Better Support at Lower Cost Improving efficiency and effectiveness in services for older people in Wales April 2011
4See Contents
www.ssiacymru.org.uk
Transformed Care System Universal Services
Targeted Interventions
Information and Advice – including self-funders
Equipment and Aids to daily living and Telecare Products
Health Services Well-being and community offersocial capacity
➜
Intermediate Care and Reablement Supported Housing
➜
DFGs /Adaptations Care and Repair Falls clinics
Care and Support
Supply
Eligibility Criteria applied
Commissioning the right range of services
Assessments and Care Management Direct Payments
Macro and Micro procurement Contracts and Spot Purchasing
(Advocacy and Support)
➜
Direct Payments and supply of Personal Assistants
Contents
Executive summary
04
1. Introduction 1.1 Challenges 1.2 Methodology and approach
05 06 08
2. Background and context 2.1 The data 2.2 Key policy issues in Wales 2.2.1 Charging 2.3 Conclusions
10 11 16 16 17
3.
Strategic direction: How councils are planning for the future 3.1 Strategic plans 3.2 Planning services for the future – impact of demography 3.3 Cutting the cost of frailty 3.4 Conclusions
18 19 20 26 27
4.
Approaches to prevention 4.1 Defining prevention 4.2 The community and the third sector 4.3 Information and advice 4.4 Reablement and intake models 4.5 Falls prevention and ‘keeping well’ programmes 4.6 Assistive technology – telecare and telehealth 4.7 Housing solutions 4.8 Reducing admissions to residential care 4.9 Conclusions
29 30 30 31 33 37 38 40 43 52
5. Future approaches to the delivery of care: Redesigning services, changing structures and reducing costs 5.1 Citizen centred support in Wales 5.1.1 Direct Payments 5.2 Models of procurement and commissioning and unit costs 5.3 Redesigning services: Towards a new model of social care 5.4 Conclusions
53 54 54 57 60 63
6.
Final conclusions
64
Appendices Appendix 1 Appendix 2
67 68 70
John Bolton
81
Executive summary The current environment is one of unprecedented challenge for social services in Wales. The pressures on public finances combined with an ageing population pose particular problems for those who lead and work in social care. Whilst there is recognition that ‘more of the same’ won’t do, a consistent and realistic understanding of the radical change required has yet to emerge. It is increasingly recognised that the twin goals of improving efficiency and delivering better outcomes for service users are not necessarily in conflict with each other. Some councils recognise that the kinds of service transformation they are now contemplating would make sense in terms of service improvement even if current financial constraints – which require Welsh councils to find 4% annual efficiencies over the next 3 years were not present. The policy context in Wales presents particular opportunities and challenges. The Welsh Assembly Government’s commitment to ‘Citizen Directed Support’ sits well with models that aim to maintain and support independence for the individual in ways that suit their specific circumstances. However, imminent changes in national charging policy will place a limit of £50 a week regardless of the package of care in question and the individual’s ability to pay. The resulting need for councils to make up the difference will mean additional pressure on budgets that are already severely stretched. This study reveals that against this backdrop all councils in Wales have begun to reshape their services for older people, with much evidence of a shift towards a reablement approach to care and general reductions across Wales in the number of older people being cared for in traditional residential settings. As would be expected, the rate of progress is mixed and some councils are further down this road than others. The configuration of services and balance between, for example, residential and non-residential care is mixed across the country. However all councils demonstrate effective practice in one or more areas of their service, and a commitment to build on this as they move into the future. In doing this it will be important to concentrate on creating robust financial plans to support their commissioning strategies, developing further the use of assistive technology and reconfiguring services through the decommissioning of traditional, high cost services in favour of more preventative models. Genuine partnership with health (already evidenced through a number of joint strategies for older people and cross-sector approaches to service delivery), the third and private sectors will be important in maximising efficiency and ensuring that people are supported proportionately and in a way that maintains independence as long as possible. Ensuring that other local government services – notably housing and leisure – are involved in the development of new models will also be vital. Drawing on examples of good practice in Wales and evidence from successful models elsewhere in the UK, the report suggests a future model of care for Wales which seeks to improve outcomes for users, encourage support within the community thus reducing pressure on traditional social care services and develop new approaches to commissioning which optimise the money available. Establishing such a model will involve significant challenges for councils and their partners: shifting prevailing cultures within social services as patterns of care change, being prepared to see numbers of people cared for go down as more people are supported effectively ‘outside the system’ and seeking genuinely citizen-centred approaches that will call into question traditional modes of delivery. The clear evidence is that councils and other organisations are up to this challenge. With support from national government and agencies like the Social Services Improvement Agency (SSIA) the opportunity is there to consolidate recent advances and build older people’s services fit for the 21st century. 4 www.ssiacymru.org.uk/olderpeople
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Section 1. Introduction
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1. Introduction 1.1 Challenges The current environment is one of unprecedented challenge for social services in Wales. The pressures on public finances combined with an ageing population pose particular problems for those who lead and work in social care. Whilst there is recognition that ‘more of the same’ won’t do, a consistent and realistic understanding of the radical change required has yet to emerge. This report was commissioned by the Social Services Improvement Agency for Wales (SSIA), its aims to review current practice on the approaches used by Welsh councils in delivering efficient care and support services for older people, report on notable practice and make recommendations on ways in which local councils could continue to take forward this work in partnership with other relevant agencies. The project was aimed to help councils in their approach to make best use of their scarce resources. The report was produced at a time when all councils in Wales were facing a projected annual budget reduction for the next 4 years. Though the Welsh Assembly Government has tried to offer some protection to social care, as adult social care takes just under 50% of the controllable expenditure in Welsh councils (excluding the money they spend on education and schools) it will be absolutely essential in coming years for all councils to use the money they have in the most effective way. Towards the end of this programme councils were receiving the details of their settlement – those councils which reported suggested that savings of around 4% per year in real terms were required for the next 3 years (depending on the levels of increase in Council Tax). This report has been laid out in six main sections: • • • • • • •
Methodology and approach Background and context Strategic direction: How councils are planning for the future Approaches to prevention Future approaches to the delivery of care: Redesigning services, changing structures and reducing costs Final conclusions Appendices providing further details of service models and developments across Wales
The report has been produced after discussions that have involved every council in Wales. The author is grateful for the open and honest conversations that took place between councillors, senior social care managers, Health Board representatives and occasionally other stakeholders that made the content of this report richer. He is also grateful for the support from the Institute of Public Care (Oxford Brookes University) who acted as a mentor and critical friend in helping construct this final product, the Data Unit Wales for supply and analysis of data and for Martyn Palfreman, Chris Davies and colleagues at SSIA who commissioned the report and supported the various stages of its production. None of the changes that the report highlights are easy to achieve. None of them can be achieved overnight. They will require the vision and leadership of senior staff, strong political leadership and decision making from local councillors and the energy and enthusiasm of front line staff. The report identifies that councils have adopted a range of approaches to meeting the financial challenges that they face. In some places this has required a radical approach that
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has been led by local politicians making brave decisions. Councils will find that as the money gets tighter they will be faced with a simple challenge – cut the services on offer or offer something different. The report shows how councils have reduced demand for social care in ways that deliver positive outcomes for older people; reduce the levels of demand so that less people need institutional care; lower the costs of care through a combination of closures and finding new ways of delivering services; reduce the size of the packages of care that older people receive through the use of assistive technology; reduce levels of staffing required in the system and examine creative ways of meeting people’s needs at a lower cost. One of the main findings of the report is that councils need to be aware that they may inadvertently create a system which builds dependency on care services rather than promoting the independence of older people in the way that managers and councillors may expect. Through promoting good health, exercise, recovery and recuperation programmes and through intervening in the right way at the right time many older people can be supported in the community outside the formal social care system. The social care system, if it is going to be affordable in the future, needs to be built on these principles. The approach will need to look to reduce the number of people who need personal care every day through introducing approaches that help people retain independence and reduce their need for care. This is a consistent theme throughout the report and was a key part of the conversations that took place in many of the councils during the fieldwork. Perhaps the single biggest challenge which many of the Welsh councils are facing is how to change existing culture within adult social care. The traditional system has created a paternalistic and protective set of services based on institutions and has built a culture of dependency among both service users and staff. There needs to be further change towards a service which offers real opportunity to help people become more independent both in the way they live their lives and in how flexibly they can use services. This also needs to be reflected in the development of key national strategies.
The ways in which councils are developing cost effective services in Wales include: •
•
•
•
•
reducing demand through reablement. A council running a successful reablement service can reduce demand for domiciliary care by 10% per annum whilst achieving better outcomes for older people reducing levels of demand through integrated Intermediate Care and joint working with health. Councils can reduce demand for residential care by up to 20% if they plan the right interventions for people when they need care with a particular focus on avoiding admissions for older people directly from hospital reducing unit costs by closing buildings-based services (residential and non-residential) and using new approaches including working with the independent sector. Councils can reduce their costs by no longer providing services themselves but procuring them effectively (with other councils in some cases) from the independent sector reducing costs of packages by using assistive technology to help people remain safe in their own home whilst reducing the overall cost of the package of care they are receiving developing creative care models for example using direct payments and extra care housing as alternative approaches. Councils are finding creative solutions to help reduce their costs by working closely with older people. Continued 4
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•
reducing staffing by reviewing processes, for example undertaking fewer assessments following reablement. Many councils are using ‘lean’ thinking to help them look at how they can reduce their costs by simplifying the processes through which people receive care and support, considering the contribution of the customer, the carer or the community. This may be in the form of people taking more responsibility for managing their own care, making a greater financial contribution or optimising the contribution of communities through volunteering, fund raising and community activity.
SSIA is committed to working with councils through its current programmes in Wales which include: • • •
promoting and supporting the development of new models of provision such as reablement, assistive technology, extra care housing, co-production with older people and decommissioning some traditional services with a focus on prevention through whole systems approaches process re-engineering by building lean systems supporting commissioning and procurement in partnerships nationally and across regions and sub regions supporting other collaborative work across councils
The work of the SSIA will continue to assist councils in meeting these challenges, with support from those that have already demonstrated improved outcomes and lower costs through new ways of working.
1.2 Methodology and approach The approach adopted to produce this report included: • • •
an investigation of the data available from Welsh councils on performance and finance a local ‘summit’ with every council in Wales examination of key documents produced by councils including their recently produced annual reports (some were at draft stages), commissioning plans, joint Health, Social Care and Well-Being Strategies and other documents setting out their approaches to serving older people
Unfortunately the final ‘summit’ with councils in the former Gwent area scheduled for December 2010 had to be postponed because of poor weather and the information relating to these councils included in the report has only been received in a written format. The council summits produced evidence of good practice across Wales and much discussion on the future direction that should be taken. All of the summits involved senior managers from the councils’ adult social care services; some included contributions from health colleagues, some involved elected members, some involved people with wider corporate council responsibilities (including a number of chief executives) and a few included partners from the voluntary sector. In a couple of councils, visits to specific projects also took place as part of the summit. The style of the summits varied between councils. Typically, they involved presentations from the councils and their partners and discussions led by the author of the report. Some councils joined together on a sub-regional basis for the summits. A member of SSIA was also present at the majority of the summits.
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The approach adopted in the English Report ‘Use of Resources in Adult Social Care’ published by the Department of Health in 2009 was also used to help with the analysis of the data and activity in Wales. It is worth noting that applying the simple formula used in that report on the proportion of spend on residential care spent by a council, overall Welsh councils out-perform their English counterparts. Those councils which spend higher proportions on residential care in Wales do not spend as high a proportion as the highest spenders in England and those Welsh councils which spend relatively low proportions on residential care are similar to the best in England. In relation to programmes designed to achieve efficiencies and reduce costs across Wales, councils are offering as much imagination and creative drive as their English counterparts. The best in Wales is at least as good as anything that the best English councils are doing! The report focuses on the actions and spending power of councils in commissioning and procuring services for older people. It does not give much consideration to the wider issues of the social care market in which a growing proportion of the spend is undertaken by ‘self-funders’ - citizens who as a result of a means test or personal choice purchase their own care. The shape of the social care market is clearly influenced by a combination of the action of councils and the behaviours and preferences of self-funders. The report has limitations. It is not a formal piece of research and therefore may not stand the test of formal researchers. Rather it is a report on how councils have defined for themselves their cost-effective interventions based on dialogue with the author. Most of the case examples include text provided directly by councils, some of which have been summarised for the purpose of this report.
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Section 2.
Background and context
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2. Background and context 2.1 The data Care services for older people in Wales are funded through a combination of RSG and grants from the Welsh Assembly Government (some of which are monies for the council and some of which are specific grants for adult social care), alongside locally raised Council Tax and contributions from citizens through charging. The Assembly Government receives a single grant from Westminster and it can determine the priorities for Wales and how this money is allocated and spent. Councils have responsibility for setting their own budgets which means that there are differences between councils as to the proportion of their total budget that they allocate to adult social care and services for older people. Figure 1 Proportion of total council budget spent on adult social care (including service strategy) 2008-09 25%
20%
15%
10%
Vale of Glamorgan
Cardi
Swansea
Newport
Blaenau Gwent
Bridgend
Caerphilly
Powys
Pembrokeshire
Neath Port Talbot
Merthyr Tydfil
Flintshire
Gwynedd
Carmarthenshire
Torfaen
Rhondda Cynon Taf
Ceredigion
Denbighshire
Monmouthshire
Conwy
Wrexham
0%
Isle of Anglesey
5%
Source: Local Government Data Unit ~ Wales
Figure 1 shows that the proportion varies between 13% and 19% of the total council budget. This may be influenced by a number of factors including: • • •
from which budgets do councils allocate grants to third sector organisations? what is the balance between very old and very young in the local population? what are the other competing priorities for the council and from which budgets do investments in the community come?
There are no right or wrong answers to these questions. Many of these patterns of spend have been set historically (in some of the data that is reproduced within this report it is noticeable that councils that were part of the same authority prior to local government reorganisation in Wales in 1996 have similar patterns of spend today as they would have had 10 or more years ago). There have been small changes over that period of time. Both the proportionate low spenders and the proportionate high spenders achieve positive outcomes for many older people.
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In addition to the variance in the proportion of spend on adult social care services between councils there will also be a variance within the adult social care budget on the proportion which is spent on services to older people compared with other customer groups such as younger disabled people, people with mental ill health, with learning disabilities etc. In a typical Welsh council between 50% and 60% of the budget for adult social care will be spent on services for older people. The following two diagrams show the patterns of spend within adult social care for each authority (Figure 2) and the average distribution for all Welsh councils (Figure 3). Figure 2 The balance of spend between client group by local authority 2008-09 100%
Service strategy
90%
Older People
80% 70%
Physical disabilities (under 65)
60%
Learning disabilities (under 65)
50%
Mental health needs (under 65)
40%
Other services (under 65)
30% 20%
Cardi
Newport
Monmouthshire
Torfaen
Blaenau Gwent
Caerphilly
Merthyr TydďŹ l
Vale of Glamorgan
Rhondda Cynon Taf
Bridgend
Neath Port Talbot
Swansea
Carmarthenshire
Ceredigion
Pembrokeshire
Powys
Wrexham
Flintshire
Denbighshire
Conwy
Gwynedd
0%
Isle of Anglesey
10%
Source: Local Government Data Unit ~ Wales
Figure 3 Proportion spent on each client group 2008-09 0.35%
Other services (under 65)
4.14% 0.35% 6.31%
4.14%
52.99%
52.99%
Mental health needs (under 65) Other services (under 65)
6.31%
27.98%
Learning disabilities (under 65)
27.98%
8.22%
Physical disabilities (under 65) Older People
8.22%
Service strategy
Mental health needs (under 65) Learning disabilities (under 65) Physical disabilities (under 65) Older People Service strategy
Source: Local Government Data Unit ~ Wales
(Other services to older people include: peripatetic support staff who supervise people living in the community and liaise with other agencies, community psychiatric nurses etc and staff whose duties do not fall under home care, such as community support and outreach workers expenditure).
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(Figure 4) looks at the spend per head by councils on services for older people (within adult social care budgets). The same principles apply – high spend does not equate to better outcomes nor does lower spend equate to worse outcomes.
£'000
Figure 4 Spend per older person (65 and over)
4
2008-09
2 Monmouthshire
Carmarthenshire
Cardi
Neath Port Talbot
Rhondda Cynon Taf
Swansea
Bridgend
Isle of Anglesey
Merthyr Tydfil
Flintshire
Ceredigion
Pembrokeshire
Wrexham
Powys
Newport
Conwy
Vale of Glamorgan
Torfaen
Denbighshire
Caerphilly
Gwynedd
2009-10
Blaenau Gwent
0
Source: Local Government Data Unit ~ Wales
In a similar vein, there is no close correlation between the spend per head identified in Figure 4 and the levels of deprivation in Welsh authorities (Figure 5). In fact Blaenau Gwent with the highest levels of deprivation has the lowest spend in Wales. Wales is divided into 1,896 Lower-Layer Super Output Areas (LSOAs) each having about 1,500 people. Deprivation ranks have been calculated for each of these areas: the most deprived LSOA is ranked 1, with the least deprived 1,896. Figure 5 uses this LSOA approach for the areas within each council as a proxy measure of the levels of deprivation within a council area. Figure 5 Percentage of LSOAs in the most deprived 50% in each local authority 2008 100% 90% 80% 70% 60% 50% 40% 30% 20%
Monmouthshire
Powys
Ceredigion
Vale of Glamorgan
Flintshire
Pembrokeshire
Gwynedd
Conwy
Swansea
Denbighshire
Wrexham
Cardi
Newport
Carmarthenshire
Bridgend
Isle of Anglesey
Torfaen
Caerphilly
Rhondda Cynon Ta
Neath Port Talbot
Merthyr Tydfil
0%
Blaenau Gwent
10%
Source: Statistical Directorate – Welsh Assembly Government
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Equally there is little correlation between these levels of deprivation and admissions to residential care by councils or the numbers of people being helped by councils to live at home. The average spend on residential care in councils is 37% of the total budget for older people with 28% being spent on domiciliary care and an additional 14% spent on Direct Payments. There has been a significant increase in the proportion of spend on Direct Payments in recent years and this is likely to continue. However, this does mean that more money is being spent by councils on helping people to stay in their own homes (Figure 6). Figure 6 Proportion of the adult social care budget spent on each service for older people 2008-09 (excluding service strategy) 0.78% 1.67% 2.09%
9.64%
3.73%
residential care nursing placements supported and other accommodation home care day care equipment and adaptions meals Direct Payments assessment and care management
36.55%
27.00% 14.09%
0.98%
Source: Local Government Data Unit ~ Wales
Figure 7 demonstrates that over the last decade the Welsh Assembly Government’s policy of helping older people to remain in the community is working, the proportion of clients being helped to live at home rising from 79% to 84% of the total of those getting help. There is a steady move in Wales away from institutional solutions to helping people remain in their communities. The report shows how councils are achieving this and how it can be sustained. Of course it would still be possible to have more people entering residential care and an increase in the proportion of older people helped to live at home if both figures were increasing. Figure 18 later in the report shows a decline in overall admissions to residential care by almost one third over the last decade. Figure 7 The percentage of clients aged 65+ who are supported in the community during the year 85% 84% 83% 82% 81% 80% 79% 78% 77%
2005-06
2006-07
2007-08
2008-09
2009-10
Source: Local Government Data Unit ~ Wales
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Councils are starting from different positions. Some began the transition away from residential care a decade ago whilst others are just starting that journey now. This is demonstrated in the variation in the proportion of the spend on older people that goes on residential or domiciliary care. Figure 8 shows a range of spend from almost half the budget of one council to a quarter of the spend in others. This gives more scope for those councils who currently have a higher spend to find some savings than for others who may already be making lower levels of placements. Figure 8 Proportion of local authority spend on older people that is spent on residential care 2008-09 50% 45% 40% 35% 30% 25% 20% 15% 10% 5%
Powys
Monmouthshire
Cardiff
Blaenau Gwent
Torfaen
Flintshire
Rhondda Cynon Taf
Wrexham
Pembrokeshire
Caerphilly
Newport
Swansea
Vale of Glamorgan
Neath Port Talbot
Merthyr Tydfil
Ceredigion
Isle of Anglesey
Denbighshire
Conwy
Bridgend
Carmarthenshire
Gwynedd
0%
Source: Local Government Data Unit ~ Wales
Figure 9 shows the similar proportion of spend on domiciliary care which varies between 38% and 24% of the spend on older people’s care and support services. Figure 9 Proportion of local authority spend on older people that is spent on day and domiciliary services 2008-09 45% 40% 35% 30% 25% 20% 15% 10%
Denbighshire
Ceredigion
Monmouthshire
Blaenau Gwent
Isle of Anglesey
Conwy
Vale of Glamorgan
Bridgend
Cardi
Gwynedd
Caerphilly
Wrexham
Merthyr Tydfil
Newport
Rhondda Cynon Taf
Pembrokeshire
Torfaen
Neath Port Talbot
Carmarthenshire
Flintshire
Powys
0%
Swansea
5%
Source: Local Government Data Unit ~ Wales
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One aspect of this study was to ask each council to consider their figures and discuss whether they were satisfied with existing patterns of spend. In almost every council there was a desire to further reduce the proportion of spend on residential care and increase the proportion spent on helping people to remain in their own homes.
2.2 Key policy issues in Wales The Welsh Assembly Government places a number of requirements on Welsh councils including the need to produce an annual report for social services providing information on the achievements of the previous year and identifying future improvement priorities. Councils produce a range of additional documents including separate commissioning plans and joint plans with health boards – Health Social Care and Wellbeing Strategies. There is currently discussion between ADSS Cymru and CSSIW around coordination of reporting against statutory plans to avoid possible conflict or duplication of effort. Medium term financial strategies were a noticeable absence among these key documents in councils across Wales. Through the discussions that have taken place during this study Welsh councils can recognise the necessity of linking their future plans to the money that is available, and work to accomplish this in the future is strongly recommended.
2.2.1 Charging In 2008 the Welsh Assembly Government determined that it would look to subsidise the costs of care for older people living within their own homes. They stated that under the Social Care Charges (Wales) Measure 2010, from 2011 onwards councils would be permitted to charge a maximum of £50 a week whatever the size of the care package and whatever the personal finances that the person receiving care contributes to those costs. The Government agreed to meet any differences between the income that councils have been able to raise in previous years and that raised under this new policy - a pivotal policy of the Assembly and part of its commitment to older people in Wales. This change has created a genuine anxiety amongst councils as to the possible impact on demand for services – particularly from those older people who in the past funded their own services. This could increase the costs for all councils. In addition, the policy seriously restricts the opportunities that Welsh councils have to raise more money towards the cost of local services. At present all Welsh councils offer a subsidy to people receiving services towards the cost of those services as they do not charge for the full costs. If a council chose to operate a means test on all of its citizens who were eligible for social care and then charged each person the full amount for the costs of the services they were receiving, an additional income could be raised. With the introduction of the new charging policy this option is no longer open to them. English councils that have adopted this approach have found that on average a third of citizens still pay no charge (as their means are not sufficient for them to afford to pay anything); one third are likely to have to pay a bit more than they currently do and one third (who are the wealthier group of older people with either occupational pensions or significant savings) are likely to pay significantly more. Welsh councils no longer have the ability to raise additional monies in this way. The implication of this policy is that in Wales councils will need to be even more efficient than their English counterparts.
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Another significant risk posed by this policy is its potential impact on other strategies. It might introduce a perverse incentive for councils to place people in residential care (where they can recoup more of the money) rather than keeping people in their own homes. Finance Staff in Ceredigion County Council have already examined the impact of this policy of their stated intention to help more people at home and to reduce their spend on residential care. They have calculated that it will now cost them an additional quarter of a million pounds a year to reduce admissions to residential care and help more people in their own homes. (This has not been included in the Assembly Government’s calculations). More details of Ceredigion’s impact assessment are provided in Appendix 2, page 70.
Most Welsh councils reported that they thought they would lose income as a direct result of this policy. This will have the impact of increasing the savings targets that councils will have to find in Wales.
2.3 Conclusions 1. There are different patterns of spending on services for older people among Welsh councils. Some of these are historical whilst others have been changed through strategic commissioning in recent years. 2. It is important that councils understand their data and have a clear interpretation of what it means in their context. Though there may be no right or wrong answers, intelligent use of the data will help ensure the right planning decisions are taken in the future. The next section of the report details how councils are continuing to change the ways in which they shape their local services through their strategic commissioning plans. The challenges they face are to reduce the levels of spend, at a time when levels of demand are predicted to increase.
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Section 3.
Strategic direction: How councils are planning for the future
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3. Strategic direction: How councils are planning for the future 3.1 Strategic plans The study found that some councils are preparing in a very thorough way for the likely challenges ahead. Others were waiting for the final settlement figures that the Welsh Assembly Government announced in December 2010 before planning their savings. In order to get a full year effect of any savings that need to be made in social care plans should be drawn up for those savings at least one year in advance. This approach is evident in Carmarthenshire, Conwy, Denbighshire and Wrexham councils where medium term financial strategies for the next three years include savings targets that have to be reached before the financial year in question. It is worth noting however that even with these councils’ well-presented and developed plans they will be hard pressed to make savings at the levels required by the settlement. Councils are aware of this and are continuing to work on contingency plans to ensure that they do succeed.
Examples of different approaches to strategic planning in Welsh councils include: • • • • • • • •
Carmarthenshire County Council: Identification of clear principles for change reflected in a three year budget strategy, supported by complementary strategies for accommodation, domiciliary care and community-based support Conwy County Borough Council: Adoption of a strategic project management approach for delivering savings targets whilst transforming services Isle of Anglesey County Council: Development and implementation of a commissioning strategy informed by the core principles of maintaining and promoting independence and reablement and integrating services with health and other partners Denbighshire County Council: Development of a medium term financial strategy to achieve 6.7% savings over the next 4 years Bridgend County Borough Council: Adoption of a commissioning strategy for adult social care based on a principle of reablement Powys County Council: Development of a change management programme for older people’s services Torfaen County Borough Council: Adoption of a holistic approach to user care delivered through a Customer Care Centre Cardiff County Council: Remodelling of services to achieve a better balance between domiciliary and residential care
More details of each of these initiatives is provided in Appendix 2, pages 70-77
Many Welsh councils have introduced panels of senior managers to promote notable practice and to act as guardians for people who may get access to services. In Denbighshire, the council received 371 cases at their panel in 4 months from 1 April 2010 and has found that 30% of the proposed packages were amended or withdrawn after discussions at the panel. One can see from the various approaches strong common themes which are being pursued by councils and are in line with the Welsh Assembly Government’s policy: looking to move from residential solutions to community solutions; keeping older people fit and well with an emphasis on recovery and recuperation; and ensuring that older people are signposted to the right services and not necessarily brought into state supported social care services where alternatives can help.
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Most councils are focusing their efforts on changing the shape of local services. The predominant themes are the reduction of the use of residential care, an increase in the offers of domiciliary care following a period of reablement and with assistive technology available to support the care package and the delivery of services at a lower cost. The key message must be that councils need to set a clear strategic vision for the future shape of local services. This must be linked to their medium-term financial strategy. It is helpful if a plan for delivering the vision is laid down in stages with critical milestones and goals. In the future the expectation will be that these plans are jointly produced with health boards and other appropriate partner agencies. Where appropriate they also need to look at possibilities for collaborative working across councils.
3.2 Planning services for the future - impact of demography During this piece of work, most councils submitted their commissioning plans as part of their evidence and contribution to discussions in the local summits. These raised a complex issue in planning for services for the future. Authorities rely on a simple formula to project the future needs of communities. The formula looks at the projected population increase and makes a simple calculation that social care needs will grow at that same rate. There is some evidence to suggest that the picture is not that simple. The following issues must be taken into consideration when planning for demographic growth: (i) If demand for social care increases in line with the growth in the population why has the demand and use of care not grown at this rate over the last ten years when significant new resources have been put into the system?
Councils should consider what factors have come into play in the last ten years that may have influenced either demand or need for care services – e.g. significant gains and improvements in health services; use of eligibility criteria; development of some preventive services; and a policy direction that has focused on helping people live independent lives at home. The last ten years have seen a reduction in both use of residential care and in the number of older people being helped to live alone, and an increase in the number of people who have sufficient resources to fund their own care.
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Figure 10 The rate of older people (aged 65 or over) supported in the community per 1,000 population aged 65 or over at 31 March 140 120 100 80 60 40 20 0
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
Source: Local Government Data Unit ~ Wales
(ii) If we are planning to focus strongly on reablement based domiciliary care in the future what impact might this have on demand?
If their reablement service operates to the standard of the best councils in England or Wales councils might typically expect to reduce demand for domiciliary care and residential care by about 10%. These top performing councils are achieving a success rate where about 60% of older people who enter a reablement service do not require further services after a 6 week intensive period of help and assistance. This must be taken into account when preparing figures for service demand in the future. Councils must consider that if they are going to put any resources into prevention and early intervention they are doing so with the likely outcome that they will be reducing demand for social care in the longer run. The impact of reablement is captured later in this report.
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Figure 11 Number of people aged 65 or over supported in the community 5000 4500 4000 3500 3000
2008-09
2500
2009-10
2000 1500 1000
Monmouthshire
Merthyr Tydfil
Isle of Anglesey
Conwy
Pembrokeshire
Wrexham
Vale of Glamorgan
Blaenau Gwent
Denbighshire
Flintshire
Ceredigion
Cardi
Torfaen
Bridgend
Newport
Carmarthenshire
Powys
Neath Port Talbot
Gwynedd
Swansea
Caerphilly
0
Rhondda Cynon Taf
500
Source: Local Government Data Unit ~ Wales
(iii) What is the likely impact on future service demand from councils of a growing proportion of older people owning their own homes - now at an all-time high - and the fact that the next generation of older people are more likely to have reasonable occupational pensions to supplement their income? The number of people reliant on the state for help may reduce (depending in part on future charging and funding arrangements for care). (iv) What will be the impact of improvements in health care on future generations of older people?
Councils should be aware that gerontologists appear to be divided as to whether in the future we will live longer with extended or reduced periods of morbidity. The decline in those industries that contributed to ill health and general improvements in life expectancy achieved through better diets, improved free health services and greater public awareness may assist in reducing the prevalence of a range of long term conditions. This will impact on the number of older people needing care and assistance. We do know that a person aged 60 today can expect to have a much healthier life style than a person aged 60 would have had 25 years ago. Even areas that pose a real challenge for care services today such as the increasing levels of older people living longer with dementia may significantly decline when new drugs that are currently on trial are launched onto the market with the likely result of reducing the speed of the onset of dementia and a similar reduction in the potential care needs for part of the population (though some psycho-geriatricians are sceptical).
(v) What is the likely impact on the demand for care of improved housing options open to older people alongside a fast developing set of technologies which will enable people to live independent lives in their own homes for much longer?
Councils will be aware that older people have more choice than earlier generations in terms of accessing both different housing schemes (from sheltered housing to care
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villages) and of new assistive technologies, which can transform people’s lives and reduce their demand for personal care.
Most councils in England and Wales are planning for an increase in demand for social care services of around 3-4%. A recent study commissioned by the Department of Health in England from the Personal Social Services Research Unit (PSSRU) indicated that current trends show a 1.9% demographic pressure per annum.
Perhaps the single biggest challenge which many Welsh councils are facing is how to change the prevailing culture within adult social care. The old system has created a paternalistic and protective set of services based on institutions and has built dependency both from service users and staff. There needs to be further culture shift towards a service which offers real opportunity to help people become more independent both in the way they live their lives and how flexibly they can use services.
The issues raised in this section show that projecting future demand is not a simple process and will be affected in part by the way in which councils shape their services over the coming years. Building a care and support system that focuses on keeping older people out of residential care and using reablement models of care may assist not only in achieving better outcomes for individuals but also in reducing demand for services that may have otherwise occurred.
There is evidence that some of those councils are helping more people to live at home and also helping more people in residential care. This suggests that either councils are inadvertently pulling people into their care system leading to increased dependence as their care needs increase, or that some councils are effectively diverting older people away from formal care settings and reducing demand for residential care.
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Figure 12 The rate of older people (aged 65 or over) supported per 1,000 population aged 65 or over at 31 March 2009 180 160 140 120 100
Supported in the community
80 60
Supported in care homes
40
Cardi
Conwy
Carmarthenshire
Pembrokeshire
Monmouthshire
Wrexham
Flintshire
Powys
Vale of Glamorgan
Bridgend
Denbighshire
Swansea
Isle of Anglesey
Newport
Neath Port Talbot
Gwynedd
Rhondda Cynon Taf
Torfaen
Ceredigion
Merthyr Tydfil
Blaenau Gwent
0
Caerphilly
20
Source: Local Government Data Unit ~ Wales
Figures indicate a significant fourfold difference among councils in Wales in the numbers of older people that they claim to help to live at home. This is unlikely to be an accurate picture, given the different ways in which councils calculate this figure. There is a group of councils who are supporting more than 100 older people per 1,000 - around 10% - and a further group who are supporting less than 60 per 1000. Generally, the councils who are supporting lower numbers in the community are also not supporting high numbers in residential care. In other words they may have developed good systems that support people in staying out of the formal social care system. This data clarifies for councils that helping people to live at home does not necessarily mean that they will have lower admissions to residential care. A key premise in this report is that councils should be focusing both on how to keep people outside residential care and reducing the number of people coming unnecessarily into the care system in the first place. A single issue which challenges all Welsh councils is the increase in the numbers of people with a diagnosis of dementia coming forward for help. In many places new models to help address the specific challenges of meeting these people’s needs have yet to be developed. General solutions are still very strongly reliant on commissioning more specialist residential care – even though there are those that would argue that placing people with dementia in ‘ordinary’ settings may offer a better environment for them. Some councils are beginning to look at more community based options for people with dementia, although this does in part depend on contribution by health who have a key role to play for example in setting up memory clinics and ensuring early diagnosis. Some councils include dementia care as part of their reablement services helping people manage their conditions (and often supporting carers). One or two councils have established specialist dementia domiciliary care teams that are specifically trained to help people with the condition manage at home.
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Conwy County Borough Council established a project with the University of Bangor to develop a model for carers who support people suffering from dementia. It has a positive element of peer group support aligned to ‘training’ of carers to manage the condition and to find techniques that help both them and the dementia sufferer to cope. In Conwy many older people have moved to the coastal towns and relatives live a distance away which is why the Council’s dementia domiciliary care service is critical to delivery of its policy of supporting people in their own homes. The Health Board employs Community Psychiatric Nurses who work specifically with older people and they play an important role in this community support network.
Monmouthshire County Council has made significant advances in reducing the use of residential care and increasing the number of people supported to live at home. This is illustrated in Figures 13 and 14 below. Monmouthshire’s future plans will rely on: • • • •
the development of a reablement service the continued remodelling of residential care wider collaboration with partners – especially health tendering for domiciliary care on a zonal model (which has demonstrated savings in both Wrexham and Cardiff shown elsewhere in this report) joint commissioning with health and joint panels and assessment for continuing health care single point of access support to the regional Gwent Frailty Project
• • •
Figure 13 Older People Supported in Residential Care 500 450 400
Clients helped at home (aged 18+)
350 300
Linear(Clients helped at home (aged 18+))
250 200 150 100 50 0
2007
2008
2009
2010
Source: Monmouthshire County Council
Continued 4
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Figure 14 Older People Supported in the Community 1400 1350 1300
Clients helped at home (aged 18+)
1250 1200
Linear(Clients helped at home (aged 18+))
1150 1100 1050 1000
2007
2008
2009
2010
Source: Monmouthshire County Council
What is clear is that the overall shape of services in Wales is moving significantly away from models of care that rely on institutions towards community based solutions. There has to be a warning that as shown elsewhere in the report, there is not necessarily a direct correlation between lower admissions to residential care and higher numbers helped to live at home. In fact it could be argued that in future social care should not only be helping fewer people in residential care but through better use of reablement and building community capacity that councils should also be directly supporting fewer people at home as well. If councils are supporting 100 fewer people in residential care but helping 200 more people in the community it is possible that savings are not occurring at the levels which the reduction in funding available for services may require.
3.3 Cutting the cost of frailty In South East Wales the former Gwent Authorities are collaborating on a programme that is focusing on the cost of frailty in social care – the Gwent Frailty Project. They have used the following definitions for their work: •
Dependency - Chronic limitations on activities for daily living with one or more physical or social needs, including those who have dementia
•
Vulnerability - ‘Running on empty’. Usual coping mechanisms aren’t working
•
Co-morbidity - People with a chronic condition who as a result may have health, social care and/or housing needs
The Project is looking to develop a model of practice which is based on Community Resource Teams run jointly between health and social care and which focus on: • • • •
urgent fast-track assessments rapid response services emergency care at home reablement services
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These services will sit alongside traditional longer term support such as chronic conditions management and palliative care services that already exist. More information on the composition of these teams and the services they will offer is provided in Appendix 2, page 78. The current proposals are that these teams will be financed at £9 million over 3 years between 2010-11 –2012-13 through a combination of existing posts and additional funding from the Welsh Assembly Government’s Invest to Save programme. The business case predicts pay-back within 5 – 7 years. This though will depend on a significant shift in resources and activity between the acute sector and community-based services. The arrangements will require formal legal pooled budget arrangements between the NHS and the five councils involved in the project. The success of the Project will need to be shown by: • • • • • •
reduction in acute beds = transfer/reduction in staff reduction in community beds = transfer/reduction in staff reduction in residential care beds = transfer/reduction in staff reduction in domiciliary care packages reduction in staff travelling time through use of technology slower growth in number of complex care cases
This is the kind of approach which many councils and health boards will be looking to adopt in order to reduce overall demand in the system – or to reduce the levels of demand as they find ways that are more cost effective and community based and deliver better outcomes to service users. The biggest challenge is taking the public along with these changes as efficiencies can only be realised if there is a corresponding reduction in the number of acute beds that exist within the system. Closures of hospitals that result from this are traditionally highly emotive and politically sensitive. Similar kinds of approaches are however being developed by councils and partners in other parts of Wales. The challenge of delivering successful models of this kind is immense and change will require political ownership as well as rigorous project management.
3.4 Conclusions 1. Every council in Wales has a strategic plan for services for older people. Most have been produced by councils through consultation with health colleagues; some have been developed in partnership. Many of the plans are ambitious and aim to transform existing services whilst saving money. A number of councils are working closely together – some informally such as Merthyr Tydfil and Rhonda Cynon Taf County Borough Councils and others more formally, for example through the South East Wales Improvement Collaborative (SEWIC) and the North Wales Social Services Improvement Collaborative (NWSSIC). 2. Councils that are most likely to succeed in delivering their strategic plans are those that combine a clear vision with a robust approach to project management. Managing the performance of a series of interlinked projects, ensuring that milestones are reached and reviewing progress in order to refocus where things are not working, are all important components of such an approach. 3. The strategic plans consistently include elements of reablement and recovery; alternatives to residential care and a focus on supporting people in their own homes.
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4. What is clear is that councils need to plan to deliver more cost effective services that will help them meet their savings targets whilst improving outcomes for users. The two main approaches for achieving this could be described as ‘preventive’ or ‘cost effective’. 5. Preventive services focus on helping people stay out of longer term care services through reablement, intermediate care, information and advice and housing support. All of the above should reduce demand for longer term care. 6. The second approach focuses on changing either the provider of services or the model through which services are provided. The aim here is to reduce costs by finding a cheaper way of delivering the same service (e.g. closing in-house provision and relying on the larger social care market to provide services) or by commissioning a different service (using extra care housing as an alternative to residential care or assistive technology to offer a different level of reassurance to older people in their own homes) These two approaches will be explored in more detail in the following sections.
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Section 4.
Approaches to prevention
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4. Approaches to prevention 4.1 Defining prevention During discussions with councils the much vexed question of ‘what is prevention in social care?’ came up time and again. Councils discussed the evidence from international studies which demonstrate that offering even small amounts of low-level social care carries the risk of the need of the person involved for further care and their dependence on care both accelerating. The challenge of ensuring that older people receive appropriate early help and advice from social care and elsewhere in a way that does not create unnecessary and counter-productive levels of dependency is one that is exercising the majority of councils. There is more work to be done to develop a coherent prevention strategy which is evidence based. Many of the investments that councils are making are hard to track definitively as preventive measures. Developing a business model that tracks investments and looks to monitor the returns would assist councils in making future planning decisions. The discussions about prevention came under six headings: • • • • • •
the role of the community and the third sector the importance of information and advice the nature of interventions such as reablement, falls prevention and ‘keeping well’ programmes housing solutions the role of assistive technology reducing admissions to residential care
4.2 The community and the third sector Much can be made of the potential to further engage the third sector in the development of services across Wales. Councils report mixed outcomes from their engagement with the third sector to date. Some voluntary sector organisations continue to offer similar paternalistic and protective services to those traditionally provided by councils. There is a general view across many councils that often it is not the service that matters but the way in which older people are, and feel, engaged in the development and delivery of those services. Evidence suggests that when a statutory or other agency runs a luncheon club the outcomes for users are not as positive as is the case when the club is run by the people themselves. Under the latter approach people feel intrinsically more engaged and energised by the activity involved and this brings broader benefits in relation to their wellbeing and independence.
One of the best examples of the work with the third sector highlighted through the study is being led by Conwy County Borough Council. The Council has conducted a review of the contribution of the voluntary sector in delivering local services as a whole. This review was conducted by a task and finish group of elected members which examined the monies going from all parts of the council to the third sector. They formed a much clearer view on what the council was commissioning and where there were risks of duplication of effort. From this review and subsequent renegotiation of contracts with the third sector the council was able to give a much stronger sense of stability to the sector in relation to their future funding intentions whilst reducing the overall spend within the sector by 4%. Continued 4
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Over the last few years, the Local Authority Council and Health Board have agreed their commissioning intentions and aligned monitoring procedures with in relation to voluntary organisations. As a result some important service changes have been made. For example, priority has been given to services which keep older people out of the care system such as a Red Cross scheme to support older people on discharge from hospital (Conwy achieved the lowest rates of delayed discharges in Wales in 2009). A cross roads carers scheme, a Care & Repair scheme and social activities supported through Age Concern are among other programmes with consistent emphasis on promoting independence and wellbeing which have continued to be funded as a result of the review. This fits with the Council’s long term prevention strategy which also includes a welfare benefits check for every older person referred to the council for help, a handyperson service for simple repair jobs, high quality information and advice for the public and alternatives to support older people outside the social care system through a range of provision including a meal service for older people not meeting the Council’s eligibility criteria.
Pembrokeshire County Council is looking to expand its already successful Good Neighbour Schemes. At present they have 6 schemes in the county but in order to achieve a wider coverage the Council is working with communities with the aim of having 12 schemes in place by the end of next year. They are using a tried and tested community development model offering support to new schemes to get started but aiming for the council to withdraw once people have found their own confidence in running them. One positive way they are achieving this is for the people from the existing 6 established schemes to assist in the early development of the new ones.
Most councils have made significant investment within their communities and with the third sector. But few have mechanisms in place to evaluate the impact of the work or to determine which of their services should be sustained in the future.
4.3 Information and advice It is critical that councils provide good information and advice services that can assist older people at the right time and help them resolve issues without necessarily requiring longer term care and support from the council. This might include putting people in touch with appropriate community provision or helping them sort out their benefits or other matters where they require good quality advice. Councils recognise that whilst they are making significant investments in these services they are not always delivered in a coordinated way. In simple terms, these services are rarely directly commissioned by councils but tend to have grown organically over time. Councils typically fund Age Concern, Citizens Advice Bureaux, law centres, community groups and other voluntary organisations to provide these services as well as developing central call systems to deal with enquiries to the council and provide more specific advice in relation to social care services. Many councils recognise there is more work to do to be clearer for the public on how they can receive the right helpand advice at the right time.
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Rhondda Cynon Taf County Borough Council has undertaken a review of its adult duty arrangements with the aim of offering a more consistent service that provides good information and advice to callers in a way that feeds into a unified assessment with health. Their process has two key elements: a basic screening service which offers clear information and advice and directs people to the appropriate service by asking the ‘right’ questions; and for those needing specific social care support and advice a Duty Team then offers follow up and further help. The response times for the service have improved and better referral information is being captured for social workers, through better data and improved management information. The Council has noted that 54% of its contact assessments are referred from families and friends, 28% from health and 18% from other sources.
A similar review has taken place in Merthyr Tydfil where the County Borough Council looked at the whole system for older people’s services from duty through assessment to issuing care packages. They have identified that among all the enquiries lodged with their duty teams, a significant proportion do ot lead to an assessment. Figure 15 Number of enquiries 4,727
5,000 4,500 4,000 3,500
4,631
4,253
3,232
3,000
2,604
2,500 2,000 1,500 1,000
500
0
2006/07
2007/08
2008/09
2009/10
2010/11
Source: Merthyr Tydfil County Borough Council
Continued 4
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Figure 16 Assessments 2,500 2,000
Number of assessments
1,500
Number of Services resulting from Assessments
1,000 500 0
2006/07
2007/08
2008/09
2009/10
2010/11
Source: Merthyr Tydfil County Borough Council
In addition, a further proportion of the enquiries do not lead to a person receiving a service. Through changing its duty arrangements in common with its neighbours in Rhondda Cynon Taf, the Council has developed a better screening system that helps to direct customers to the right service (often not within social care) that can give them the help they need. This has led both to improved outcomes for customers and the freeing up of social work and care management resources to focus on improving performance on case reviews. Performance in this area has risen to 83% of reviews completed on time compared with a Welsh average of 71%.
4.4 Reablement and intake models The development of reablement (sometimes referred to as enablement) services represents the single biggest change for older people’s services in Wales over the last decade. This approach is built on the simple premise that when older people become ill or have a medical intervention they can get better. Its basis lies in the disciplines of occupational therapy (OT) and physiotherapy, helping older people rebuild their strength both physically and emotionally after a critical event so that they can live independently once again. The evidence shows that many older people can be aided to a full recovery after a 6 week period of intensive support. In essence, reablement services are based on the principle that the older person should be encouraged and assisted to look after him or herself, in contrast to traditional service models in which the carer does everything for the older person. Hence this approach is markedly different from traditional approaches for both staff and the older people. The best reablement services help about 66% of older people referred to them, to ‘get back on their feet’ and function independently with no further need for social care services. Typically newly established services achieve around a 50% ‘success’ rate in their first year of operation. The impact of reablement services should be a reduction in the region of 10% in demand for domiciliary care services over a 3 year period – reducing costs at the same level. Every council in Wales has begun to develop a reablement service, although the pace of development varies considerably across the Country. Some councils have considerable work still to do to get their services properly established but authorities such as Neath Port Talbot County Borough Council, Bridgend County Borough Council, Denbighshire County Council
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and Isle of Anglesey County Council are already making good progress. Most councils already report a minimum 50% reduction in the need for further care services following a period of reablement. Total figures across Wales are in the range of 40-70% with a further 10-20% needing a lower level of service and about one third (33%) requiring a continued longer term service. Figure 17 shows a typical set of outcomes that can be achieved through an effective reablement service – with about 50% of customers not requiring a further service. It shows outcomes for Merthyr Tydfil County Borough Council’s reablement service which forms part of its hospital rapid response service and therefore also takes patients with palliative care needs (explaining why the figures of supporting people to have a dignified death are higher than those schemes that do not include palliative care within their reablement service). Figure 17 End of Service Outcomes Initial Response April - August 2010 Long Term Care / Deceased 14%
Ended service 45% Ended service Reduced service Long Term Support Long Term Care / Deceased
Long Term Support 28% Reduced service 13% Source: Merthyr Tydfil County Borough Council
Councils are taking a number of different approaches to running their reablement services. These can be categorised as follows: • • • •
a post hospital support service a service to which selected people are referred following a request for help a service which deals with all new referrals for personal care for older people and which makes the initial assessment a joint service with health to which older people needing health or social care support are referred (often part of the wider Intermediate Care services)
A national programme run by SSIA and started in 2007, continues to support the development of reablement services and the sharing of emerging practice. The programme has developed a set of standards for reablement services, tools for councils to self-assess themselves against these standards and a computer-based modelling tool to help inform development of a business case for reablement services and projection of likely cost savings. Further work continues on the development of a skills matrix for effective reablement teams.
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Work undertaken by the Care Services Efficiency and Delivery (CSED) Programme in England has demonstrated that reablement teams are most effective where certain conditions apply. These are: •
•
•
•
•
staff are fully trained and supported in the new way of working and supervised in a way to ensure that if any individuals find the new approach too difficult they can receive tailored support. In some areas taking on new staff and specifically training them in this approach is seen as a very positive step regular training is offered to staff as the scheme develops, allowing time for them to reflect on practice and to learn from each other and therapists as to which approaches work in which circumstances. Particular attention should be paid to the emotional wellbeing of the older people as well as to their physical recovery programmes the performance of the reablement teams is closely monitored and managed by senior staff to ensure that the service is achieving the expected outcomes and thus delivering the required savings therapists are employed alongside domiciliary care workers to ensure that older people and staff get the right guidance if they come across complex conditions or staff need specific guidance in how to assist a particular service user the council-run reablement service and wider Intermediate Care services (usually run by health) align in a way that provides a single care pathway for older people
Rhondda Cynon Taf County Borough Council established its reablement service in 2002. The service brought together occupational therapists, physiotherapists and reablement workers and though it initially reported good results they only provided the service to a selected group of people who were referred to them. In 2007, with the advent of the Joint Working Support Grant (JSWG) from the Welsh Assembly Government, the council created an Intermediate Care service which undertook short term rehabilitation for up to 6 weeks with a wider number of people, with equally positive outcomes. In 2008 the Council brought together its various services into one service with a single point of access and pooled funding. This has delivered impressive outcomes – notably that between 75% and 85% of people using the service do not require further social care support. The Council is now looking to increase further the number of people accessing the service, including direct referrals from the hospital discharge team and to provide free access to telecare for the period of the intervention.
Working relationships between councils and the health boards in the development and implementation of reablement services appear to vary. Rhondda Cynon Taf County Borough Council reports very positive relationships with good outcomes and Bridgend and Neath Port Talbot County Borough Councils also demonstrate excellent outcomes from joint services. However in other parts of Wales councils reported difficulty in engaging with health partners, most noticeably when structures and people have changed making it harder to align health responsibilities with council boundaries. In Conwy there are positive examples of joint multi-disciplinary community-based teams where health and social care staff collaborate together to share customer information (where appropriate) and focus on getting better outcomes for their customers. All councils have expressed concerns over the future viability of their joint Intermediate Care services as the grants that have been used to fund a significant part of them (e.g. Joint Working Grant or the Independence and Well-Being Grant) are discontinued as part of the financial settlement. However councils are getting better at developing the business case for securing alternative funding (often internal) for services in the future. A key question remains whether this can this be part of a jointly-funded service with health boards.
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Bridgend County Borough Council has an excellent Intermediate Care service comprising the following features which reflect the National Framework for Older People in Wales (2006): • • •
enables people to maintain their health and independence and home life promptly identifies and responds to older people’s health and social care needs, helping avoid crisis management and unnecessary hospital or care home admissions enables timely discharge or transfer from acute hospital settings to more appropriate care settings which promote effective rehabilitation and a return to independence
The Bridgend service was brought together from April 2009 to offer a County Borough-wide service, combining existing integrated reablement, community disability rehabilitation and Bridgelink telecare services and developing a new early response service and specialist interface nurse post. The integrated teams of health and social care workers (including nurses, occupational therapists, physiotherapists and therapy technicians) are co-located with community occupational therapists and assessment services for adults with physical and sensory impairment. The service also links with the community equipment service and the Bridgestart enabling homecare service on the same site. More information on performance and outcomes of the Service is provided in Appendix 2, page 78.
Isle of Anglesey County Council has a well-developed joint Intermediate Care service with health and is working towards a Section 33 agreement (an arrangement generally less common in North Wales than in other parts of the Country). Service users have access to a range of services including - therapeutic support, community reablement, rapid response service, residential intermediate care (step up/step down beds), telecare, equipment, adaptations and home safety, all placing an emphasis on self-management for those with longer term chronic conditions. Crucial to the Intermediate Care strategy is the development of an integrated adult service Single Point of Access (due to be piloted in Spring 2011) which will provide a streamlined referral pathway for adults to both ease discharge from hospital and prevent admissions. These arrangements for partnership working are laid out in the document ‘Model Môn Locality Development Group – An Integrated Framework for Delivering Health and Social Care’ produced by the County Council and Betsi Cadwaladar University Health Board.
Another way of achieving positive outcomes is to ensure that specialist residential Intermediate Care services are available to older people offering a place where they can recuperate when they are not well but may still have a good chance of recovery.
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The City and County of Swansea has developed a service which offers a number of beds in local authority care homes as an emergency service for older people for whom mobility has significantly deteriorated. This has the combined impact of reducing emergency admissions to hospitals and to residential care. This is linked to the Council’s Early Response Service through which a nurse led team will respond within 4 hours to a crisis for an older person and will keep them at home for up to 10 days. Neath Port Talbot County Borough Council provides 5 beds for a similar purpose although they have some evidence which suggests that this number should be increased. Pembrokeshire County Council is the first council in Wales to put in place a management model for the joint running of health and social care. Since early 2010 the Director of Social Services has also been leading the health service in the County as County Director for Hywel Dda Health Board. The Council and Health Board believe that this is already bringing benefits by both simplifying processes and creating a culture in which health and social care professionals can work constructively together. Although it is recognised that it may take up to 5 years before the full benefits of this arrangement are realised across the community, positive feedback from customers is already being received in response to the new approach. One immediate action that has been taken is the bringing together of health and social care staff in each locality on a weekly basis helping prevent admission to hospital and enabling users to remain at home. In one part of the County a day centre and local day hospital already offer an Intermediate Care facility with a focus on reablement and support for older people and helping avoid admission to the acute hospital. There is an intention to replicate this in the rest of the County.
4.5 Falls prevention and ‘keeping well’ programmes Associated with the development of reablement services is an increasing emphasis on helping older people maintain their independence through general promotion of health and wellbeing. Indeed it seems sensible to back up reablement services with programmes designed to keep older people fit and well. Councils do not have to run costly social care projects to encourage older people to keep fit – in Pembrokeshire the Council runs a ‘Fit for Fun’ programme which is widely supported by over 50s forums in the area. Research has indicated that both health and social care can save money when they work together in the area of falls prevention. Isle of Anglesey County Council coordinates a very successful community based falls prevention service in partnership with Betsi Cadwaladr University Health Board and Bangor University. Initial modelling research within Bangor University’s Health Economics Department showed positive results in reducing hip fractures and giving more ‘Quality Adjusted Years (QAYs) compared to those who had no intervention. For females the use of Postural Stability Instruction and Tai Chi showed positive results whilst for males both these interventions plus medication reviews demonstrated positive gains. The study confirmed that investment in screening for risk of falls amongst older people would save money and produce better longer term outcomes for older people. These findings resulted in the commissioning of an initial pilot project in the North East of the Island, leading subsequently to a whole County integrated service, which is based on three key stages:
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1. A Falls Risk Assessment Tool (FRAT) used for people in the community aged 65+. Those scoring a positive result (3+) are then sent to stage 2 2. MRA (Multifactorial Risk Assessment) offered to all those scoring 3+ on the FRAT and delivered in community or home setting in partnership between Physiotherapy and Leisure Services 3. Following the MRA result participants are referred onto any number of evidence based interventions to reduce their risk of falling and subsequent injuries, such as Postural Stability Instruction (PSI) 32-week gentle exercise classes, medication review, home safety check, social services, and podiatry The key to sustainable health improvement and reduced risk of falling is then to ensure clear and timely referral pathways to other long term community based activities. This is continually being developed and refined by linking referral pathways into Community AgeWell clubs (run by Age Concern and the Council), over 50s clubs, and walking groups. The service has also benefited from further support provided by Bangor University, via a KTP (Knowledge Transfer Partnership) where a member of staff was able to apply robust research methodology to evaluate qualitative and quantitative outcomes. This has resulted in the publication of an academic paper, presented in a 2010 conference in the USA, which demonstrates the service’s positive impact on functional capacity and fear of falling. More information on this excellent programme can be found at: http://www.ynysmon.gov.uk/doc.asp?cat=5151&Language=1
4.6
Assistive technology – telecare and telehealth
A Welsh Assembly Government grant for implementation of assistive technology has provided councils with a genuine incentive to push forward with developments in this area. All councils in Wales are using this approach to some degree to help people live at home, but with varying outcomes. At the current time few councils really know if the investment that they are making in assistive technology is saving them money. Councils appear to be divided between two approaches in the use of assistive technology. There are those councils who want to use the products of telecare as a universal offer developing the previous technologies of community alarms linked to call centres (though not every council has a response service). Others are more specifically targeting assistive technology on older people who are eligible for social care support and are looking to use it both to reduce the size of care packages and as part of wider preventive measures. Several councils issue telecare products as part of assessment within their reablement programme. There are two main types of telecare products – those which act as aids to daily living and operate solely within the confines of a domestic setting, and those which encompass alarm systems and may require an external response service. Some councils are looking to use both types of products but are not always clear how they can maximise the use of each.
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Denbighshire County Council is piloting a self assessment process to supplement community care assessment but loan telecare products for a £15 charge per month (unless people are on Housing Benefit). A personal care response service is also available and is in the process of being evaluated. Vale of Glamorgan Council has recognised the need to increase take up of telecare products. It has established a programme with the local Health Board which has the following features: • • • • • • •
raising awareness linked training joint call monitoring linked response teams trial of new equipment improved purchasing power roll out of proactive calling service
A small number of councils use a product called ‘Just Checking’ to help with assessments. This offers sensors which can monitor a person with dementia and offers reassurance to carers and care agencies as to the level of risk a person might be presenting, for example by wandering away from home or showing irregular sleep or eating patterns. It is surprising, given the level of concern that councils express about the growing pressure on services for older people with dementia that this relatively new system is not being used more widely. One of the issues with which councils are grappling is how they should commission response services to telecare services. Though all councils have some kind of call centre (which might cover the area of one or more authority) not all include the ability to respond to emergencies relating to people who do not have a neighbour or family member living nearby. Similar technology has been used in both England and Scotland, in particular to give support to older people in isolated or rural communities. Ceredigion County Council is considering developing its approach to address issues of rurality. English councils are beginning to examine the evidence emerging from ‘Whole System Demonstrator Sites’ where new telehealth products are being trialled by the health community alongside councils’ telecare products. There is little evidence of this happening yet in Wales. A number of studies have been undertaken in England and Scotland which attempt to demonstrate savings arising from the use of assistive technology. The Department of Health reports that savings of around 1.5% could be obtained through the wide use of the new products. There is no evidence yet of this level of savings being achieved by Welsh councils. However the further development of new technology in the coming decade will give councils real opportunities to make overall savings whilst helping more people live independent lives in their own homes.
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4.7 Housing solutions One of the biggest challenges facing councils is the need to provide grants to help older people adapt their homes so that they can continue to live in them. Common adaptations that are funded through Disabled Facilities Grants include replacing baths with showers, installing hoists, putting in stair lifts, building downstairs toilets, creating space for an older person to sleep downstairs, ensuring that homes have rails where required, putting in ramps for wheel chair users and improving overall accessibility. Most councils find that they cannot fully meet the demands of their communities within available budgets, most of which comes from the Welsh Assembly Government. Nearly all councils report difficulties in managing the grant and many have considerable waiting lists of older people needing adaptations. It is interesting to note that few councils had considered the use of Direct Payments to enable older people to make their own arrangements for adaptations.
One of the most discussed examples of good practice in Wales in this area is the work undertaken by Neath Port Talbot County Borough Council to improve the process and outcomes arising from the demand for Disabled Facilities Grants. This is an excellent example of systems thinking delivered in action. They identified the problem – they were not sufficiently customer orientated – and redesigned the service to focus on the desired outcome of providing the right help for the customer in a way that maximises independence. The Council reviewed its existing process, which had 291 stages taking 675 days to complete. The new arrangements reduced this to 34 stages which were completed within 64 days. The average cost of works was reduced from £7,000 to £6,509 and a 52% reduction in car mileage costs was realised (achieved by fewer parts in the process). As a result of this, work is typically completed three months quicker than previously. The average costs of delivery of the equipment also reduced from £499.76 to £319.98. In addition, the council identified that it needed five fewer staff in the service saving £140,000. It saved £859 per grant issued, and achieved a reduction in overhead costs of £5,700. It was able to use the existing workforce more efficiently which gave them a total cashable saving (to reinvest back in the service) of just over £0.5 million. Another solution which many councils have developed is the use of extra care housing as a way of offering older people suitable, well designed facilities along with social care when required. This is a development of the use of sheltered housing which was popular from the 1950s onwards, providing an environment where older people could live in relative safety with some level of support. A key challenge for councils is that much of their sheltered housing stock now needs modernisation but they have not been able to make the investments required. As a result this form of housing has become less popular. One or two councils are considering whether they can invest in their current sheltered housing stock to bring it up to a standard where it could be used as an extra care scheme without the costs of building a totally new scheme.
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The programmes set out below highlight some of the commissioning challenges facing councils, including: • • • • •
how many residential care home places will be required in the area? what impact will extra care schemes have on longer term requirements? can dementia care services be included as part of extra care? should extra care programmes concentrate on providing housing alternatives for older people or should they focus on extra care housing as an alternative to residential care? with the ending of the Welsh Assembly Government grants for extra care housing what proportion of new developments should be for sale and how much for rent?
Denbighshire County Council has an extra care housing programme with one scheme open, one about to open, a further one being built and two additional schemes in the pipeline. The original schemes have all been funded through a grant from the Welsh Assembly Government covering almost half of the capital costs. However this grant is unlikely to be available for the final two schemes and so discussions and feasibility studies are taking place with housing associations to look at building schemes with some ownership or part ownership to meet part of the capital costs. Denbighshire have already closed one of their in-house residential care homes as a result of opening the first extra care scheme and expect to close a second home on the back of the third scheme opening. When this programme is delivered the council expects to save £550,000 through reduced use of residential care. Pembrokeshire County Council has built two extra care housing schemes in the County and is planning a further development. It is also grappling with the model of extra care housing which appears for them to have led to applications mainly from fit and well older people. For some there are uncertainties as to whether this model of housing will replace residential care or just offer older people in the area a new housing option. Neath Port Talbot County Borough Council has been clear that unless extra care is part of its broader social care and housing strategy and offers an alternative to residential care, its value may be limited. The Council has closed 3 in-house residential care homes and replaced these with 2 extra care housing schemes. As part of its ongoing Transforming Older People Services (TOPS) Programme, it is now refurbishing current sheltered housing schemes, particularly in valley communities, as well as developing new schemes. It has also identified £7 million within the new NPT Homes investment plan to sustain this refurbishment programme. By doing this the Council will be able to offer this accommodation to larger scale extra care housing schemes which would not be viable in valley communities. The programme for extra care housing in Merthyr Tydfil was informed by work commissioned from the Institute for Public Care (IPC) in January 2005 to assist with the development of a long term strategy for services to older people. The resulting report recognised the need to develop an increased range of options suitable for older people and formed the basis of the council’s Homes for Life Strategy. One of the key priorities identified was the development of specialist extra care provision within the County Borough. Key elements of the business case for the programme are included in Appendix 2, page 79.
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Two models of extra care housing are prevalent across England and Wales. One is where extra care housing is seen primarily as a housing choice option for older people. The aim is to build a community of older people where there is social capacity and each person looks out for each other. In these schemes those running the support do not want to have too high a proportion of residents with higher care needs. They often express this in the form of ‘those in the community should be approximately one third with no care needs, one third with low care needs and no more than one third with high care needs.’ This is the most common model and has been adopted by most Welsh councils. The model is popular with providers of the schemes. However, it does not always meet the requirements of adult social care when it is required as an alternative to residential care. There are instances in Wales of a second model, marked by a clear policy that extra care housing should only be allocated to those who are already in need of residential care, or who are at risk of needing high level care in the near future. As one housing manager put it: ‘We cannot build enough extra care housing to address the totality of the housing needs of older people so we have focused our efforts on looking to make better use of the Disabled Facilities Grants, Care & Repair schemes and offering good advice to older people about their housing whilst developing extra care housing as an alternative to residential care.’ Not every council is as clear in their strategic direction for older people’s housing. The latter model is more appropriate if a council wishes to close a residential care home and offer the option of extra care on closure to the residents. This is known to work effectively. The other advantage of the second model is that it will bring higher levels of savings to the council. If all of the tenants are people using extra-care housing as an alternative to residential care, then it certainly is a lower cost model of care (under the current regulations). Most extra care housing schemes in Wales have been reliant on significant capital grants from the Welsh Assembly Government. This grant will not be available at the same level in the future. The most common ways in which extra care housing might be created without grant funding will be either through conversion of existing good quality sheltered housing or through reliance on the sales of the accommodation to private owners who will contribute to the capital costs previously met through the grant. If the majority of people who enter a scheme are purchasers the former model (mixed care needs) is more likely to reappear. The other issues that councils may consider in developing their extra care housing include: • • • •
do they want (some or any) nomination rights – and if so are they willing to pay for voids? do the smaller housing associations in Wales have the ability to borrow money at competitive rates to develop new housing at an affordable cost and to take the risk on sales? in the absence of grant funding from the Welsh Assembly Government will councils put in any subsidies for new schemes (e.g. free land)? if there is no grant available will the larger English-based housing associations with greater borrowing power enter this market?
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A further important point about extra care housing is that it does not need to be commissioned directly by councils as there is little evidence of providers building schemes in Wales without direct support from councils although this has been the case in a number of areas in England. In summary, councils do need to be clear whether they are commissioning extra care housing as an alternative to residential care or as part of a housing solution for older people. Working with the third sector to improve housing conditions is also common across Wales. Several aspects of housing services can play a critical role in ensuring that older people can live independently within the community. Many councils sponsor Care and Repair services which assist older people through provision of simple solutions to their housing needs.
4.8 Reducing admissions to residential care Every council in Wales is looking to reduce its admissions to residential care for two good reasons. First, every council that talks with people hears the message that this is not the preferred model of care in old age. Second, it places the highest demand on resources in adult social care and if admissions can be delayed or avoided the money saved can be spent in keeping people independent. Councils are examining a range of alternative ways of providing the support required by older people to help them to remain in their own homes. This has been the direction of policy for the past decade and whilst there has been an annual reduction in state funded residential care places of around 2% per annum in England over the past decade, this figure is almost 3% in Wales. This demonstrates the success of councils in delivering Welsh Assembly Government policy. Gwynedd Council ran a series of events with older people in the County to find out their views on the services that should be planned for the future. The overwhelming response was that they did not want residential care but would prefer reablement services to help them regain independence. They also wanted to be able to use assistive technology that would help them remain safe and enable a quick response when they had a crisis; they wanted domiciliary care that would help them at the times and in the way that suited them. Gwynedd presently runs 13 residential care homes. The Council notes that it consistently has around 66 vacancies across these homes. This is costing £1.6 million a year. The Council also notes that though it has been the highest user in Wales of residential care (as a proportion of spend) the numbers of people in residential care have declined year-onyear for the past five years. In 2005-06 the Council was supporting over 750 older people in residential or nursing care. This has now reduced to 673 and this figure is reducing further in the current year. The Council has established a programme of building new extra care facilities. It has introduced a corresponding programme to close a small number of council run residential care homes for older people, replacing them with extra care schemes. They recognise that probably they should close a couple of their current care homes. There are difficult political choices to make here but the Council is facing up to these – it knows things have to change.
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Figures 18-21 show the current use of residential care by councils in Wales. There is not one single solution that will change the nature of the population in residential care overnight but the gradual development of new services and alternative approaches will deliver lower admissions over a period of time. The rate of progress will vary. There is an evident variation in the numbers of people supported by councils in residential care in Wales (though not as wide a variation as exists in England). Each council needs to examine the reasons why their admissions are high (or low). There are a number of steps that councils might need to take together with health partners to see how they might reduce this figure. Figure 18 The rate of older people per 1000 of population in Wales (aged 65 or over) whom the authority supports in care homes at 31 March 35 30 25 20 15 10 5 0
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
Source: Local Government Data Unit ~ Wales
Figure 19 Proportion of Local Authorities spend on older people that is spent on residential care and nursing care 2008-09 70% 60% 50% 40% 30% 20%
Monmouthshire
Cardi
Powys
Caerphilly
Flintshire
Rhondda Cynon Taf
Swansea
Torfaen
Wrexham
Pembrokeshire
Carmarthenshire
Isle of Anglesey
Neath Port Talbot
Newport
Vale of Glamorgan
Blaenau Gwent
Denbighshire
Merthyr Tydfil
Ceredigion
Conwy
Bridgend
0%
Gwynedd
10%
Source: Local Government Data Unit ~ Wales
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Figure 20 Percentage of older people aged 65+ in residential care as of 31 March 2009 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5%
Monmouthshire
Powys
The Vale of Glamorgan
Cardiff
Pembrokeshire
Swansea
Flintshire
Bridgend
Torfaen
Newport
Carmarthenshire
Caerphilly
Merthyr Tydfil
Conwy
Ceredigion
Wrexham
Neath Port Talbot
Denbighshire
Isle of Anglesey
Blaenau Gwent
Rhondda Cynon Taf
Gwynedd
0.0%
Source: Local Government Data Unit ~ Wales
Figure 21 The rate of older people (aged 65 or over) whom the authority supports in care homes per 1,000 population at 31 March 35 30 25 2008-09
20
2009-10
15 10
Gwynedd
Rhondda Cynon Taf
Blaenau Gwent
Isle of Anglesey
Denbighshire
Neath Port Talbot
Wrexham
Ceredigion
Conwy
Merthyr Tydfil
Caerphilly
Carmarthenshire
Newport
Torfaen
Bridgend
Flintshire
Swansea
Pembrokeshire
Cardi
Vale of Glamorgan
Powys
0
Monmouthshire
5
Source: Local Government Data Unit ~ Wales
Blaenau Gwent County Borough Council’s performance provides an example of how over a three year period, the numbers of older people placed by Councils into residential care is declining faster than the overall decrease in numbers of older people in the population. Figure 22 shows that since 2008 the steady reduction of councils supported admissions continues across Wales whilst Blaenau Gwent starting from a high position has been able to accelerate its reduction in placements.
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Figure 22 Number of people aged 65 or over supported in care homes at 31st March 31 29
BlaenauGwent
Rate Per 1,000
27 25
Other Local Authorities
23
Wales
21 19 17 15
2007/08
2008/09
2009/10
B.G. (green) is Blaenau Gwent; OLA (in blue) is their comparator group and the Wales average is shown in red. Source: Local Government Data Unit ~ Wales
This accelerated reduction has been achieved through the following: • • • • • • • • • • •
• • • •
disinvestment in residential care and the closure of four of the five council run homes (Focus remaining home on EMI provision) a move towards 24 hours/7 days/365 days support. Services based on four main community areas services developed with other stakeholders including health and housing reinvestment of resources to achieve the strategy three year fee level agreement with providers Joint QA panel with health to agree funding and manage discharges Gwent Wide Integrated Equipment Store (GWICES) – partnership across Gwent reduction in community hospital beds new locality hospital development of first extra care housing scheme modernising in-house service to include 7 to 11, flexible working, focus on reablement/ complex care. External Home Care – long term partnership and block contracts for external home care, with investment in contract monitoring capacity. A split of 43-57% between in-house and external services has been achieved. introducing a brokerage role establishing a new in house dementia day service introducing Direct Payments (which have been historically very low) and assistive technology floating support for older people
In 2008 the Institute of Public Care (IPC) produced a research summary for the Department of Health’s Care Services Delivery Efficiency Team (CSED) of the main reasons for admission of older people to residential care. They identified the following seven conditions, which may not be the prime reason or the reasons stated, but were nevertheless the most common conditions that were present at the time of an admission: • • • • • • •
dementia incontinence urinary tract infections/ hydration strokes podiatry dental falls
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There are two important issues that arise from this list. First, all of the conditions are treatable or managed more effectively if identified and diagnosed early and second, they are conditions which do not always get treated as top priority within local health services. It therefore requires a concerted effort between the health boards and councils to ensure that the health care of older people with these conditions is addressed appropriately, with the strongly probable consequence of a reduction in admissions to residential care. Councils are encouraged to start a conversation with health boards as to how together they might examine the commissioning of services to reduce admissions, for example through developing early on set dementia clinics, creating community incontinence services, and jointly developing falls preventions services and foot care clinics etc. In addition growing evidence suggests that the biggest single factor that has been identified as having an impact on admissions to residential (and nursing) care is what happens for an older person during a hospital admission. Far too many older people are assessed as needing residential care whilst they are still ill (and possibly recovering) in a hospital bed. Wrexham County Borough Council has a policy that it will not admit anyone from a hospital to a residential care home (as a new admission).
In 2010 Cardiff and Vale University Health Board identified up to 200 older people who would be spending Christmas in a hospital ward when they could be at home with their families or living more independently in an appropriate setting. They also estimated that up to 40 older people were being admitted as emergencies to hospital across Cardiff and the Vale of Glamorgan every day, and that 25% of these cases could have been avoided if appropriate social care could have been provided for them. The Health Board recognised the importance of addressing blockages in organisational frameworks across health and local government, and getting both sectors to work together to identify and deliver person and/ or population-focused solutions. By doing this they achieved a significant reduction in the number of patients experiencing delayed discharges from hospital, as illustrated in Figure 23. Figure 23 Delayed Transferes of Care - Number of Patients Delayed 2,500 2,000 1,500 1,000 500 0 Number of Patients Delayed
2006/07 2,198
2007/08 1,684
2008/09 1,422
2009/10 1,142
Source: Cardiff and Vale University Health Board
Continued 4
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However, they also found that expenditure on Continuing Health Care over the same period grew correspondingly, as shown in Figure 24 below. Figure 24 CHC Expenditure £30,000,000
Expenditure
£25,000,000 £20,000,000 £15,000,000 £10,000,000 £5,000,000 £0 CHC Total Spend
CHC Older Adults
2006/07
£10,863,181 £2,242,523
2007/08
£14,159,902 £2,911,984
2008/09
£20,650,575 £3,762,377
2009/10
£26,841,501 £6,356,539
Source: Cardiff and Vale University Health Board
The experience in Cardiff and Vale shows how reducing bed days in hospital can give rise to new financial pressures elsewhere in the system. Addressing this will be a key challenge to councils and health boards in improving outcomes for service users and reducing the overall costs of care.
The data in Figures 25 and 26 shows that there are significant variations in the numbers of older people who were admitted from hospital directly into residential care across Wales (these numbers will include self-funders). Note the figures relate to the former local health board areas.
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0
LHB
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Powys LHB
Torfaen LHB
Blaenau Gwent LHB
Denbighshire LHB
Newport LHB
Merthyr Tydfil LHB
Carmarthenshire LHB
Vale of Glamorgan LHB
Flintshire LHB
Wrexham LHB
LHB
Powys LHB
Torfaen LHB
30
30
50
190
130 160
130
140
120
130
120
70
30
Blaenau Gwent LHB 0
Denbighshire LHB
Newport LHB
90 90
Merthyr Tydfil LHB 20 30
Carmarthenshire LHB 20
Vale of Glamorgan LHB
Flintshire LHB
Wrexham LHB 20
Bridgend LHB
Caerphilly LHB 20
Isle of Anglesey LHB 10
Rhondda Cynon Taf LHB 20
Cardi
60
60
270
120
150
400
50
360
500
480 170
NHS nursing/group/residential care home
Bridgend LHB
Caerphilly LHB
Isle of Anglesey LHB
Rhondda Cynon Taf LHB
Cardi
Conwy LHB
150
90
500
Conwy LHB
Swansea LHB
Neath Port Talbot LHB
Ceredigion LHB 0 50
110
300
Swansea LHB
30
Pembrokeshire LHB 20 50
Gwynedd LHB
250
200
Neath Port Talbot LHB
Ceredigion LHB
Pembrokeshire LHB
Gwynedd LHB
0 Monmouthshire LHB 20
100
Monmouthshire LHB
Percentage
Figure 25 Episodes ending between 01/01/2009 and 31/12/2009 by Welsh Local Health Boards to Council Areas 600 Non-NHS (not local auth) Res Care Home
400
Source: Statistical Directorate – Welsh Assembly Government
Figure 26 Discharge of Patients to Residential Care (as percentage of total discharges) 2009
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
Source: Statistical Directorate – Welsh Assembly Government
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A number of factors may be giving rise to these variations, including: •
•
•
the impact of local Community Hospitals - do they deliver more positive outcomes? (Some of the places which have higher admissions from acute hospitals significantly are in areas without a Community Hospital) a proportion of these admissions will be for short-term residential care. Do we know the outcomes of different services who offer short term care as part of an Intermediate Care service? What percentage of people are still admitted long-term and does this vary between homes? a proportion of these people will be self-funders where the professionals in the acute hospital will have worked with the patient and the family to support a residential care placement. Do these people get the advice of social care professionals on the alternatives that may be available for them to remain in their own homes? Across Wales significant numbers of people are referred to social services every year because they have run out of money, some of whom should never have been placed in residential care, with major cost implications for councils. Conwy County Borough Council reports more than 100 such cases a year
Looking at this from a whole systems perspective, the interests both of health and social care are served by avoiding admissions directly from hospital to social care. Best practice suggests that assessment of an older person’s long term care needs should not be made whilst that person is in hospital. A period of intermediate care, either in a community setting, community hospital or a residential care bed, is often the best solution, as long as the focus of the service provided is to support the older person’s recovery through a reablement approach. The evidence would suggest that a 20% decrease in admissions to nursing care and to residential care is possible from this approach. Cardiff and Vale University Health Board, for example, is working closely with both councils in its area to build intermediate care capacity whilst examining the procurement of residential and nursing care. Ceredigion County Council faces similar challenges. The council investigated the cases of 42 older people who were discharged from hospital and handled by the social work teams. This revealed the following breakdown of subsequent care: • • • • • •
19 admissions to residential/nursing care (45%) 3 died/moved away (7%) 10 living at home with hands on care (24%) 1 living at home supported by day centre (2%) 2 living at home with telecare/equipment/adaptation (5%) 7 living at home independently of any service (17%)
This compared with 89 people who were referred from hospital to the Discharge Service, resulting in 27 people being offered reablement, 9 people being offered telecare and 2 people being referred to the OT service. When the Council considered the total picture it came to the clear conclusion that too many people were going from hospital directly into residential care.
Councils across Wales are now beginning to analyse equivalent data to help them explore new ways of reducing these kinds of admissions into residential care.
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Pembrokeshire County Council is considering the establishment of a night time community based team that will offer cover for people in their own home equivalent to that which might otherwise be provided through residential care. The Council is preparing a business case for the investment of £300K investment for this which must pay for itself through a similar level of cost reductions in admissions to residential care. This would equate to a reduction of 12 places from a total of just over 480 older people currently in residential and nursing care. The Council is in fact looking to achieve a target of 10% reduction in that number.
Flintshire County Council has identified the need for greater investment in preventative and reablement services. In doing this we are seeking to reduce reliance of social service support, make better use of scarce resources and enable people and particularly older people to live as they would prefer – independently in the community. Flintshire Futures – a medium term strategy introduced by the Council will provide the basis for taking forward this change programme. Areas for further change will include a more focused approach on developing the personalisation agenda for young adults. The future social care market, use of voluntary organisations and intelligent communication also feature highly in the Council’s next steps. The Council recognises the need for: • •
• • • • • •
organisational transformation and cultural change in some areas. the need for a clear message to all staff that they should be looking to provide services which enable and empower older people and should not be using residential care except where all other options have been ruled out use of assistive technology such as ‘Just Checking’ to help monitor the risks that people are really under and put in place measures to mitigate those risks consolidating the existing reablement service to focus on people getting back on their feet after a crisis or a medical intervention developing a ‘Living Well with Dementia’ service to help people to live in the community for as long as possible developing accommodation and extra care housing which includes special dementia units within the schemes and new build premises for adults with learning disability. reviewing existing domiciliary care packages with a view to exploring reablement potential working in partnership with the independent sector to deliver outcome based support services
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4.9 Conclusions 1. There is no doubt that a good reablement service has to be the core of an effective and efficient older people’s care service and is most likely to provide the evidence that prevention can work. 2. Typically, a council which has an effective domiciliary care reablement service can expect to see a 10% reduction in demand for domiciliary care through a combination of measures which have been outlined in this section of the report. For example, Denbighshire County Council is currently reporting a 20% reduction in the number of people helped to live at home. Councils should be sure that they are monitoring the performance of their reablement teams to ensure that expected improvements in outcome and financial savings are achieved. 3. There is evidence that some teams are more effective than others – the opportunity offered through the cross-Wales working group on reablement facilitated by SSIA, should ensure that best practice is identified and replicated in other areas. 4. There is much evidence to suggest that the use of telecare products can make a difference in both enhancing the day to day living experience of older people, making them feel safe and helping them retain their independence as well as providing an emergency response service for older people who are at risk. More work needs to be done between councils to help develop a knowledge and evidence base as to how best to use these products to help older people retain independence. There is evidence that where successfully applied technology can also bring a reduction in costs of care both through reducing some admissions to residential care and using the products as a means of responding only in times of need rather than checking up on people where this may not be necessary. 5. Every council is aware of the challenges in this area and work continues to identify how they might further reduce the numbers of people who require residential care. It is encouraging to see that the figures for 2009-10 show a further reduction in a number of areas. 6. In summary, the key areas through which councils across Wales are seeking to reduce admissions include: • • • • • • •
having a stated policy that no one should be admitted to residential care for a new long term placement directly from a hospital bed improving Intermediate Care in partnership with health to include beds with a focus on reablement ensuring older people receive appropriate health interventions making better use of telecare to help people remain in their own homes, for example use of the ‘Just Checking’ system to support home living for older people with dementia providing better support for people to remain in their own home development of extra care housing as an alternative model to residential care considering the closure of council-run care home provision where there is plentiful supply of care - a move which will provide the greatest potential savings
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Section 5.
Future approaches to the delivery of care: Redesigning services, changing structures and reducing costs
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5. Future approaches to the delivery of care: Redesigning services, changing structures and reducing costs 5.1 Citizen centred support in Wales At the current time the Welsh Assembly Government has a clear policy stance not to follow the English model of personal budgets. However, some Welsh councils have looked at the model developed from the Resource Allocation System (RAS) that has become the currency in England and which converts a person’s assessed needs into an allocation of money that should meet that person’s needs. For example, the City and County of Swansea has begun to explore whether the RAS could be used (outside of personal budgets) to reassure managers that resources are being allocated fairly to people who have eligible needs. Wrexham County Borough Council has been exploring a similar approach. There is certainly evidence in most councils that the package of care a person receives may not be entirely associated with the needs that have been identified. For example, some adults with lower level learning disabilities receive more resources than people with higher care needs. This may equally apply to older people, where the decision of the social worker and their manager on a particular day may have more impact on the amount of care users receive than an objective assessment of need would suggest. A person presenting with similar needs early in the financial year may receive a more generous package of care than a person with similar needs who presents later in the year when budgets are overspending or being more carefully monitored to reach a satisfactory out-turn. In this context, the use of the RAS can at least help to ensure that fairness and equity underpin the setting up of packages of care.
5.1.1 Direct Payments The Welsh Assembly Government has strongly promoted the use of Direct Payments as a means of empowering users of services. Later in the report it is shown that people who are in receipt of a Direct Payment generally require less money to meet their needs than a person receiving a traditional package of care. A personal assistant engaged under a Direct Payment arrangement will typically be employed by a service user at around £10 an hour whilst a council would pay a domiciliary care agency almost £15 an hour and their in-house services £20 an hour for the same service. (These rates appear to vary between councils but unit costs in Wales can be unreliable as explained in the next section of the report). Some councils in England commission organisations to support people receiving Direct Payments so that they can offer independent advice, run payroll services, arrange suitable insurance cover (employers and third party liability) and offer human resources advice and support to the user. These same organisations are now recruiting personal assistants in advance of individuals needing them so that when people come forward indicating they might consider a Direct Payment arrangement, there is a pool of willing and able people with appropriate checks and references from which the service user can make a choice. In Wales, the amount a council is prepared to offer a Direct Payment recipient as a sum of money varies significantly (see Figure 27) but it still is only a significant minority of service users who are taking this option.
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Figure 27 Council
Amount offered per hour as a Direct Payment
Anglesey
Number of recipients 2009/10
£10.00
20
£8.92
45
Bridgend
£11.25
119
Caerphilly
£6.58
88
Cardiff
£9.07
186
Carmarthenshire
£9.75
236
Ceredigion
£9.79
132
Conwy
£10.10
102
Denbighshire
£10.20
102
Flintshire
£9.71
146
Gwynedd
£11.35
112
Merthyr Tydfil
£10.00
48
Monmouthshire
£7.66
72
Neath Port Talbot
£9.56
151
Newport
£7.49
106
Pembrokeshire
£10.00
252
Powys
£10.80
141
Rhonda Cynon Taf
£9.75
341
Swansea
£8.34
219
Torfaen
£8.55
110
Vale of Glamorgan
£10.03
104
Wrexham
£10.00
87
Blaenau Gwent
Source: All Wales Direct Payment Forum and Welsh Assembly Government – Direct Payment Survey 2009/10
Ceredigion County Council and Conwy County Borough Council are among those councils actively seeking to reduce costs by increasing take up of Direct Payments as an effective alternative to remodelling the current domiciliary care market.
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Ceredigion County Council has made the following calculations: AVERAGE WEEKLY COSTS OF DOMICILIARY CARE PACKAGES 2009/10 TOTAL SPEND Total Spend £ 18+
3,195,051
Total Clients
Average Cost/Week £
Average Hourly cost £
369
167
23.92
Average Hours/week 6.96
A 20% shift from home care to Direct Payments based on an average of 7hrs/wk could generate £154k saving per annum average weekly costs of direct payments in lieu of domiciliary care 2009/10 Total Spend £ 18+
590,934
Total Clients
Average Cost/Week £
Average Hourly cost £
53
214
9.79
Average Hours/week 21.90
A 20% reduction in hours linked to functional re-assessments could generate £118k saving per annum
Conwy County Borough Council’s savings programme mentioned earlier in the report includes a core programme offering all new recipients of services the preferred option of a Direct Payment. This is based on two simple propositions: This approach offers much more flexibility in services to everyone, and it can be delivered at a lower cost. The fact that a Direct Payment costs £10.10 per user in comparison with an hourly rate of £22 for in-house services provides a compelling argument for this policy direction. Even with block contracts with the Domiciliary Care market, the Council is paying around £13 per hour. To achieve the desired change, the Council has introduced a training programme for all assessment and care management staff along with a target of a minimum of one new Direct Payment recipient a month for each member of staff. To support the policy the Council has recruited 160 people as personal assistants through their support agency, working closely with local job centres in promoting this as a positive employment opportunity. Users selecting a Direct Payment will have the opportunity to choose a personal assistant from this pool, which is shared with Denbighshire County Council. The expectation is for development over time of a pan-North Wales arrangement. So far 97% of new people taking up a Direct Payment have chosen to take the option of employing their own staff – either using people they already know in their community or through the pool of personal assistants. The Council has increased the take up of Direct Payments by over 150 new customers last year and are intent on doubling this in 2011-12. Savings targets of £700k in 2011-12, £1million in 2012-13 and £1.5 million in 2013-14 have been set, requiring a massive shift of all new users onto Direct Payments. In parallel the inhouse workforce will be refocused on reablement and dementia care service. The Council is anticipating the Welsh Assembly Government to adopt the English ruling that people who lack capacity can receive a Direct Payment through a third party, and the evolution of personal health budgets in Wales will further increase demand for this service. Other future efficiencies include that they will continue to pay clients who receive Direct Payments the money net of their contributions (a maximum of £50), whereas currently providers are paid the full cost and the contributions collected separately from clients.
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There is strong evidence of scope to make further savings from the wider use of Direct Payments although research from elsewhere is not as optimistic as assumptions of the Welsh councils cited on the level to be achieved. There are some specific challenges in taking this approach to transforming services. There are the critical issues of the supply, training and support of personal assistants as well as the risks associated with moving from one care model to another. Developing an unregulated market may also present some safeguarding risks, although councils in Wales are aware of this.
5.2 Models of procurement and commissioning and unit costs Another challenge facing councils when seeking opportunities for improvement and collaboration is gaining a common understanding of the current costs of the services they are either providing or procuring. Many councils do not know the real costs of their existing services, although a number of councils have made an attempt to establish what they are. The South East Wales Improvement Collaborative (SEWIC) has laid out a potential programme of work where the 10 councils in the region will work together on procurement. They are considering the creation of a regional procurement hub which will focus on the following areas: • • • • • •
review of high cost adult care packages (residential care) future procurement of adult care packages an extension of the ‘shared lives’ schemes – formerly known as adult placements the commissioning of supported and extra care housing the procurement of assistive technology the commissioning of fostering and adoption services
The councils in South East Wales are working together to develop a business case to take this work forward. Early scoping of the programme indicates substantial efficiency gains for participating authorities. There is still much work to do to establish the detailed rules of engagement but there is a strong desire amongst councils to move forward together in this area. Similar approaches are being considered and commissioned between councils in the other two regions of Mid and West and North Wales including the possibility of procuring domiciliary care as well as some aspects of assistive technology including call centres and response services. There is strong evidence of a developing culture of collaboration whereby councils increasingly share information and explore opportunities for working together to achieve more effective services at lower costs. Wrexham County Borough Council has looked to re-tender its domiciliary care contract. The council has engaged with providers in a positive way and in return received high levels of interest in the bidding process. The Council has recognised the different costs for providers between urban and rural settings and agreed to pay a premium for providers who will include a guarantee of reaching their more rural areas within the contract. Significantly, the council expects to reduce current costs of domiciliary care through this process. Wrexham can demonstrate substantial savings in moving from in-house services to contracted services with the independent sector. This is equivalent to £1 million a year even when taking into account anticipating increases in contracting and brokering costs.
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This is a similar saving that Cardiff County Council expects to achieve through a process of re-tendering their domiciliary care service by focusing on how providers can reduce their own costs. This has involved allowing providers to bid for area based contracts to ease the issues of travel time and make rotas easier to manage. Reports from some providers indicate that the lower prices may impact on their future business in the City and so caution needs to be exercised.
The rate of councils outsourcing to the independent sector varies markedly. Notably Wrexham County Borough Council (the above) has now contracted out almost all of its services to the independent sector (around 85% of domiciliary care and almost all of its residential care homes). In Wrexham and Carmarthenshire where most progress has been made in preparing medium term financial strategies for the future, the way in which local councillors have led this process is significant. In both cases there has been full engagement with lead members, with a strong scrutiny and analytical process supporting consideration of the options open to the cabinet member. Wrexham indicates that the role of the councillors in both keeping the public informed about what changes were going to take place and explaining why they had to take place seemed to be making the transition much easier. Carmarthenshire County Council has developed a set of unit costs which appear robust and available for benchmarking with other councils. These are set out below. Service Area Domiciliary Care - Independent Sector
£ 14.74 per hour (includes travelling)
Domiciliary Care – In-House
21.91 per hour
Through the night service
22.01 per hour
Enablement Services
25.49 per hour
Direct Payments
9.75 per hour
Day Care Centres Day Clubs
31 - 46 per day 27 - 52 per day
Residential Care – Council weekly operating costs Residential Care – (EMI) – Council
521 - 648 per week 694.51 per week
Residential Care – Independent Sector
380 per week
Residential Care – Independent Sector (EMI)
404 per week
Spend per head of population on adaptations
13
These figures show yet again the significantly higher costs on in-house run services compared to similar quality services run by the independent sector. This seems to be one of the single biggest areas of concern for Welsh councils. Taking an average sized council with around £25 million for older people’s services and more than in-house residential homes there could be savings in the area of £1 million through externalisation. Typically an in-house home with around 30 beds is costing the council £650k (controllable costs) or £758k (inclusive of noncontrollable costs). Continued 4 58 www.ssiacymru.org.uk/olderpeople
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To buy the equivalent number of places in the independent sector would cost about £600,000. The choice that many members may face is either to take the action to reduce the spend or to shut other services so that the more expensive homes can stay open. Almost every Welsh council is facing this challenge.
Benchmarking clubs can be helpful in assisting councils in working together to look at performance and cost differences. This table reflects collaborative work undertaken between the six North Wales councils to compare the price they were paying for residential care in 2009. Conwy £
Denbighshire £
Flintshire £
Wrexham £
Isle of Anglesey £
Gwynedd £
Residential Minimum
342.00
332.00
407.81
334.09
375.00
345.94
Residential Maximum
437.00
415.58
433.43
426.20
411.00
397.67
Nursing
557.90
536.15
553.99
546.76
549.90
540.49
EMI Residential
437.00
427.72
469.73
465.12
445.00
397.67
EMI Nursing
597.90
561.53
590.29
585.68
594.90
572.97
In making comparisons, councils need to be aware of local circumstances which impact on price – for example Wrexham’s proximity to Cheshire may add to the price of residential care but it also is likely to assist the Council when it comes to tendering for domiciliary care. It is however noticeable that Denbighshire either has the lowest or the second lowest costs for all sectors - relying mostly on the independent sector market (where there is plenty of supply). In Denbighshire and Conwy over 30% of spend in the residential care market comes from selffunders. This leaves a challenge for the councils should these people run out of money. The Review of North Wales Domiciliary Care Expenditure, facilitated by SSIA, has raised a number of interesting questions. The review was explored the real costs of providing or procuring care but it found a number of key issues that needed to be addressed before coming to conclusions. The cost of the in-house services could only be determined after consideration of the following points: • • • • • •
has the council implemented single status? has the council included its contribution to pensions? has the cost of delivering to a rural community been considered? is there consistency in looking at the range of costs incurred by the council in running the service ( such as HR/finance/IT costs)? what impact does running the in-house reablement service have on costs? the larger the size of the in-house services, the lower the possibility of spreading and reducing the costs Continued 4
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In the same way when examining the comparison with the costs paid to external providers the following issues needed consideration: •
• • • • • • • •
were the costs reported on an hourly or a half hourly rate or partial? (some councils have contracts where providers accommodate partial hours within their costs whilst others charge a premium for partial hours worked) what are the costs of contract monitoring? what are the costs of contract compliance (including use of electronic monitoring)? what are the costs of financial controls? does the external service take on a full range of work or does the in-house service retain certain particular duties? what are the costs of brokering the service? are providers operating in a competitive or a monopolistic environment? are there any specific conditions that were placed in the contract? have any costs arisen as a result of externalising an in-house service – e.g. TUPE regulations? The adjusted internal costs include additional sums for pensions contributions and the implementation of single status
The work in North Wales has yet to be concluded with each council reviewing its figures and learning more about the hidden costs it might not have considered. The final conclusion to this piece of work is likely to demonstrate that there are still considerable savings to be made from putting domiciliary care services out for competitive tendering. The overall finding in North Wales is that savings at this level are available to most Councils and those with the highest proportion of current in-house services may have most to gain if the changes are managed in an incremental way.
5.3 Redesigning services: Towards a new model of social care Several councils are looking at process-engineering as a possible means of improving effectiveness of services and reducing costs. A number are applying lean methodology to this work. Examples of lean thinking in Wales include, in addition to the work by Neath Port Talbot County Borough Council on disabled facilities grants: •
Wrexham County Borough Council is particularly interested in the balance of professional staff and skilled vocationally-qualified staff involved in delivering services for all client groups including older people. The Council has made changes across professionally qualified workers, support workers, care managers and administrative staff leading to increased productivity at lower cost.
•
Pembrokeshire County Council has reviewed its services related to the role of the social care case manager in the arrangements of the discharges of patients from hospital. (Pembrokeshire, which has a single management structure for health and social care, has the lowest rates of hospital discharge in Wales).
The Council has also started to offer social services transport to the local hospitals to help with patient journeys. It sells its service to the hospital trusts when the vehicles are not being used for social services transport (usually known as ‘down – time’), usually in the middle of the day when the ambulance service is also stretched. In October 2010 the Council facilitated the discharge of 90 people from hospital earning £2000 towards the cost of the transport service. Continued 4
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The Council in partnership with the health board is also looking at alternatives to institutional care through the commissioning of a third extra care facility and delivering extra care in existing sheltered accommodation; increasing the use of assistive technology; live in carers, adult placement and reablement.
One of the key questions when looking at process in older people’s services relates to the point at which assessments for eligibility for care and support services takes place within the system. Specifically do older people need to be assessed before they are admitted into the reablement service? There are divided opinions in relation to assessment. Some suggest that an assessment by an occupational therapist or a physiotherapist is necessary before someone is offered a programme of support whilst others argue that for many straightforward conditions it is clear what a person requires and only more complex situations need to be referred to a specialist therapist. What many agree though is that a social work assessment is not necessary before a person starts a programme of reablement and that this should only be offered to those people who have completed such a programme and are likely to require on-going care and support. If a council is reducing the number of people requiring on-going support by around 50%, then it follows that they ought to be able to reduce the numbers of assessments by a similar amount.
A number of councils in Wales considering a service model along the lines of that set out in Figure 28. This model presents a new care system which proposes: •
•
•
starts with a focus on universal services, essentially providing appropriate information and advice and other services that promote and sustain healthy, independent lifestyles in the community, including health care, benefits information and wellbeing services such as exercise programmes - enabling people to remain outside the formal social care system includes a second phase prior to entry to the formal social care system ensuring people are provided with one or more of the following: intermediate care, reablement, housing adaptations, equipment and assisted technology then involves assessment of eligibility for state funded care. This is the point at which people will be offered either Direct Payments or the services that will help meet their personal care needs. Following completion of the above, and possible reduction in need, there will be progression onto formal social care packages
The final part of the system is the effective commissioning councils and all partners of appropriate services required at the second and third phases. This model was discussed with many councils during the summits and was generally found to be a helpful way of describing a new social care system. Denbighshire County Council is one which is looking to develop their services in a way which closly follows the suggested model.
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Figure 28 Transformed Care System Universal Services
Targeted Interventions
Information and Advice – including self-funders
Equipment and Aids to daily living and Telecare Products
Health Services
➜
Supported Housing
Supply
Eligibility Criteria applied
Commissioning the right range of services
Assessments and Care Management
Intermediate Care and Reablement
Well-being and community offersocial capacity
Care and Support
Macro and Micro procurement
Direct Payments
Contracts and Spot Purchasing
(Advocacy and Support)
➜
➜
DFGs /Adaptations Care and Repair
Direct Payments and supply of Personal Assistants
Falls clinics
Another example is Merthyr Tydfil County Borough Council, which is planning the following approach to care in the future: Figure 29 Merthyr Tydfil County Borough Council new model of care for older people
Current Service Model
Duty
Intake Team Social Workers CCW’s UAP Adult Protection
Initial Response 6 Week Service and Review
Care Mgmt Team
Annual Review
Social Care Services
Res / Nursing Home Care MOW’s Day Services
New Service Model Universal
Duty Advice signposting
Reablement Service Initial Response COT’s Telecare Direct Payments Visual / Hearing Impairment Support Workers / CCW’s Social Regeneration Carers
Targeted Professional Support UAP / CPA
6 week Review
No Service
Family Support Service
Commissioned Services based on outcomes
Social Regen
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Specialist LA
Third Sector
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A common feature of the emerging models is reablement. The most successful models in terms of putting people through reablement and reducing the number of people who progress further through the system are those that operate ‘intake’ systems in which all new cases being assessed for social care support are offered reablement. •
Rhondda Cynon Taf County Borough Council has also introduced electronic call monitoring to help them manage their domiciliary care costs. The Council believes that the use of the call monitoring has the following benefits:
• • • • • •
lone worker protection ensure that service users get the care that has been commissioned improves the productivity of al staff secures efficiencies in business process transactions improves the quality of the services offers better intelligence for future commissioning and a better understanding of the requirements of customers.
The success of the implementation is demonstrated by fewer complaints; a reduction in the need to use the in-house service (freed up for reablement); the automated pay roll and travel expenses; automated invoicing including for debt recovery; and better management information.
5.4 Conclusions 1. Councils must ensure that the process of access to care and support underpins a philosophy that helps older people remain independent where possible. Appropriate use of universal services, Intermediate Care and reablement are all key 2. Councils should continue to strive to work together to establish a common understanding of costs. They should continue to support benchmarking clubs to facilitate this 3. In the longer term councils should consider their local circumstances and agree when it might be appropriate to collaborate with neighbours in developing common approaches to commissioning and procurement 4. Councils must encourage imaginative use of the resources that are available to them and look to reduce process costs at every opportunity 5. In all the examples included in this section, councils are seeking to find ways of using fewer resources more effectively. This approach will need to continue as councils look to ensure that they are making best use of the resources available to them in the future 6. The methodology adopted by those that use lean process thinking has been found to be helpful
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Section 6.
Final conclusions
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6. Final conclusions Efficiency savings and improved outcomes for service users are not necessarily conflicting goals. Many of the new service arrangements already introduced by councils in Wales and the recommended model set out in this report have the potential, over time, to deliver both. Overall the savings and improved outcomes councils need to achieve have to be delivered in two key ways: •
Firstly, councils need to have a clear strategy setting out their direction and goals which focus on reducing demand and costs. They need to adopt a project management approach to delivering the strategy, with clear milestones and robust monitoring arrangements
•
Secondly, savings can be realised by adopting approaches which provide good information and advice and promote community based solutions alongside robust reablement and effective health interventions, reducing the demand for residential and domiciliary care
The report has identified a range of ways in which Welsh councils are already addressing these challenges. In taking this forward councils should consider the following fundamental questions: 1. Can demand for social care be further reduced by diverting people to communitybased solutions? 2. How can people best be helped to recover and regain independence after a personal crisis or medical intervention? 3. How can people best be supported in maintaining control over decisions affecting their lives and influencing the nature of services they receive? 4. How can housing based solutions be developed to help reduce the need for institutional care? 5. How can demand for residential care be further reduced through working with health to address successfully the conditions that might trigger a need for residential care and by improving the care pathway from hospital? 6. How can new technologies be delivered which reduce the need for intensive care packages or supplement a less intensive care package? 7. How can systems and processes be improved to reduce bureaucracy and keep down costs? 8. Are opportunities for collaboration with other councils, health and the third sector being optimised as a means of achieving more efficient and effective services? 9. How can existing performance frameworks be improved to measure impact of services on users in terms of clear outcomes?
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Crucially: • •
Councils must ensure that models of care are underpinned by a philosophy of helping older people remain independent where possible Councils must encourage imaginative use of resources that are available to them and look to reduce process costs at every opportunity
The SSIA is committed to working with national and regional partners in supporting councils in remodelling elements of their services for older people in response to the conclusions of their local summits and the findings of this report. Learning from this work will be rolled out across Wales to support the radical changes in the way in which services are delivered as recommended throughout the report.
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Appendices
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Appendix 1 The author with help from Jeremy Cooper from iMPOWER has produced the following list of areas in which councils across the UK have looked to make savings in adult social care. Not all of these approaches are recommended. They are listed in the order in which the highest ones will produce the greatest returns (on current available evidence) but not necessarily the fastest way to make savings. •
Reablement/ Intermediate Care – as cited in the report
•
Reduce use of residential care – as cited in the report
•
Direct Payments (PAs) – as cited in the report
•
Citizen contributions – as cited in the report but not available to Welsh Councils
•
Telecare (Telehealth) and Equipment – as cited in the report
•
Housing with care models – as cited in the report
•
Housing Support (housing advice, care and repair, DFGs)
•
Employment and Training - for younger adults as alternatives to day care employment programmes
•
Work with Health – (The Health Services Management Centre at the University of
•
Birmingham – Policy Paper 8) – reducing costs through partnership working with some examples in the report. One of the significant ways in which health can help produce savings for social care is if they improve the outcomes for older and disabled people from their interventions. (This is cited in the report). The examples of tackling dementia care, reducing levels of incontinence, reducing falls, podiatry services, dental services can all contribute to decreasing demand for social care.
•
Lean process –some examples cited in this report
•
Better commissioning – some examples cited in this report
•
Reduce reliance on relatively expensive in-house services
•
Mobile Working – using technology/ paperless offices and hot desking
•
Reviews – using the process of reviews to reduce the cost of care packages when people need less care
•
Procurement (collaborative) – some examples cited in this report
•
Continuing Health Care – no saving to the wider system – usually health and social care looking to make ‘savings’ at each other’s expense – better solutions to this issue are given in this report.
•
Targeted prevention – falls - The Health Services Management Centre at the University of Birmingham – Policy Paper 8) – example from Anglesey cited in report
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•
Stricter eligibility – some evidence that it does not quite produce the longer term savings that might be apparent from the simple numbers as people quickly become eligible
•
Management and Team structures – deleting posts and making management structures slimmer
•
Customer contact – some examples in this report
•
Sickness absence – better management of the relatively high levels of sickness that are found in parts of social care within the public sector
•
Electronic Care Records – managing domiciliary care as shown in Rhonda Cynon Taf in this report
•
Productivity Management – looking to increase productive time of staff either through work load management or measurement of outcomes/outputs.
•
Skills Mix – some examples in this report of making better use of higher paid professional staff
•
Screening - The Health Services Management Centre at the University of Birmingham – Policy Paper 8)
•
Changing culture – an issue highlighted in this report on reducing the dependency culture within social care
•
Administration/ IT solutions – looking for streamlined processes as with lean thinking
•
Personalisation – (RAS and PBs). The Health Services Management Centre at the University of Birmingham – Policy Paper 8
•
Reshaping existing posts – employing people at lower grades – particularly learning disabled adults by pulling together a range of simple tasks carried out by a number of people in their job descriptions can create a new post and reduce other posts
•
Children’s Transitions – better planning for the future
•
Patient self-management – ensuring that people take some responsibility for managing their own health and care.
•
Volunteering – using volunteers to supplement the work of paid staff or replacing activities that were once funded by paid staff
•
Big Society – using social capacity within communities
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Appendix 2 Ceredigion County Council: Assessing the impact of new charging arrangements Continued from Section 2.2, Page 17 When considering the re-modelling of services from an existing residential setting to a domiciliary setting (including extra care), the impact of income foregone arising from the different charging regimes that apply should not be under-estimated. The current extent of this impact will be influenced by the proportion of service users assessed as paying full-cost under CRAG (Charging Arrangements for Residential Care) and the localised Fairer Charging policies that apply. From April 2011, the impact will be further compounded with the introduction of the Social Care Charges (Wales) Measure 2010 - First Steps Improvement Packages where the maximum charge for services subject to a Fairer Charging financial assessment will be capped at £50 per week. The following illustration demonstrates the income differential that can apply to residential versus domiciliary care service models: In a scenario where a resident pays full cost for their residential placement, a shift to an extra care or care at home setting could result in an additional net cost of £189 per week or £9,828 per annum. In a scenario where a resident pays a minimum contribution towards the cost of their residential placement, then a shift to a care at home or extra care setting could result in a net cost reduction of £47 a week or £2,444 per annum. GROSS/NET EXPENDITURE ILLUSTRATIONS
£
Variance £
Residential Care - standard charge 416 Home Care, say £23.92x10hrs
239
Residential Care - ‘full coster’
-416 2011/12 Maximum Charge -50
SSD Net Expenditure
0
£
SSD Net Expenditure
Residential Care - standard charge 416 Home Care, say £23.92x10hrs
£
189
189
£
£
239
Residential Care - minimum contribution
-130 Nil Contribution
0
SSD Net Expenditure
286 SSD Net Expenditure
239
-47
The impact of these incremental cost/saving differentials will be wholly dependent on the relative wealth of the service user base affected by the re-modelling of services and the ratio of ‘full-costers’ to those paying minimum contribution. This will clearly vary from setting to setting and can, from a purely financial perspective, undermine the business case for service reconfiguration.
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Carmarthenshire County Council: Three year budget strategy Continued from Section 3.1, Page 19 The Council has laid down eight key principles for change: • clear strategic direction • end the dependency culture • build new models of service • reduce reliance on residential care • create a mixed market of provision • build strong relationships and work closely with the independent sector • work in partnership with health services • build community capacity to create well-being for citizens The Council has set the following objectives to support the older people’s budget strategy which could be adopted by all councils in Wales. These capture the essence of the messages from this report. Councils should be creating services that: • enable older people to achieve independence through adopting an approach which focuses through enablement (sometimes called reablement) toward positive outcomes • implement user centred care assessments and focus on decommissioning obsolete services and promote new models of working • implement clear and well communicated management standards based on comprehensive quality assurance framework • build closer alignment with health creating integrated services with the NHS where appropriate • improve safeguarding services • work within the required legislation and policy framework from the Welsh Assembly Government • manage resources effectively within the current financial constraints The Council is developing a three year budget strategy which aims to deliver £8.5 million of efficiency savings over a three year period. This is one of the most ambitious of the current plans for a Welsh council. In addition the Council has developed an Accommodation Strategy for Older People which: • maximises the number of residential care beds in the independent sector • rationalises the use of Council care home beds with the option of using some of the beds (in a specialist home) with health for Intermediate Care to support people coming out of hospital and avoid an unnecessary admission to residential care • maximises the option to provide better respite facilities and convalescence (as above) • improves the use of sheltered housing accommodation to develop extra care provision from within the current housing stock which will both reduce costs and reduce the demand for expensive residential care The Council’s Domiciliary Care Strategy for Older People provides for: • a domiciliary based enablement (reablement) service offering early intervention before a social work assessment and focused on older people regaining their independence • an out-of-hours service which works with Health to establish a way of avoiding unnecessary hospital admissions and which focuses on keeping people out of institutional care • a broker system to create more efficient procurement of services in the community • the commissioning of services through a new framework agreement with the
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independent sector that will deliver improved quality at a lower cost A strategy for community based support supports the above by: • focusing on how eligible older people will get support for day care programmes • recommending that all luncheon clubs should be run by the third sector including local communities (not by the Council) This will deliver a 15% saving. The overall targets for savings for older people’s services are: Council Residential Care - £970,000 (13% reduction) Independent Sector Placements - £1,000,000 (19% reduction) Community Services - £400,000 (11% reduction) Home Care – £1,581,000 (15%) Framework Contract-£431,000 Enablement -£750,000 In-House Costs -£400,000 Staffing reductions - £222,000 Supplies and Services - £148,000 Total - £4,321,000 – approximately 15% reduction (over 3 years)
Conwy County Borough Council: Project management approach Continued from Section 3.1, Page 19 Conwy has adopted a Prince 2 project management approach for delivering its savings targets whilst transforming services. It has set itself a 3% efficiency savings target over the next 3 years which might have to increase now the details of the Council’s settlement are clear. The Council has adopted a medium term financial strategy which has clear milestones for savings from specific pieces of work that need to be delivered within the three year time frame. The basis of their programme is a move away from residential care and the promotion of Direct Payments as the most cost effective way of delivering efficient services. The Council has embarked on an ambitious modernisation programme to reduce the number of residential homes to one specialising in dementia and developing two extra care housing schemes with two others planned. One facility will pilot two respite apartments in partnership with the Health Board. The Council also has a programme in place to roll out reablement across the area. It has completed a full review of the grants given to the voluntary sector as reported elsewhere and is examining high cost packages of care, including procurement for adults with learning difficulties in the residential sector, as part of the North Wales Collaborative project. Conwy’s approach is impressive as it looks to all aspects of the system including how to reduce admissions to residential care, and considers the nature of the community support available to older people to help keep them outside the care system. It is noticeable that each of the programmes of change in the Council is led by a senior officer and elected members are included in the project boards that oversee the changes. Officers from Conwy report that this has helped the smooth running of the transformation programme considerably, even when difficult decisions have to be faced.
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Isle of Anglesey County Council: Commissioning strategy Continued from Section 3.1, Page 19 The County Council has started to develop a clear commissioning strategy based on a set of principles similar to those set by other councils: • • • • •
maintain and promote independence and reablement put people at the centre of everything we do, so that we actively support choice and enable people to have control over their own lives integrate services with health partners and other partners remove the barriers that older people face in their daily lives that prevent them from living the lives they choose improve access to right support so older people can maximise independence.
This provides the simple triangle of care with which most people involved in social care are now quite familiar. A Whole System of Support
The Council’s stated intentions are: • • • •
commissioning services that ensure more people achieve their full potential for recovery following illness or injury and maximise their independence commissioning good quality and flexible care services to support people who require intensive support and care in the community developing a whole system approach to ensure support can be brought together in a way that best matches the needs of each individual influencing the development of preventative service options.
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Denbighshire County Council: Medium term financial strategy Continued from Section 3.1, Page 19 Denbighshire’s strategy aims to achieve 6.7% savings in adult social care and business support services over the next four years as part of a corporate approach to deliver savings across the Council. This equates to a saving of £2.1 million from its budget. The Council has developed a strategy with the following features in place to reduce demand: • • • • • • • • • • • • •
use of extra care housing (as an alternative to residential care) Intermediate Care services provided jointly with Health reablement based on an intake model telecare occupational therapy support and provision of equipment adaptations low level preventative work involving the third sector increasing services and support to carers direct payments citizen directed support dementia care project workers social workers working in outcome focused ways housing support schemes
Bridgend County Borough Council: Commissioning strategy for adult social care Continued from Section 3.1, Page 19 Bridgend’s commissioning strategy has been written in a very clear style and includes a range of approaches to modernising services to make them more effective in the future. The strategy is based on a principle of reablement, developing services which provide individuals who are not familiar with the care system with resources and support to navigate their way. It is based on a stated vision: ‘to support vulnerable adults to live independently in their communities for as long as possible promoting choice, empowerment, dignity and respect’. To deliver the vision the Council is committed to remodelling social care, developing integrated services with health and improving transition arrangements for young people. The Council’s strategy (including older people’s services) is based on the following principles: • • • • • •
people are empowered to take greater responsibility and control for their own support arrangements with reduced dependence on direct support arrangements people receive appropriate support for assessed personal and social care needs to minimise risk to independence, based on enabling, self-determined approaches people are enabled to live as independently as possible within their own communities, and are given opportunities to become valued members of local communities support is available to those experiencing a sudden, serious or acute health event as an alternative to being admitted to hospital/ residential or nursing care people with complex or challenging needs which cannot be met in their own homes to live in an appropriate environment where care and support is flexible and not restrictive carers have an enhanced quality of life and both continue performing their caring role and participate fully in the community
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• •
young People with complex needs are able to achieve their potential by being supported through adolescence into adulthood to choose and access the support necessary people are motivated to develop work related skills and personal competencies and are prepared for open employment with appropriate support
Powys County Council: Change management Continued from Section 3.1, Page 19 Powys has adopted a set of programmes to help manage change in older people’s services. These focus on: • • • • • • •
access to services (Information and Advice) reconfiguration of care management people receiving less than six hours care a week people receiving 20 hours care plus stimulating communities to help find local solutions development and provision of reablement services across the County development of a prevention strategy
The changes that councils need to bring about to deliver these new approaches to social care and to make the savings require good project management skills. Currently few councils appear to be investing in those people who will ensure that: projects are identified, leadership for each project is in place, targets and measures are set, milestones are laid down and clear savings figures are monitored against the quarterly budget out turns.
Torfaen County Borough Council: User care Continued from Section 3.1, Page 19 Torfaen has taken a holistic approach starting with a customer care centre that receives all referrals for older people. Here there is a dedicated duty officer within the Older Person’s Service and a clear multi-agency pathway for alternative access arrangements for hospital patients and people in receipt of Intermediate Care services. The Council is developing further enhancements including: a qualified social worker and occupational therapist in customer care; self-assessment/online tools for occupational therapists; locality implementation group for the Gwent Frailty Project; and reviewing/re-training care managers in respect of eligibility criteria and unified assessment. Partnership working has been established within the Assessment and Care Management Service to encourage cross-agency understanding between health and social care. The Intermediate Care Team and partners are being used to develop reablement programmes aimed at reducing care packages. Every effort is made where appropriate to prevent hospital admission or to ensure people are discharged from hospital in a timely manner. The council is also developing: • • •
a one stop older person’s service for assessment and care management screening for all service users placed in nursing homes at review by the RGN (Registered General Nurse) or RMN (Registered Mental Health Nurse) within the older person’s team self-assessment/online tools for OT to reduce waiting lists – timescale for implementation September 2011
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The following services are already in place: • • • • • • • • • • • •
intake service and dementia service block domiciliary care, residential and EMI contracts intensive support service to provide 24 hour care in the community as well as night time service a brokerage team used by all care management teams when commissioning new services community meal service, telecare service (assessment and implementation) and a falls service step up/down beds in residential care and sheltered housing extra care facility at Tŷ George Lansbury day activity arrangements have been reviewed assessments for simple equipment now being undertaken by other social care staff rather than OTs. older person’s service use of short term intervention independent living broker ensuring the promotion and appropriate use of Direct Payments outcome based commissioning
With the support of Torfaen County Borough Council’s Social Care and Housing Department, a local registered social landlord has reconfigured the provision of housing for older people, extending support to include older people in general needs housing and owner occupier properties. Finally, the council is also developing: • • • •
integrated care pathways to and from core services supporting the Gwent Frailty Project increased capacity for signposting to non-statutory support fast track or simpler referral routes for minor adaptations and enhancement of the contract with Care & Repair ways of maximising the use of GWICES (joint Gwent equipment service)
Cardiff County Council: Service remodelling Continued from Section 3.1, Page 19 Cardiff achieves one of the better balanced profiles between spend on domiciliary care and on residential care in Wales and reports that the following actions continue to sustain this direction: • • • • • • • • •
remodelling of external domiciliary care (leading to a saving of £1 million) enhanced dementia project end to end review of care management process built in low level approaches across contact functions joint working on transitional care joint work with the NHS on intermediate care approaches (CELT) increased use of telecare with 1000 users across the City brokerage across domiciliary care working on shared teams and boundaries with the Cardiff and Vale University Health Board
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The number of care hours being delivered by the independent sector continues to grow in Cardiff as this is the only way the Council can afford the increased level of demand in the City for domiciliary care. The Council is now focusing on its in-house reablement service to see what impact this can have on reducing future demand for services. The positive impact of this approach is a sustained effort to support older people in their own homes as an alternative to residential care. The Council currently supports 84% of their older people with eligible care needs in the community. In Cardiff and the Vale of Glamorgan there is a growing recognition of the interdependence between health and social care. Both Councils are undertaking a number of projects with the Cardiff and Vale University Health Board. These projects include integrated approaches to hospital discharge and joint working in mental health and learning disabilities. A key project related to the balance of care for older people is the Securing Long Term Care Project. The project initiation document identifies the following aims for the joint work: • • • • • •
collate information regarding current long term care placements for Older People. understand the current methodologies for setting care home fees across the three agencies understand the current demand for care home places in Cardiff and the Vale of Glamorgan map the future demand for care home places in Cardiff and the Vale of Glamorgan review the contacting arrangements with the independent sector across the three organisations ensure there is no competition for beds between local government and Health
In the longer-term, the focus will be to: • •
develop block contracts for care home placements where appropriate develop capacity within the care home sector to meet particular needs, especially elderly people with mental ill health (EMI)
The project will consider: • • • •
the demographic pressures facing health and social care services the availability of care beds for elderly people, at an appropriate cost and quality the method of procuring care home placements across Cardiff and the Vale of Glamorgan the differing care home market in both areas
A key outcome of this work will be a framework for the management of the care home sector across Cardiff and the Vale of Glamorgan. Through joint working and better understanding between agencies, both councils will be able to set care home fees at a level which will ensure appropriate capacity within the sector at a cost that the agencies are able to afford. The project will have a long term benefit of improving working relationships with providers as fees will be agreed within a framework that is open and transparent to all involved. This will reduce the time currently required for negotiation and agreement of placement costs.
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Gwent Frailty Project : Community resource teams Continued from Section 3.3, Page 26 The new multi-disciplinary teams being established through the project will comprise the following professionals from across agencies: • • • • • • • • • • •
Registered General Nurses Registered Mental Nurses social workers pharmacists speciality doctors occupational therapists physiotherapists dietetics/SALT/podiatry consultant physician/appropriate medical input a team of support & wellbeing workers administrative support
The Community Resource Teams will offer: • • • • • • • •
single point of access 7 days a week 365 days a year with access from 8am to 8pm as a minimum 2-4 hours response time (for both health and social care urgent components) comprehensive needs assessment management of hospital@home for up to 14 days in response to assessed need ‘hot’ clinics for rapid access to specialist and diagnostic services rapid access to equipment and minor adaptations up to six weeks reablement and review onward referral where required
Bridgend County Borough Council: Intermediate care service performance and outcomes Continued from Section 4.4, Page 36 Within the first year of operation to April 2010 the Council reports the following outcomes from the service: • • • •
helped 145 people to leave hospital early with a theoretical cost saving £152,000 enabled 28 individuals to avoid a hospital admission with a theoretical cost saving £42,000 enabled 115 people to change their home care needs releasing 987 hours saving £613,888 enabled four service users to avoid an admission to residential care/nursing care saving £91,728
The telecare response team dealt with 390 responses in the first nine months to March 2010 – 152 of these were ‘clients on the floor’. They estimate that the service avoided 128 ambulance call out, a theoretical saving of £41,600 which then equated to £4,000 saved on admission avoidance with a further £39,900 saved through other admissions avoided. The total saving to the health system is estimated at £85,528. There are currently 504 telecare users in Bridgend and the average cost of a telecare package is £435 with service users
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paying £5.26 per week subject to fairer charging. The Council’s estimate is that this service has saved £74,880 in adult social care. The performance of the ‘Bridge Start’ Reablement service in the first year was as follows: •
707 service users with 388 requiring no on-going homecare and a 25% reduction in the hours required by those who did receive on-going support. There has been a 10% reduction in the need for home care support across the service with this team.
The Council will be developing this service further to provide for people with early on set dementia as part of the evolution of the scheme.
Merthyr Tydfil County Borough Council: Extracts from business case for extra care programme Continued from Section 4.7, Page 41 The proportion of admissions to care homes from hospital highlights the limited provision of intermediate care services and this is also the case with people being admitted into residential care because of the lack of community support services. Despite a decline in the overall population the number of older people is predicted to rise by 6% by 2010, 20% by 2015, and 29% by 2020, with the over-85 population predicted to rise by 55% by 2020. The Council in partnership with Hafod Housing Association submitted a bid to the Welsh Assembly Government’s Social Housing Grant Fund to support the development of the first extra care housing scheme in Merthyr Tydfil County Borough. Services to older people have been reconfigured to make them relevant and sustainable for the future. Reconfiguring services to maximise independence and self-determination is a key customer focus. As part of the reconfiguration, the Council has reduced the number of council residential beds to 64 (moving to two rather than four council-run homes) and reinvest the existing running costs and capital receipts into new community care services such as extra care. Demographic statistics and trends suggest that by 2020 a minimum of 243 Extra Care Housing places will be required to meet future demand. Capital funds of £5.5million have been secured. This covers 58% of the capital cost with the balance being secured by Hafod Housing through private finance borrowing. The overall cost for the development is calculated at £9.5 million. The reconfiguration of accommodation services will save the council in the region of £750K. £260,250 has been ear-marked for investment in extra care provision. Revenue costs fall into two areas – firstly, rent and service charges to cover cost of accommodation and on-site charges. Secondly, the Council will commission services to meet the tenants housing and social care support needs. With regard to Council funded services, tenants will be subject to a financial assessment to determine how much they have to contribute. Rent levels and services charges have been estimated at: £170 for a one bedroom unit and £195 for a two bedroom unit.
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Draft Extra Care Housing Allocation and Eligibility Policies have been developed. This will identify roles and responsibilities of all partners and determine the protocol for entry into this provision.
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John Bolton John started as a trainee in 1971 and then qualified as a social worker in 1974. He had a career in Local Government which took him through Warwickshire, Solihull, Lewisham, Wandsworth, and Camden where he was an Assistant Director for Quality and Resources. He then moved to the Audit Commission and became the Director of the Joint Review Team overseeing the programme of reviews of Councils in England and Wales. John then had almost six years as Director of Social Services and Housing, and then Director of Community Services in Coventry where he took Coventry’s social care from special measures to three stars. His final career move took him to the Department of Health where he was the Strategic Finance Director responsible for social care. His work published under the title – Use of Resources in Adult Social Care has become a main guidance to help councils in England. John has established his own company – JRFB Ltd – after 40 years’ experience of working within the public sector on issues related to social care. John’s new company is taking him into a range of different areas with a strong focus on making best use of resources in adult social care. John recently completed a contract as the Interim Director of Adult Social Care in Warwickshire. He is offering one day diagnostics for Councils, is working with the Social Services Improvement Agency (SSIA) in Wales and with Welsh Councils, doing some work with McKinsey on health and social care, working with Capita Insurance on products for personalisation and has just joined the Institute of Public Care at Oxford Brookes University where he has been appointed as a visiting professor. Professor John Bolton – Independent Consultant John.bolton@jrfb.co.uk
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