Lessons to be learned from the Better Care Fund audit

The Better Care Fund which was launched in 2015 in an attempt to save NHS money by ensuring that patients with long term conditions were treated properly at home has come under severe criticism by the National Audit Office. The scheme which was designed to reduce the numbers attending A&E and ensure that if people did end up in hospital they would be discharged very quickly.

In a recent report the NAO found that far from reducing numbers of emergency admissions of these patients the numbers actually went up by 87000 from 2014/25 to 2015/16. Nor was there any improvement in the bed blocking situation, where patients have to stay because there are no services for them in the community; the numbers rose over the same period costing the NHS an extra £311 million.

This meant that the Health Service spent vast amounts of money caring for patients in hospital in addition to the £5.3 million trying to treat them at home. The NOA said there was no compelling evidence that the scheme was ever going to work and some MPs described it as ‘flawed’ and ‘no more than a pipedream’.

The report added “the Fund has not achieved the expected value for money in terms of savings, outcomes for patients or reduced hospital activity despite the £5.3 million expenditure spent in 2015/2016.

Why has the fund failed to live up to expectations and what are the lessons to be learned?

In the first place it can be seen that there was far too much hype placed upon the success of the scheme and claims of prevention of admissions to hospitals unrealistic. As Amyas Morse head of the NAO said “So far the benefits have fallen far short of plans despite much effort. It will be important to learn from the over optimism of such plans when implementing the much larger NHS sustainability and transformation plans”.

Secondly, we all know by now that the lack of investment in community care services would greatly impact on the ability of the plans for the fund to prevent hospital admissions. As labour MP Meg Hillier chairman of the public accounts committee, said “MP’s warned of flaws in the fund two years ago. The focus on reducing emergency admissions to hospital without investment in community based services was bound to increase pressure on adult social care services”.

A spokesman for the Department of Heath took up a defensive position saying that “The Better Care Fund is just one element of the Governments programme to integrate health and social care for the first time. The report recognises it has already incentivised local areas to work together better with nine out of 10 places saying their plans are improving services for patients”.

It can be argued that the lack of community care services has had a major impact on the lack of success of the fund, but it seems to have been forgotten that the single plan of care drawn up jointly by health and social services did not have any plan B. That is what happens when the patient is ready to leave hospital.

We do not know from this report whether or not patients were admitted to hospitals for sickness or caring needs. Given the lack of community care services it could well have been either. What I am driving at here is the plan of care should have realistic outcomes and alternative provision planned for long term outcomes.

Summary

The Better Care Fund has not got off to the best of starts and has received criticism from the National Audit Office and MPs. I believe it would be wrong to be too judgemental in the current climate, where everyone knows that there is a lack of community care resources. The forward thinking plan of Health and Social Care Services working together has much to commend it. However, there are lessons to be learned, and in the future we will do well not be too ambitious in our expectations. The prevention of hospital admissions will not be achieved until sufficient funding is made available for community care. In future care managers should ensure that the plan of care takes account of what happens when a patient is due to leave hospital, at the moment there seems to be only one option, to stay there.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Would social care be better off going it alone?

I have long held the view that health and social care services should work together in partnership and provide a seamless service. I believe that where an individual has health and social care needs they should form part of a person centred care plan. The plan would detail the health and social care input, which would be funded to take account of the person’s health needs (for example a stay in hospital) followed by care in the person’s own home or care home.

It seems to me that this approach has much to commend it. The benefits would include:

• Health and social care that is tailored to the person’s needs.
• An end to bed blocking
• More effective and appropriate use of resources
• Providing people with the services where they want them
• A single method of funding
• Clear accountability for services provided.

However, I recently found that David Brindle the Guardian’s public services editor raises the question ‘would social care be better off going it alone’? He says that this notion would be anathema to him alongside many others work in the social care industry. He has long been of the opinion that a seamless social care service where social care and the NHS work in partnership to deliver a better quality of service was the best approach.

Would social care be better off going it alone? While logic and principle suggest that the care and health system should be seen as an inseparable whole, and reviewed as such, he claims realpolitik may dictate otherwise.

He argues that social care should also show willingness to look at its own performance. Prime Minister Teresa May has always been convinced that there remains money to be found in the system by making better use of existing resources. Although this does not obviate the need for funding reform, it is true that better value is being found in some places more than others.

Research by the Social Care Institute for Excellence (SCIE) in Birmingham shows that significant savings could be made if the city adopted three models of care reform pioneered elsewhere: the Living Well scheme of support for older people in the community, developed in Cornwall; Kent county council’s hospital discharge programme; and the Shared Lives concept of family-based accommodation for people with disabilities.

Using data supplied by Birmingham council, SCIE estimates that applying the three approaches could save the council £6.6m a year and the NHS £1.4m. To put that into perspective, the council has to make cuts of £78m in its overall budget in 2017-18 and the care and health economy across Birmingham and Solihull faces a £720m shortfall by 2020. But £8m is not to be sniffed at. Equally important, the kind of community support fostered in SCIE’s models plays perfectly to May’s vision of a “shared society”. If that’s the flow, Brindle suggests that social care needs to go with it.

While giving cognisance to his arguments, I do not share in Brindles view. I accept social care services should be open to new practice and make cost savings, but these approaches in themselves will do little to alleviate the social care funding crises and indeed may deflect attention from the central issue of funding reform.

In summary, the new research by the Social Care Institute in Birmingham should be applauded in that it provides evidence of cost savings in three models of care reform. Although these are worthy of exploration by other local authorities and along with other initiatives of reform that may come along in the future. I hardly think they add up to giving consideration as to whether or not social care services should go it alone.

I would maintain that we should follow the example of Scotland and Northern Ireland and recognize that the way forward is a seamless Health and Social Care Service.

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Is this a step too far and an invasion of privacy?

To those who work in the care industry there seems to have been little respite of late from media that continues to report on the crisis in social care and more particularly the shortfall in social care funding. Since the government passed over to local government more responsibility for domiciliary care funding, some of the hard pressed councils seem to be taken their increased responsibility very seriously indeed.

A case in point came to light this week where it is reported that Surry County Council in carrying out their duty to obtain information about a person’s ability to pay residential care home fees, went so far as to carry out searches of a nursing home resident’s empty property looking for bank statements to see how much the person can afford to pay. This new tactic came to light when they carried out a search of one of the residents now living in a nursing home and discovered they had more than £39000 in savings. As those in the industry know where the authority finds that the person has savings or assets of more than £23250 they will be made to use their savings or sell their property to fund their care.

Now can I say at the outset that I have no issue with the council following central government obligations relating to people funding their care. But what I do have a fundamental issue with, is the methods they used in this case. It transpires according to the council that the resident had permitted the council to search her home. A month later the resident who suffered from dementia died.

This case raises some serious issues. Where does the balance of power lie? It certainly was not with the resident in this case. What protection of the person’s rights was carried out by the council? Why did the council use such draconian methods to establish the finances and assets of the person? They could have applied to for a Court of Protection order called a deputyship to take over the person’s finances.

In a care industry where the Care Quality Commission, the CQC are enforcing regulations that include safeguarding, protection of residents and privacy and dignity which are legally enforceable. The approach taken by Surrey County Council would seem to be at odds with what the Care Quality Commission is trying to achieve, let alone good administrative practice.

The niece of the resident said “I am horrified by how much councils can look into people’s personal finances given that they have paid taxes and national insurance all their lives.”

Liberal MP Norman Lamb a former care minister said “This feels like an invasion of privacy
and quite undignified. Councils should not be chasing people with these issues at a time when they are old and at the end of their life”.

Campaigners branded the tactic used when an elderly person is admitted to a care home and does not have a family or friends to help ‘an invasion of privacy’. They questioned the need for officials to enter a person’s home when banks say they typically disclose such details if the individual gives written permission.

A spokesman for Surrey County Council said “There was no one in the family who could help with the management of the person’s finances so she agreed that we could do it. While we accept that these situations are difficult and sensitive we have an obligation to collect this money”.

In summary, there are a number of issues in this case that are a cause for concern that should be addressed. No one is criticising the council for carrying out their obligations to collect the money. However, where does people’s privacy and dignity feature in all this, let alone their rights and protection. What is of concern is that the council could have used other methods to obtain information about the person’s finances and assets, for example through the Banks and Court of Protection.

One wonders why the council have not explored these avenues as part of their policy for collecting monies from people. What is needed is a policy that is transparent and balances the requirement to obtain information about the person’s finances and assets alongside the rights, protection and privacy of the individual.

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

The real cost of care home fees

It is hard to believe but we are now talking about a ‘care tax’ that takes the form of a subsidy by private paying care home residents to cover the shortfall arising from local authority payments.

A report this week highlights the true cost of care in residential care homes. A report by the care industry analysts Laing Buisson clams that local councils are typically paying care home providers £100 too little towards the real cost for a place for a state funded resident. Given that 6 out of 10 residential care places are being funded by local authorities, providers are left with no choice but to take the money.

But given the current financial situation, providers are attempting to make up the short fall by charging more to more vulnerable residents and their families who pay their own bills.

The report said that in England residential care homes with average staffing and pay levels need to charge between £590-£680 pounds per week. However, local authorities are paying just £486 a week which is £104 below the minimum cost for a care home place. Filling the gap costs for more than 168,000 care home residents who pay their own bills around £8,000 per year or £150 per week. The report suggests that the entire care home sector for older people is being kept afloat by the 40% of private fee paying residents.

The chief executive of Laing Buisson, William Lang said the total cost of the shortfall amounts to £1.3 billion and this is a conservative estimate. He said “this can be viewed as a care tax that Government and Councils are content to see private fee payers contributing to keeping mix funding homes in business.

A response from care charities for older people agree with the report. Stating that the burden of subsidising the state with a care tax, added another layer of unfairness. Caroline Abrahams of Age UK said ‘more and more older people are paying for their own care home fees and they are increasingly at risk of a raw deal because they are propping up a system that is seriously underfunded. It is an utterly miserable situation as we can all see and it is now undermining the NHS’.

Margaret Wilcox of the Association of Directors Adult Social Services said: without significant sustainable and long term funding; the funding crises means thousands of more people will face an increasing struggle to get the care and support they need.

In summary, the Laing and Buisson report puts more meat on the bones through their statistical analysis of the crises of funding in the social care sector. What is new however is the level of contribution that is being made by private fee paying residents to the funding contribution of local authority funded residents. In which other sector would you pay more for the same. There is no 5-star rating that demonstrates private fee payers receive a better service because providers are required to deliver the same quality of service to all residents regardless of what they pay.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy