneficial major service design and efficiencies, but also by squeezing provider fees, tightening the interpretation of eligibility without saying ‘You don’t meet the criteria’. Offering a bit less to fewer people, charging more, reducing or ceasing funding of valued and important, but discretionary services, and the changes that result whilst potentially devastating and certainly impacting negatively on the lives of individuals and their families, and sometimes the NHS remain invisible at collective or national level. So the government thinks oh well they have managed so far, so they can do a bit more, and the cycle continues.
The impact of the squeeze of social care on the NHS is well rehearsed, and we have heard a bit about that with the graph with the orange line. But I know that there is a huge focus on this in councils. When I was at DAS you spent a lot of time worrying about that, and a lot of time investing money in it, and I know that colleagues do. And often as a significant diversion of resources within the social care departments to tackle those very issues, at the expense often of people waiting in the community for a much needed service. And I wonder if it would be interesting to assess, not necessarily to provide an answer, the level and shift in social care resources and people and services devoted to helping at the interface with the NHS, because I am not sure it would show a reduction. I think it has increased at the expense of other areas of service.
But also what is often less discussed is the impact that the squeeze on community and primary healthcare also referred to by Richard has on the type and level of demand for social care, and also the impact of earlier discharge, meaning increased acuity and higher support needs of people coming out of hospital. So the point at which you are deemed to be fit for discharge has changed, and that impacts on what is needed when you arrive back in the community. Things like effective stroke rehabilitation, treating incontinence, keeping people mobile in hospital, can all reduce the need for ongoing social care support. And there is real evidence that some of those things are not happening, and it has been evidenced for some time and yet somehow just as Health would say ‘Why haven’t you got this discharge process right?’ we might say ‘Well how come people are still having these needs when they could have been prevented if the Health Service had done the right thing at the right time?’ So it is a two way street.
So councils are dealing with reduced resources, rising numbers, and also a moving boundary about what social care can and should do. Over the long term it’s clear I think if we all think back, I remember looking at some of the long service awards in Hertfordshire, and the history of councils, looking at pictures of home helps, helping women who had just had a baby, or doing a bit of housework around the place. We have moved a long way from that to high end domiciliary care supporting people with very complex needs. We have moved from retirement homes to nursing homes for people with dementia. We had those things then, but the increasing longevity of people means that there are more and more people with those higher end needs. And that subtle, or it is subtle at the time, but no so subtle over time, that subtle shift continues. So low paid home care workers administer medication, and undertake tasks that were once done by those district nurses whose graph has gone down like this.
Longer lives, increased numbers living with dementia, mean that there is also a very heavy burden, which tends to fall on the care rather than the health sector. So the majority of spend on supporting people with dementia is within social care, not within the health system, and yet it is a disease. It is a disease which people have to live with, so the support ends up in a different place.
So just coming towards a conclusion. The report suggests a new approach to funding is needed, and we certainly agree with that. And we agree that as an absolute bare minimum we need to bring forward that new better care fund money, it is needed now, 1890, 1920 is too late. We certainly need an acceptance that as the structure of society changes we will need to spend public resources differently, yet we struggle on and we tinker at the edges. Even where it’s clear that overall resources could be used to better effect, we struggle to agree because of different drivers and organisational barriers, and some of the examples I gave earlier are a case in point.
So the latest NHS drive for a solution in the form of sustainability and transformation plans, will only succeed if the community’s social care and preventative infrastructure is joined up and focused on prevention. Now many of the plans recognise that, but the route to achieving it is unplanned, and efforts tend to be diverted sometimes deliberately and sometimes just purely by dint of need, to dealing with the results as a fact that that infrastructure isn’t there at the moment, and so the spiral goes on.