Adult Social Care and health
Rejuvenating democracy
summary Summary 1 Key propositions 3 Policy principles 5 Detailed discussion 6 Propositions in more detail
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Conclusion 13
The next phase of development in social care and health services must be towards integration: integrated services are much more likely to improve people’s health and wellbeing in ways which treat them with dignity and respect, and it makes financial sense to get rid of duplication and waste. Services need to work with people as a whole: as individuals in their family context and their neighbourhoods, not as a series of isolated problems, crises and traumatic life events. A place-based public service budgets approach, which enables integrated commissioning of social care and primary health services, is the most effective way to put in place the right support to achieve the best health and wellbeing outcomes and reduce the need for, and costs of, inpatient treatment. Integration should now be a mainstream activity, not a series of experiments in small areas. The scale and pace of integration across England needs to accelerate dramatically in order to tackle the challenges posed by an ageing population, increasing costs, and reduced resources. Community Budget pilots are showing the way in developing service models around prevention, active risk management and support to people at home to deliver reductions in demand for hospital and residential care. Work undertaken by Ernst & Young on behalf of the Local Government Association (LGA) modelled national savings to the NHS and social care of over £4 billion.
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recognising and supporting the crucial role of family, carers and neighbours in keeping people independent and within their community
We will always need a safety net for those with the severest need or most limited resources but the overwhelming majority of people will either not need health and care services or will not be eligible for support and will make their own arrangements. Local government must have a universal offer for all of our citizens, including families, neighbours and friends who are informal carers. This means moving away from a means-tested system that helps an ever decreasing number of people, too often focused on acute needs, crisis response and dependency, and moving towards supporting people to actively plan for their old age. But local government and the health sector also have a shared interest in supporting them to take responsibility for their health throughout their life, in order to prevent them developing the long-term conditions that limit their health and independence in later life. There is already plenty of information and advice to help people do this. Councils across the country have been effective in driving behaviour change in things like recycling and smoking – the next revolution in behaviour needs to be seen in improving health.
Health and Wellbeing Boards combine political, professional, commissioning and community leadership to turn the vision of better health for everyone into reality. They need to exercise this leadership on behalf of their communities, and in dialogue with them. To achieve transformation in local services to maximise and maintain local health and wellbeing, they need the power to influence and ‘sign off’ all local health commissioning plans. In many areas, it may be more effective to redirect resources towards early intervention and communitybased care and support rather than on hospital care. This will require councillors and professionals to engage in an ‘honest conversation’ with local people about what services we can afford. Put bluntly, unless we invest in social care and other preventative measures, as a nation we cannot afford simply to treat the ever-growing burden of an increasingly frail, older and ill population.
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key propositions Drive local public service effectiveness and end waste and red tape at all levels by bringing local services and decisions together in one place, for each place, for issues ranging from economic development to health and law and order.
End flawed and bureaucratic tick-box inspections and replace them with a process where genuine consumer champions focus on the service local people receive from schools, hospitals, policing or care homes.
All health and social care should be consistently coordinated around the needs and wishes of the individual, within an approach that supports the whole community, by:
Health and wellbeing boards should be strengthened to extend their leadership across local services to ensure child and adult health and wellbeing is at the top of local agendas by:
• focusing on the capabilities and resources of individuals rather than what they can’t do
• involving the full range of health services including community, mental health and acute trusts
• using “personal wellbeing budgets” to provide choice and control to individuals for the services and support they require to improve their health, wellbeing and independence, enabling people to make choices that sustain their independence
• signing off health and care commissioning plans to ensure alignment with democratically-mandated local services
• recognising and supporting the crucial role of family, carers and neighbours in keeping people independent and within their community. Place-based public service budgets should be the main mechanism for addressing local service requirements so that: • local commissioners can direct resources to have the greatest impact on the health and wellbeing of local communities • ring-fenced budgets become irrelevant, as an unnecessarily restrictive means of funding local services • savings in acute services from more effective prevention and re-ablement can be reinvested in better support in the local community.
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• extending joint commissioning across core social care and health budgets.
Integration should now be a mainstream activity, not a series of experiments in small areas
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Policy principles The wider principles for our approach to securing a future for our communities are also central to our ambitions for adult social care and health. Put people at the heart of our work The whole purpose of greater integration of health and social care resources is to wrap them around the needs of people, rather than the convenience of our separate organisations. We must never forget that most people do not use social care services and many will pay for their own support from a wide range of individuals and organisations: we must support them to exercise their choice effectively. Take a ‘whole community’ approach to services Such is the pressure on adult social care and the NHS, we cannot keep pace with demand by just making services more efficient. We need to redesign our support to make sure that all parts of the system are working towards the same shared outcomes for health and wellbeing. Autonomy of place Local areas should take responsibility for developing their own priorities for improving health and wellbeing and putting in place a range of support, services and information that meet their population’s needs. Health and wellbeing boards, bringing together political, professional and community leadership, are best placed to make these decisions.
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detailed discussion Background to the policy issues Key role of adult social care and support: reform Good adult social care involves a number of components based around three fundamental principles: that the person receiving care is at the centre of the process; that the care and support enables outcomes to be achieved; and that the relationship between the user and provider is based on dignity, safety and respect. The commissioning process is key to this, particularly in shifting to a focus on outcomes, backed up by strong baseline information gathered from a range of sources, including the people who use services. This Government has committed to a significant programme of reform for adult social care and support. We agree with the ‘Vision for Adult Social Care’ published in 2012, based around the ‘seven Ps’ of a modern system: personalisation, partnership, plurality, protection, productivity, people and prevention. We support the intention announced in 2013 to take forward the capped-cost model of funding reform as proposed by the Dilnot Commission, which will make the system fairer for many individuals.
However, these reforms do not address the long term demands on services. More substantial change is needed to secure the sustainability of the health and care system over time in the context of increasing demand for adult social care and the growing complexity of needs. Adult social care has experienced significant cuts since 2010 – £2.68 billion or 20 per cent over the last three years. So far, many of the reductions have been made through efficiencies but continuing to make this level of savings is simply not possible without severe consequences for the people in need of services. Councils are facing an increase in demographic pressures of 3 per cent a year and it costs £400 million a year just to continue to provide the same level of service. The greatest demographic pressure currently comes from adults with a learning disability (44 per cent of total demographic pressure), followed by older people (40 per cent). Pressures faced by providers are mounting as food and utility costs, and the National Minimum Wage, all increase. The average fee increase for providers stands at 1.5 per cent, well below the rate of inflation. Councils have to manage these pressures against a policy background that promotes market diversity and stability, and a focus on quality to improve outcomes for individuals.
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The significance of this agenda cannot be overstated. Achieving sustainable arrangements for care and support is crucial for many thousands of people who depend on care and support services, and on other council commissioned services on a daily basis. It is also important for the future sustainability of local government and for the NHS: if the bill for social care continues to grow at the current rate, it will swallow up resources for every other council service. And if the social care system fails to provide support to vulnerable people, many will end up needing costly health treatment. The only sustainable way forward is by adopting a place-based public service budgets approach across health, social care and public health services. Health and integrated care and support So how do we meet growing demands for services in the context of shrinking resources and a policy commitment to personalisation and improved quality? Service users consistently say that they don’t really mind who provides their services: they simply want to be supported to live their lives in the way they choose. This will require health, social care and other services to join up commissioning, funding or staff teams. Many areas already provide a measure of integration but the challenge for us all now is to shift gear so that integration becomes a mainstream rather than marginal activity.
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The LGA, along with the Department of Health and other key organisations nationally (including NHS England, Public Health England, Monitor, the Association of Directors of Adult Social Services and Association of Directors of Children’s Services) have developed a joint programme to significantly escalate the scale and pace of change. Underpinning this joint work is a commitment to put individuals’ experience and outcomes at the heart of what we do, and to ensure that we take a joint approach to allocating and using resources. The LGA has already demonstrated that placebased public service budgets can achieve major savings for health and social care. In line with government policy we are seeking to accelerate the pace and scale of integration by: focusing services on individuals rather than organisations; shifting resources from acute hospital activity to cost effective community settings; and focusing on early diagnosis and better management of long-term conditions. Seeing the person in the context of their family and neighbourhood Services need to work with people as whole people: as individuals in their family context, not as a series of specific problems, crises or traumatic life events.
With the right support, they are able to choose a care package that is right for them
We have good evidence to show that working with people and their families to determine what support they want, leads to better health outcomes and less reliance on costly and high intensity health and social care. We need to focus on people’s assets and capabilities, what they can do, rather than their deficiencies. Growing dependence on intensive care and support for individuals can be a sign that we have collectively failed to provide the right support early enough. We all have a part to play in supporting families and neighbours to maintain their capacity and independence. At the forefront of informal care and support are carers, without whom the entire system of social care and health would collapse. According to the 2011 Census, there are over 5.8 million carers in the UK, over 2 million providing over 20 hours of care a week and 1.36 million providing care for over 50 hours each week. This informal care and support from families, friends and neighbours saves the state £119 billion a year. We need to make sure that they have access to help, support and advice and that we work with our schools, neighbourhoods and community organisations to grow our pool of carers to ensure that caring is a characteristic of a resilient community rather than being an increasing burden on isolated individuals.
Services for the whole community While councils and the health service will always need to provide a safety net for those with the most pressing and complex needs, the vast majority of people in our communities either don’t need social care, or if they do they will pay for it themselves. We need to ensure that everyone, irrespective of whether their support is paid for by local authorities or not, has access to comprehensive and trusted information so that they are able to choose the support that best suits their needs. It doesn’t necessarily have to be the council that provides this information, simply that there is a single point of access to reliable information. Schemes such as the Gloucestershire Village Agents programme uses volunteers to make contact with elderly and isolated people to put them in touch with information on social care, benefits, housing, employment, health issues and leisure and cultural activities. All councils have a wealth of information about services, support and activities in their area and this is a valuable local resource. But it will be necessary to provide some people with support to understand information, for example, adults with learning difficulties. With the right support, they are able to choose a care package that is right for them.
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Public health The LGA supports the central proposition of the Public Health White Paper, ‘Healthy Lives, Healthy People’ (2010), that it is not sustainable for the NHS to simply continue to treat an ever growing burden of ill-health. The White Paper identified the key role of public health in supporting communities and individuals to make healthy choices. But it is not just a question of investing more in public health services to support behaviour change: to make a lasting and significant impact on health outcomes, health improvement must be the core business of local government and the responsibility for each citizen. Professor Sir Michael Marmot’s report ‘Fair Society, Healthy Lives’ (February 2010) eloquently frames this debate: “Differences in access to health care matter, as do differences in lifestyle, but the key determinants of social inequalities in health lie in the circumstances in which people are born, grow, live, work and age.” The contribution of social and economic factors on health outcomes is the driving force underpinning the transfer of public health into local government. The challenge for local government is to build a solid evidence base that will show us and our citizens what we can all do to improve our population’s health, including an understanding of the impact of mainstream local government plans, and strategies on health. Health and wellbeing boards are the engine houses of this shift in approach. They combine political, clinical and community leadership to develop a shared understanding of local health needs, the resources we have at our disposal to address them and the most effective deployment of shared resources.
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What people have said Everyone we have spoken to – people with social care needs, patients, carers and professionals – has said support and services need to be designed around people, not organisational structures or boundaries: “It’s about people, not institutions”. They also told us that this requires true ‘coproduction’ – services and packages of support that are designed and developed with individuals. This personalisation doesn’t have to cost more money and in many cases it gives people exactly what they want at less cost: you will get better services if you involve people in their design. Several people referred to the closure of day centres as a way of personalising resources and giving people the choice of support. Releasing the money from buildings enable resources to help people choose the activities that suit their interests and lifestyles – from taxis to visit relatives, football season tickets or lunch in the pub with friends.
boundaries between organisations and funding more porous, and in incentivising their delivery agencies on the ground to participate in local integration. There is a great deal of consensus that the current relationship between the State and citizens is not sustainable; that is the public’s expectations about what could and should be delivered that is out of kilter with the reality facing the public sector. A related topic was the need to look at the whole population from “cradle to grave” and across the whole community: only councils have a broad enough remit, and the democratic mandate to do this. “We need to move from people being consumers of public services, to citizens.” “We need to keep an eye on universality at a time when the mantra is ‘focus on the most vulnerable.” “People don’t think ‘I’m saving the council money’. They are just doing what families do.”
People are also crucial in terms of our workforce and questions were raised as to whether we currently have the flexible, adaptable workforce needed to deliver services in a very different way. People broadly considered whole system transformation, for example through place-based public service budgets, to be essential: a bit of a ‘no-brainer’ in fact, given the challenges facing the public sector. Though making it happen in reality is of course more difficult than signing up to the principle. Many thought that central government has a role to play in driving this, by making the
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Propositions in more detail Health and social care will always be coordinated around the needs and wishes of the individual, and will maximise existing capabilities and resources of individuals rather than focusing on what they can’t do. Coordination will be the norm, not the exception, with ‘personal wellbeing budgets’ a commonplace mechanism for providing choice and control to individuals for the services and support they require to improve their health, wellbeing and independence. Furthermore, people, their families and neighbours will have access to reliable, relevant and up-to-date information to enable them to make the best choices about services to support them, whether councils pay for their care services or they fund these themselves. All local people will have a better understanding of their rights and responsibilities with regard to health and social care, including the importance of making healthy and informed choices about their own health and wellbeing and those of their families, friends and neighbours. The role of carers will be recognised, with more information about sources of support for existing carers. There will be a commitment for all areas to increase the pool of families, friends and neighbours who give a little informal support to those in their community at risk of losing their health, wellbeing and independence. This is what people say they want: a little bit of help with every day chores and occasional problems. This reduces the risk of them needing intensive and inpatient care and treatment, and losing their independence.
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Place-based public service budgets will be the main mechanism for ensuring that public resources are directed towards priorities that will improve population and individual health and wellbeing. Ring fenced budgets will, therefore, be irrelevant as local commissioners work together to agree the most effective use of resources. Placebased public service budgets will be the main mechanism for ensuring that public resources are directed towards priorities that will improve population and individual health and wellbeing. Ring fenced budgets will, therefore, be discontinued as an unnecessarily restrictive means of funding local services. Local commissioners will maximise the flexibility of resources to ensure that they can be used in line with local commissioning priorities. Health and wellbeing boards will be empowered and supported to provide leadership to ensure child and adult public health is at the top of local agendas on the basis of the democratic mandate. Health and wellbeing boards bring together local political, professional and community leadership in one place to identify local priorities and ensure that they achieve improved health and wellbeing outcomes. They are also responsible for driving forward the integration of health and care services at local level. They, therefore need the authority to sign off commissioning plans to ensure that they reflect local health priorities and maximise opportunities for integrating services.
Families, friends and neighbours have a crucial role to support older and vulnerable people to live in their own homes
Health and wellbeing boards will provide local accountability for decisions about health and care spending. And elected members, who are statutory members of boards, will have a key leadership role in having an open and honest dialogue with people about whether costly inpatient services is the best use of local resources. The overwhelming evidence is that it is better to invest in services that promote healthier lifestyles and community-based care and support. All health, social care and wellbeing services will be developed with the whole of the community in mind. That is not just focusing on those with the most acute health and social care needs but taking a ‘community wellbeing’ approach that focuses on maximising health and wellbeing of all its citizens. Families, friends and neighbours have a crucial role to support older and vulnerable people to live in their own homes and continue to be active members of their communities. They, and the people they care for, will have a single access point to clear, comprehensive and trusted information about local services available to keep them healthy and independent, whether or not they pay for their own services.
We must always keep at the core of our health and wellbeing agendas the ‘whole community’ perspective. Councils, the NHS and other public sector partners, the private and voluntary sectors, working together have a formidable range of assets and resources to direct towards improving the health of our communities. But, ultimately, it is the individuals, families and communities that hold the keys to really tackle the determinants of health and wellbeing. These are rooted in the way that we support each other and in the way we live our lives day to day.
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conclusion The reforms to the health and care system present a major opportunity to do things differently. There is common consensus that joint working across health and social care is needed not only to deliver improved outcomes and experience for people using services, but also to deliver a more efficient system. The package of measures in this document is designed to help build on the current enthusiasm and put the health and care system on a more sustainable footing. Doing nothing is not an option.
We must always keep at the core of our health and wellbeing agendas the ‘whole community’ perspective
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Š Local Government Association, July 2013
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