Can we find a way through the social care ‘maze’?
Can we find a way through the social care ‘maze’?
This article, written by Jennifer and Paul Roberts, appears in the latest edition of the Journal of Care Services Management (Voume 3: Number 4). The Journal is published by Henry Stewart Publications of Russell House, 28/30 Little Russell Street, London WC1A 2HN (www.henrystewart.com). Jennifer and Paul are joint editors of the Journal.
These are extraordinary times for all involved in caring for the elderly. Suddenly, it seems that everyone has something to say about the long-term care of our ageing population. Never have so many column inches in Britain’s newspapers and magazines been devoted to a subject that in all too recent times would not have raised a flicker of interest. The words ‘crisis’ and ‘ticking time-bomb’ have dominated headlines in the great care debate. Billion-pound ‘solutions’ have been raised, praised, criticised and dissected in minute detail. The central plank of future care needs — personalisation — has provoked a mixed response. And hardly a day goes by without a new panacea being unveiled. Consequently, the good, the bad and the decidedly indifferent ideas have been exposed for all to see and discuss. That, of course, is a positive outcome from a debate that is proving pivotal to resolving a conundrum that affects us all. It provides the perfect opportunity to explore and develop the most likely ways through the care ‘maze’.
In this issue of the Journal a major new paper by Nick Rowlett, a senior business analyst at Lincolnshire County Council, proposes that local authorities will have to completely transform the way in which they approach the provision of social care services in order to achieve genuine self-directed care for all people who require them. He outlines the case for a new model — the service gateway — that would take both operational and strategic decision making related to the provision of care against assessed need out of the hands of local authorities. The gateway would transfer power to individuals, changing the role of local authorities from that of controller to one of facilitator, supporter and safe-guarder.
Mr Rowlett says that, while national policy makers have made clear their intention to deliver increased choice and control for people who require social care, ‘the current centralised model of social care delivery cannotachieve this aim because it is fundamentally designed to allowlocal authorities to control the process.Therefore, local authorities serious about delivering this excitingagenda need to move wholly away from the current mechanismsfor social care delivery and introduce a completely different set ofsystems and practices . . . The service gateway model has beendesigned from the ground up to take the principle of self-directedcare and turn it into a working reality, and therefore represents apractical and effective approach to the delivery of genuine choiceand control for individuals who require social care.’
A radical transformation of care is at the centre of the Government’s Putting People First1 programme to personalise services. It addresses the changes needed to ‘mend the failing system in the present and the short-term’. A three-year programme, it has had a decidedly lukewarm reception from many care sector leaders. The long-awaited Care and Support Green Paper2 outlines plans for long-term reform, and the Government expects it to pave the way to a ‘sustainable, affordable and fair system’. Its importance cannot be under-estimated but there are fears that its progress will be bogged down in political imbroglios and by funding implications.
In this issue of the Journal, David Behan, the Department of Health’s Director General of Social Care, Local Government and Care Partnerships, outlines the Government’s strategy. He states that ‘a whole new approach is needed that ensures that those who need care get care of a decent standard, and that carers are better equipped and supported to provide it’. No-one would dispute this point; however, there are many who doubt that the Government will be able to raise sufficient money to achieve the desired results within the foreseeable future. The Joseph Rowntree Foundation (JRF), for instance, believes it could take a decade before a new and viable long-term care funding system is in place.3
The JRF argues that the number of over-85s will double by 2050 and that spending on long-term care will have to increase fourfold in the next 40 years. In a new report, it has urged the Government to consider a series of reforms, costing more than £770m, to kickstart a series of evolutionary changes. Its proposals, welcomed by many in the care industry, include:
· an equity release scheme in which older homeowners would be able to pay for home-based care by deferring the costs until their home is sold;
· increasing capital limits for care home fees that dictate whether an individual in a care home receives support from a local authority from £22,250 to £42,500;
· doubling the £21.90 personal expenses allowance for people in care homes supported by local authorities;
· introducing free personal care for anyone requiring nursing care.4
The jury is still out on the long-term future for and direction of direct payments and individual or personal budgets. The latest Commission for Social Care Inspection (CSCI) figures show there were 55,900 adult service users receiving direct payments in March 2008, a rise of more than 15,000 compared to March 2007, with 4,800 people using individual or personal budgets.5
Putting People First,6 the principal driving force behind the new personalisation agenda, was only launched in April 2008, so it is very likely that these figures will have substantially increased since then. But it is important to remember that it will still be a small proportion of the many hundreds of thousands of people supported in community-based services.
Care Services Minister Phil Hope is very upbeat about individual budgets. He says research and the opinions of services users, carers and councils have shown that ‘individual budgets can transform lives for the better’. He says the Care and Support Green Paper7 will offer a ‘once-in-a-generation’ opportunity to reshape social care and help Britain adapt to the challenges of the 21st century. He told the annual Counsel and Care Conference in London at the end of February that personalisation gives people: ‘[the] control and support they need to become active recipients,not passive recipients of care. It safeguards quality. It drivesefficiency. And by giving people control and choice, it offers thema clearer stake in their own futures and the future of their lovedones.’8
He has frequently emphasised that individual budgets need to be carefully implemented. Few would disagree that personal or individual budgets are a good idea both in principle and in practice, provided that control of the service remains with the individuals receiving it, and that there is sufficient funding in place to make it work. There have been justifiable criticisms at the highest levels that personalisation has yet to be clearly defined, that greater focus needs to be placed on outcomes rather than on how care services are to be provided and that potential funding for ‘personalisation for all receiving care’ has been seriously underestimated.
The Social Care Institute for Excellence (SCIE) has identified that the social care agenda must now move from ‘what will we do?’ to ‘how can we do it?’. It believes that more can be done to increase proportionally the personalisation of social care services from pilot to mainstream projects, particularly for those people with complex needs or those regarded as vulnerable.9 Chief Executive of SCIE, Julie Jones, says: ‘we must remain focused on how the personalisation agenda willimprove the lives of everyone who uses social care, not just thosewho can easily articulate their choices. We know that the devil isin the detail of how to make this ambitious vision work and wemust provide all those who work in and use services withcomprehensive information and knowledge.’10
A clear indication of how elderly people’s care needs could be financed in the future is given in the Better With Age report, published in February 2009 by the New Local Government Network (NLGN) ‘think tank’.11 A precursor to the Care and Support Green Paper,12 it calls for a new social insurance fund to beintroduced in two stages between now and 2030.
The NLGN contends that a nationwide ‘combined social insurance’ offer is needed to pay for a higher quality of care for our ageing population. NLGN Director Chris Leslie has said the reforms would help more people to grow old with dignity: ‘Local and national government need to work together to solvethis enormous demographic challenge.We also believe that a new role for local government should be set out — less reliant on the council taxpayer to fund social care,but more reliant on elected councils to shape how the money isspent and how services are commissioned. A giant nationalquango for elderly social care would be too unwieldy.’13
NLGN argues that local government must remain in the driving seat when commissioning care services and facilities for older people: ‘We need tailored provision to fit local circumstances andcommunity needs. If councils extend their commissioning powersinto the wider health and social care arena over the coming decades, this would be a thoroughly good thing.’14
In a recent report in The Guardian newspaper,15 Lord Sutherland, who chaired the Royal Commission on long-term care, suggests that payment for treatment may have to be considered as part of a new settlement on funding the care and support of the elderly. He believes there is an urgent need for a review of all public spending and a redistribution of priorities between social care, housing, health and welfare benefits.
A scheme first pioneered in Leicestershire about ten years ago, and adopted by dozens of local authorities, holds some of the answers to the thorny question of dealing with future care needs. Homecare re-ablement — helping people to regain daily living skills and maintain independence in their own homes — is very much back in vogue thanks to a venture gaining momentum in Scotland.16
A team of 240 former home helps and social care workers have been retrained to operate a city-wide re-ablement project in Edinburgh. It has proved crucial in avoiding a collapse of services and in reducing care dependency. As many as ten other regions in Scotland have been keeping a close eye on developments and are likely to follow suit.
The Leicestershire model17—still regarded as the best—has been very successful. Around 60 per cent of people who have been allocated services through the local Homecare Assessment and Re-ablement Team (HART) have not required any further long-term support. There has also been a notable reduction in the number of service users going into residential care in the county. Essentially, the service is provided to people who need support to live in their own homes. Care assistants, for a period of up to six weeks, identify what people can do for themselves and assist them to regain skills of daily living. Although a number require ongoing care and support once the service has ended, it is often at a reduced level.
Ultimately, it is likely to be a combination of schemes operating at grassroots levels — including some of those listed here — thatwill provide the solution to long-term social care. There is no magic wand, no quick-fix cure. But there are enough schemes operating at the pilot and mainstream levels to pave the way to a new and better system of care.
Hard-hitting campaigns — including the most recent one in The Times newspaper18 — have ensured that social care remains at thetop of the political agenda. But there can be no let-up in calls forreform, for the entire issue could easily slip to the bottom of the‘must-do’ pile if the voice of long-term care is lost among the hueand cry over the continuing economic recession.
Paul and Jennifer Roberts
May 2009
Paul and Jennifer Roberts are the newly-appointed joint editors of the Journal of Care Services Management. A qualified nurse, Jennifer has more than 20 years’ experience in the care industry. Paul has more than 25 years’ experience in the newspaper industry, working as a journalist and editor. Together, they now run their own care consultancy business.
References
1. Department of Health (2007) Putting People First — A Shared Vision and Commitment to
the Transformation of Adult Social Care, Department of Health, London, December. The
concordat with the Local Government Association, the Association of Directors of Adult
Social Services, the NHS and others. The document outlines a shared vision and
commitment to the transformation of adult social care over a period of three years.
2. Department of Health (2009) Care and Support Green Paper, forthcoming (due to be
published in mid 2009). The paper will outline the Government’s vision for the long-term
future of social care services. Publication will be followed by a period of consultation,
after which the Government will go back to those it engaged with and test its ideas.
3. Joseph Rowntree Foundation (2009) Options for Care Funding: What Could Be Done
Now?, Joseph Rowntree Foundation, York, 4th March. It outlines a series of costed
reforms that could make a difference to older people.
4. Ibid.
5. Commission for Social Care Inspection (2009) The State of Social Care in England 2007–
08, CSCI, London, January. The figures for direct payments/individual budgets are listed
in the executive summary on p. 15 of the document.
6. Department of Health, ref. 1 above.
7. Department of Health, ref. 2 above.
8. Counsel and Care Annual Conference, ‘Right Care, Right Deal’, London, 25th
February, 2009, available at: http://www.dh.gov.uk/en/News/Speeches/DH_095630
(accessed 2nd June, 2009).
9. SCIE (2009) ‘Address the barriers – SCIE’s response to CSCI’s The State of Social Care
report’, 27th January, available at www.scie.org.uk (accessed 2nd June, 2009). The Social
Care Institute for Excellence is an independent charity funded by the Department of
Health and devolved administrations in Wales and Northern Ireland. Its mission is to
‘identify and spread knowledge about good practice to the large and diverse social care
workforce and support the delivery of transformed, personalised social care services’,
SCIE mission statement, published on SCIE website: www.scie.org.uk
10. Ibid.
11. Lacopini, G. and Leslie, C. (2009) Better With Age: Reforming the Future of Local Social
Care for Older People, New Local Government Network, London, 25th February.
12. Department of Health, ref. 2 above.
13. NLGN director Chris Leslie speaking at launch of ‘Better With Age: Reforming the
future of local social care for older people’, 25th February, London, see: www.nlgn.org.
uk
14. Ibid.
15. Brindle, D. (2009) ‘Peer calls for rethink on caring for older people’, The Guardian,
Wednesday 25th February, available at: http://www.journalisted.com/article?id=1262897
(accessed 2nd June, 2009).
16. City of Edinburgh Council (2008) Independence in Your Home, The City of Edinburgh
Council, Edinburgh. Home care re-ablement scheme based in the community across
Edinburgh.
17. Leicestershire County Council has a successful Home Care Assessment and Re-ablement
Team. Its model of service is being adopted throughout the UK.
18. The Times, ‘Care Homes in Crisis campaign’. See www.timesonline.co.uk
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