A longer read for the lockdown: Reform of health and social care without further top-down re-organisation

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In the daily update on Friday 15th May, Matt Hancock said that the current crisis had demonstrated how closely health and social care need to work together and had acted as a catalyst to reform, referring to “integration”. Care homes are not, and were never intended to be, hospitals. The residents are just as entitled to hospital care, if that is what is needed, as are the rest of us. That so many have been left to die in Care Homes, rather than being admitted to hospital, and thereby denied the benefit of oxygen, ventilators and intensive care which might have saved their lives, is the real concern. The discharge of older people from hospital to care homes, without testing, in order to free up beds for coronavirus patients, may also have spread the virus.

However, that Baroness Ros Altmann also referred to “integration” on “Good Morning Britain”, and Matt Hancock reiterated it on the 21st May, would suggest the matter is under consideration.

Countless enquiries into “child abuse” and “adult abuse and neglect” have criticised agencies for not working together. And successive Governments have tried to get Health and Social Services, in particular, to work more closely together from “joint funding” in the 1970s to the “pooling of budgets”. But no Government has grasped the nettle of the lack of common geographical boundaries, different funding streams and different lines of accountability which have been the real impediments. This does not mean a merger of health and social services, as that would further marginalise Social Work and a different combination of agencies are required depending upon the problem and desired outcome. For example: Child Protection requires children’s services, health, education, the police and foster care to work together. Older People require Adult Services, Health, Housing, Leisure Services and Income Support to work together. – But not all of them all the time. It is quite a complex multi-dimensional organisational issue across countless scenarios.

Repeated re-organisations of health and social services over the past thirty years have added to the fragmentation and cost. In my days as a Director of Social Services, my counterpart in health managed nine hospitals, five of which were regional, community services and the family practitioners committee (GPs) all with a management team smaller than is now found in each hospital trust.

Since the late 80s, health, and the early nineties, social services, have been required to separate out the management of in-house provision from that of purchasing and commissioning. This doubled the management and administrative costs. – The intention being that it would encourage a mixed economy of care and force quality up and prices down. Clearly this has not been the case and that social workers were employed on the “purchasing”, rather than the “providing”, side, led to a “minding” rather than a “mending” service, with an ever-growing case-load of dependent people. It led to over-prescription with providers unable to respond in situ to changing need or priorities and further fragmentation and lack of continuity as different component parts of a “package of care” could be purchased from different providers.

Wales, which had common boundaries for health and social services with several All Wales Strategies, went from 8 County Councils and 37 District Councils to 22 Unitary Authorities, at considerable cost. Had Government opted for the County Councils, as their unitary authorities, there would have been immediate savings on the cost of democracy and year-on-year savings as District Council Departments were merged into County Departments through natural wastage.

The splitting of Adult and Children’s Services in England added to the management costs, as did the creation of unitary authorities.

Therefore, as a first step, the answer might be to bring all services together in either the old County Council or Police Authority boundaries, returning the NHS and Police to local democratic scrutiny within central government legislation, in order to achieve common geographical boundaries, common funding streams, common lines of accountability and economies of scale. – Whilst abolishing the costly and ineffective purchaser / provider split.

A whole systems review

The NHS and social care are in crisis. Nearly two million older people are living in poverty and more and more older people are having to sell their houses to pay for their care in this the fifth largest economy in the world. Many of these people were forced into retirement and condemned to spending the rest of their lives in poverty.

However, the crisis cannot be solved by pouring more and more resources into the first aid camp at the bottom of the cliff, rather than building a fence at the top. There needs to be a whole systems approach designed to reduce demand, increase efficiency/effectiveness and find sufficient money to make health and social care (not living costs) free at the point of delivery of service.

Britain’s state pension is 29% of national average earnings compared with 100.6% in Holland, 94.9% in Portugal, 93.9% in Italy, 91.8% in Austria and 81.8% in Spain. The official definition of poverty is anything less than 60% of the median household income.

Given the correlation between income and demand upon the NHS it is hardly surprising that older people account for 4/5th of the expenditure. An estimated 1.3 million older people suffer from malnutrition, costing the NHS £19.6 billion per year. There are five main causes of malnutrition: lack of money; lack of motivation; incapacity; lack of support and social isolation.

The Netherlands, with the highest pension in Europe spends 60% of its health budget on older people compared to 80% in Great Britain.

A starting point may be to raise the state pension from 29% of national average earnings to 60% at a cost of £100.26 billion. This could be offset, in part by people who go on working, beyond the age of eligibility for the state pension, continuing to pay National Insurance (raising £4.1billion) and not drawing their state pension until they retire (saving £8.24 billion) with phased arrangements.

There would be a saving of £37.05 billion on other benefits and £14.47 billion would be clawed back through income tax from those with other pension income.

If this increased income were to reduce malnutrition by 90% it would save a further £17.85 billion, a reduction of 15% in demand upon the health service, which would still be higher than the Netherlands, a further £21 billion.

These figures are for illustrative purposes, and do not take into account a number of other variables such as population increase which would be constants but would produce a credit of £2.45 billion.

The statutory agencies need to work with housing associations to develop “extra care sheltered housing”. It is possible to put just as much nursing and social care into such developments as it is the more traditional residential care. The owner or tenant has their own front door, defended space and retains control over the essentials of daily living. This alleviates many of the harmful effects of traditional residential care and reduces the risk of abuse which is greater when the victim is subservient.

The average cost of a care home place is £29,270 per year. People would hand over their income up to the cost of the home, less their personal allowance of £24.90p per week, as now. With an increased pension of £17,802 the minimum residents could contribute would be £16,507 leaving a maximum of £12,763 for the local authority to find. (Currently people are deemed to have £1 per week income for every £250 of savings they have between the disregard and full cost thresholds and this would no longer apply). There are currently 416,000 older people in Care Homes and it is anticipated this number would reduce, possibly by 20% – as a result of this whole systems review. The cost of providing free social care (nursing care is already paid for) would be 332,800 X £12,763 or £4.24 billion – less the contributions from those with occupational pensions.

The total cost of raising the state pension to lift older people out of poverty and no longer take savings into account in the financial assessment for long term care would be £1.79 billion which would be more than recovered by the changes proposed above and below.

Align resources behind outcome

There is just as much empirical evidence in respect of organisation, management and leadership as there is medicine, social policy and social work and yet this is rarely applied in practice.
For many years, until the late 1980s, Brunel University received Department of Health funding to apply organisational analysis to health and social care. The Tom Peters Group has studied cultural change, customer care and leadership. And applying his unique whole systems methodology to a hospital in the Netherlands, Christian Schumacher (the son of the author of “Small Is Beautiful“) was able to achieve a 30% increase in output with higher morale and lower sickness levels.

Social Service and Health Service Managers are extremely lucky in that the majority of their staff are working in their chosen vocation. – It is what they want to do. It should therefore be possible to arrive at a situation whereby they can say, as many sports people do, ‘aren’t I lucky I am doing what I want to do and being paid for it?’. Why then is morale reported to be so low? It often appears that staff are doing excellent work despite the system, instead of the system helping and supporting them in their work.

People in Health and Social Care are working in some very stressful situations but which can be very rewarding if they see the outcome of their work and the improvement they have brought about in people’s lives. Many hospitals are still organised on the discredited production line model with, for example, some nurses just taking blood, not knowing why, the results or outcome for the patient.

The use of Agency Staff also distracts from the continuity of care. Agency Staff are very expensive, with money going on travel, board and agency fees, and it should not be beyond the wit of managers and trades unions to manage without them until there is no work and they have to apply for permanent positions and the savings shared in higher salaries.

Much of what underpins current management thinking is that people are motivated by, and can be controlled by, money when there is little evidence to substantiate this. People are motivated by job satisfaction and recognition of a job well done. Health and Social Services need to move away from the traditional management model of getting people to do what needs to be done by reward and sanction (the carrot and the stick) to a Leadership Model whereby people want to do that which needs to be done and the role of the manager is to train and enable.

Staff, including their managers, need the capacity (intellect X knowledge X experience) to match the complexity of work. They need the “generic skills” of their profession, specialist knowledge of their area of work, and to be employed on the work which interests and motivates them. It is little point employing someone who wishes to work with young offenders on the care of older people. They also need the confidence to take decisions up to the extent of their discretion in the knowledge that they will be supported should things go wrong – without losing sight of their accountability to elected representatives on central or local government or a board of trustees or directors, or that they work with some of the most vulnerable and least powerful members of society.

Social Workers need to be freed from “care management” and the “gate-keeping” role of assessing the eligibility for specific services thereby enabling them to practice their skills in using relationships to bring about change in motivation, behaviour, inter-personal relationships and community support by various therapeutic techniques and counselling – thus reverting to a “mending” rather than the current “minding” model.

There is a need to:

  1. take out functional divisions along patient pathways;
  2. create “whole task, right sized, multidisciplinary, inter-agency teams” aligned behind outcome with access to all the expertise and resources required to complete the task;
  3. ensure these teams can “plan, do and evaluate” their own work, which completes the learning cycle of constant improvement.

These teams can be quite local as are many “community support teams for people with learning difficulties” and co-ordinated by an employee of the lead agency with a “key worker” appointed to co-ordinate work at an individual level.

This approach was implemented successfully by South Glamorgan County Council across all areas of work in the 1980s and 90s with individual plans, local planning groups and joint management boards. It was done at a time of severe financial constraints with an outcome of within 0.1% of cash limit year on year. It did not have the benefit of common funding streams and lines of accountability.

The number of tiers of management should be kept to a minimum to avoid the party game “messages” and appropriate levels of delegation can reduce the amount of time spent in meetings.

This article is intended to stimulate discussion in order to avoid the imposition of yet further top down re-organisation.

Footnote

Prior to 1990 private residential and nursing homes were only available to those who could afford to pay. Means Tested residential care was provided by Local Authorities under Part III of the 1948 National Assistance Act and State Nursing Homes provided by the NHS. In 1980 Margaret Thatcher extended choice by enabling people to have their fees in private and voluntary homes paid for by the then Benefits Agency subject only to the availability of a place and a means test. The cost escalated to billions which Sir Roy Griffiths termed the “perverse incentive” as the money was not available for home care and it was thought there were people in residential care who neither wanted nor needed to be. The money was transferred to Local Authority Social Service Departments, by the 1990 National Health Service and Community Care Act, which had to carry out an “assessment of need” and “verification of wishes”. For some reason Sir Roy included Nursing Homes in this, which had always been a health responsibility, so that for the first time they became means tested. And what had been an “open-ended entitlement” became a “cash limited allocation” with Social Service Departments charged with “managing the market”. The majority fixed their “contract price” below the cost of their in-house provision (so much for the level playing field) which meant that private and voluntary homes have struggled financially and have had to subsidise local authority placements from the fees of private residents.

* Chris Perry is a former Director of Social Services of South Glamorgan County Council, a former Non-Executive Director of Winchester & Eastleigh Healthcare NHS Trust and a former Director of Age Concern Hampshire.

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14 Comments

  • Richard Underhill 28th May '20 - 11:48am

    Chris Perry | Thu 28th May 2020 – 11:15 am
    “the fifth largest economy in the world?”
    Is it really?
    The UK has left the EU and thereby cut ourselves off from a large export market, eg for fish, banking, etcetera.
    The Chancellor has been spending heavily on credit, using the UK’s high credit rating, as Nick Clegg planned to do, as per Financial Times page one, shovel ready projects.
    What about India? France?

  • @ Chris Perry As a former Convenor of Social in Scotland, I found this a very interesting read, and agree with your view that,

    “the answer might be to bring all services together in either the old County Council or Police Authority boundaries, returning the NHS and Police to local democratic scrutiny within central government legislation”.

    I wonder if you could comment on the findings of Professor Bob Hudson’s Report which I have given a link to below……. The failure of privatised adult social care in England: what is to …chpi.org.uk › CHPI-SocialCare-Oct16-Proof01a
    PDF
    Bob Hudson is a former Visiting Professor in Public Policy in the Centre for Public Policy and Health at the University of Durham.

    Could you also comment on events at Portree where NHS Highland has taken over the running of the HC-One Care Home after a coronavirus outbreak and an adverse Inspectors Report.

    BBC News-14 May 2020
    The Care Inspectorate has taken legal action over the running of a private … cancel the registration of the HC-One-owned Home Farm facility in Portree. ..

    I have grave concerns about the standards and the financial fragility of the privatised care home system, many of which are owned by multinational companies based in tax havens such as the Cayman Islands….. and in care at home where there appears to be a race to cut standards through cut throat unrealistic contracts.

    Surely we need a much more stable system with high professional standards for both residents and staff.

  • A holistic reform package like this should be in our next manifesto.

  • David Warren 28th May '20 - 7:47pm

    The only way forward for adult social care is to reverse the privatisation undertaken by the Thatcher government.

    The current system is protected by an unholy alliance of bureaucrats and private care providers. The big losers are the family carers, care workers and the people who need help.

    Crony capitalism at its worst.

  • Chris Perry 28th May '20 - 8:24pm

    David Raw. The present situation, as outlined by Prof Bob Hudson in the CHPI report, was an inevitable consequence of the Griffiths reforms of the 1980s which were based on a number of false assumptions, and political dogma, for which there was little or no substantiating evidence. We need to build back capacity in the public sector and re-negotiate the relationship with the private and voluntary sector in order to work together in partnership by sweeping away the purchaser / provider split.

  • Chris Perry 28th May '20 - 9:11pm

    Joseph Bourke, Thomas and David Warren.
    Thank you all for commenting so positively. Any ideas for getting this thinking to a wider audience would be very much appreciated. The widening inequality, increasing poverty and disadvantage in our society is of considerable concern to me as is the fact that our health service, social services and, for that matter, railways are not structurally fit for purpose. Those in need of the services are suffering and those trying to provide them having to constantly battle the system in stead of it helping and supporting them in their work. The last few weeks have demonstrated the commitment and dedication of those working in health and social care, in particular, and also those working in the super-markets and other essential services whose lives could be so much better.

  • @ Chris Perry Thank you for confirming my own feelings, Chris. Time to roll back the rocky offshore privateers. The old people should be the first priority and staff should receive proper training, qualifications and career path opportunities with reasonable remuneration…

  • Chris Perry 28th May '20 - 9:26pm

    David Raw. Absolutely, could not agree more.

  • John Marriott 28th May '20 - 9:34pm

    So many worthy words and what do they all boil down to? More money. Instead of putting our hands together every Thursdsy evening, we, or most of us, should be putting those hands in our pockets and paying a bit more.

  • Evidence from Canada also shows that death toll in private care homes is like 4 times greater than in municipal-run ones.

  • There is a case for bringing the nursing home system back within the public purse. This would enable more uniform policies, cost savings from economy of scale and continual flow both ways that would improve standards, training and optimum use of resources. All nursing homes should include a frank discussion with entrants and their families of issues such as admission to hospital. Many might not want this at some stage of their stay.

  • Katharine Pindar 30th May '20 - 10:54pm

    The issues of social care have been brought firmly into public attention by the sad neglect of sufficient protection of care and nursing home residents and staff in the current health crisis, leading to a high mortality rate in the homes. Yet the continuing problems of this sector were already clear even to outside observers: the cost of care in the largely privatised homes, for example, yet the minimum-wage payments to care workers, which, together with the immense workload required of them has seemed to lead to a continual shortage of these key workers.

    I and my fellow observer, Michael Berwick Gooding, have concluded that the problems of social care may need to be considered as a grave ill, as important as the other five ills we have been discussing as the modern-day equivalents of the five great evils identified by William Beveridge in the ’40s, and which we consider should be dealt with by a new social contract between government and people. We should very much appreciate it, Chris, if you would care from your expert point of view to comment on this, as part of the ongoing discussion on our current thread, libdemvoice.org/a-sixth-social-evil-64750html. I have meantime much appreciated your deliberations here, which I have been learning from.

  • Chris Perry 2nd Jun '20 - 9:50pm

    Katherine Pinder. Thank you for drawing your article to my attention. You may recall there was a Royal Commission on Long Term which reported in 1999. However this, like all subsequent reviews, spent all its time discussing funding and charging when what is required is radical reform based upon a whole systems review. The lack of respect for older people, as evidenced by Britain’s inadequate pensions and neglected social care system, is most definately a grave ill as is rising inequality and increasing poverty – particularly amongst children. It is incomprehensible that so many people gave their stamp of approval to ten years of austerity and voted for rising inequality, increasing poverty and the potential breakup of the United Kingdom at the last General Election. What happened to the 48% who wished to remain in the EU and campaigned rigorously to do so? Where did their votes go?

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