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Care: new model challenges

Every local authority service and function is being examined, but adult social care is rapidly making its way to the top of the to do list.

The problem of paying for the care needs of a rapidly ageing population was thrown into sharp relief by Barnet LBC’s ‘graph of doom’, a projection that estimated within 20 years the council would have to spend its entire budget on adult and children’s social services.

As arguments continued over recommendations made by the Dilnot Commission on how to pay for all this, the Department of Health pressed ahead with the social care white paper, Caring For Our Future: Reforming Care and Support, in July. This has been criticised by some as having a financial vacuum at its heart.

With local authorities taking on more and more functions from the NHS as part of the government’s drive to integrate services, senior managers will have to quickly work out how to remodel services and where the funding will come from.

Click here to download a copy of the survey report

Where cost pressures will be

LGC’s survey, completed in the main by adult services directors, chief executives and senior managers, revealed some of the challenges councils are having to face up to.

Unsurprisingly, services for older people were flagged up as the biggest strain on council resources over the next five years, with dementia close behind.

Learning disabilities ranked third. According to a New Local Government Network report last year, funding for learning disability services was the fastest growing part of the adult social care budget, accounting for more than 23% of the overall budget.

The Winterbourne View private hospital scandal also highlighted the need to deliver more personalised and localised services for people with learning disabilities.

In 2011-12 £648m was transferred from the NHS to local authorities to help pay for social care. But a report by consultants MHP, An Atlas of Variations in Social Care, found just 4% of this was spent on mental health.

As mental health came fourth on survey respondents’ lists, this may reveal concerns over future delivery expectations raised in the government’s mental health strategy and taking on responsibilities from primary care trusts and other NHS services. There are also indications that as services become increasingly joined up, new pressures on council resources are revealed.

Service areas not included on the questionnaire but highlighted by respondents included homelessness, housing and transition between children’s and adult services. Several also flagged taking up public health responsibilities in general.

Serco_survey_graph

Delivery priorities

When asked for their top three delivery priorities, more than 86% of respondents said allowing people to stay in their own homes. Reducing hospital admissions/ readmissions was second, with more than 68%.

Amanda Carey- McDermott, Serco partnership director, says allowing people to stay in their homes is what most people want and is the cheapest way of doing things.

“Clearly there comes a tipping point when it becomes better for an individual to be in a care home environment, but the vast majority of people want to put that off,” she said.

The MHP research backs this view. It estimates that if all councils reduced the number of emergency hospital readmissions for over-75s within 28 days of discharge to the level of the best performing authorities, about £318m could be saved a year.

In comparison, scores on the LGC survey for delivery priorities associated with personalisation were considerably lower, echoing a degree of uncertainty in answers to specific questions on personalisation. About 28% of respondents chose developing more customer choice and under half - 46% - chose giving people more control over care plans.

Improving social networks for clients was the lowest priority, with almost 18% of the vote. But responses to other questions revealed that some councils consider developing social networks should be part of wider re-ablement services. A recent NHS survey on personal social services revealed 23% of service users did not feel they had enough social contact.

Re-ablement

A healthy 61% of respondents had strong plans to establish more re-ablement services to maximise service users’ independence, with a further 29% saying some planning had been done. Just under 5% had no plans (see overleaf ).

Respondents also gave a flood of answers detailing the kind of re-ablement services they were involved in. The most common was reducing admissions/readmissions, but many outlined specific developments in telecare, telehealth and assistive technology.

Joining up services and systems was also a common theme. Comments included “integration of rehab, re-ablement, equipment and telecare/health to reduce admissions and enable earlier discharge” and “integrated strategy around telehealth, assistive technology, extra care housing, home care and local community support”.

Ms Carey-McDermott, who is helping implement a telecare programme with Hertfordshire CC as well as talking to the local clinical commissioning group (CCG) about telehealth, said: “Technology is one of the ways to enable people to stay at home and give them the confidence, and indeed their carer confidence, that they can be left.

“It could be one of the next big things. It’s already out there, but in a piecemeal way and the technology is always changing and improving.”

Innovative learning disabilities services were mentioned in addition to those for older people and those with physical disabilities.

One respondent said: “We also have pilots running in learning disability and mental health, which we hope to roll out to become the universal offer.”

A similar comment ran: “Extending the concept of re-ablement into learning disability services - particularly at transition in order to reduce long-term care costs and help people get a life.”

But it was not all positive. One respondent said there was “rarely an increase in anything” and “I haven’t seen any real shift in funding from NHS to local authority.”

Serco_survey_graph

Personalisation

Personal budgets, self- directed support and direct payments are all being pushed forward by the DH white paper. But serious questions remain over whether councils will be able to make the transition without struggling financially and organisationally.

The government has given councils until April 2013 to get all its social care users on personal budgets. There have been conflicting reports on whether this will be met.

Consultants MHP said there was “some way to go” after their social care report found nearly a sixfold variation in the weekly expenditure on self-directed support across local authorities. But research by the Association of Directors of Adult Social Services was more upbeat, citing that councils allocated nearly 40% more personal budgets in 2011-12 than in the previous year.

And according to a New Local Government Network report, Commissioning Care in the 21st Century, moving some service users to personal budgets added about £17,000 to their care.

LGC’s survey points to a significant number of local authorities admitting they are not likely to meet the deadline. Nearly 22% said they were not on track and about 44% said they may make the deadline. Only 34% were definitely on track.

Adass president Sarah Pickup remains upbeat. “There are different ways of reading results,” she said. “Regarding personalisation, nearly 80% said they will definitely or may meet the target. This does not contradict the Adass survey and particularly given the range of people responding, many may have felt they could not put ‘definitely’. Adass is aware of authorities that are further behind and is offering support through sector-led improvement.”

The LGC survey also found uncertainty over the implementation costs of personalisation. Some 23% of respondents were definitely expecting to make efficiency savings as a result, but many more - nearly 37% - were not expecting any savings.

Ms Pickup said: “Efficiency is not the driver of personalisation. Sometimes a personalised service will deliver better outcomes or a lower cost but this is not the purpose. Personalisation is the context within which we are driving services forward and delivering efficiencies and savings is not in itself an initiative to save money.”

Ms Carey-McDermott was surprised at the number of councils expecting to miss their target. “Developing local markets and giving people choice doesn’t necessarily save money which is why it’s not necessarily on their top priority list,” she said.

“I think it is possible to have your cake and eat it - improve services for less money - but sometimes personalisation can get brushed over. It is maybe sometimes seen as a secondary outcome and not seen as a main driver.”

Commissioning structures

As new legislation takes effect councils will operate in a very different environment. One of the biggest changes will be health and wellbeing boards, which already exist in shadow form, and have a duty to promote joint and integrated commissioning between local government and the NHS. Personalisation is also radically changing the commissioning process.

Respondents were not convinced the new commissioning structure will save money while maintaining service levels. About 43% were definitely not or not very confident this could be achieved, compared with nearly 36% who were very or quite confident.

When asked whether the new commissioning structures would help develop new and integrated services, answers were more positive. Sixty-one per cent were very or quite confident, while 24% were not very or definitely not confident.

Ms Pickup was not surprised by the variation. “It is NHS commissioning structures that have changed not social care and it is how council and CCG commissioners work together that will determine success,” she added. “There is huge variation across the country in terms of number of CCGs to each local authority and in some cases I know people will feel that new structures hinder rather than help.”

One of the solutions regularly touted to the problem of delivering more with less is partnerships with voluntary and third sector organisations. It is also the central plank of the government’s Big Society.

While the survey revealed the majority of councils were planning to commission more voluntary sector organisations, about 15% said they were not and just over 31% said “don’t know”.

“While I think there is a great deal of support for the contribution the voluntary sector can make and many authorities will build on existing partnerships, it is not always possible to specify what type of organisation should deliver a commissioned service,” said Ms Pickup.

“This may be determined through open tender. Also, authorities are having to make substantial budget reductions and may not see any scope for commissioning more services in their area.”

Tightening eligibility

No matter how services change, with less money available many people may have to expect less from social services.

The survey found some councils still plan to make eligibility criteria more restrictive, but 57% of respondents had no current plans for tighter criteria.

Just over a third said criteria had already been tightened and more than 6% had plans to tighten up criteria. This is despite the government asking councils not to change their criteria ahead of the proposed introduction of a national minimum eligibility threshold in 2015.

Richard Humphries, social care and local government senior fellow at the King’s Fund, says this will affect the ability of councils to manage the widening gap between needs and resources.

He said: “With 82% already limiting help at ‘substantial’ levels of need, far from heralding an end to the postcode lottery, this change will simply close the door long after the horse has bolted.”

LGC Social Care Survey, in association with Serco

Care: new model challenges