Make social care free to save NHS


The government should make social care free to everyone who needs it to take pressure off the NHS, former Labour and Tory health ministers have said.

Conservative, Lord David Prior and Labour’s Lord Ara Darzi also called for a “radical streamlining” of NHS organisations to roll back the damaging reforms implemented by former health secretary Andrew Lansley.

Abolishing means testing of social care would end the scandal of people with significant care needs facing bills in the hundreds of thousands of pounds for care, they said.

Cuts to social care funding under the Conservatives have seen the numbers of people receiving state-funded care falling five per cent a year.

But it is costing the NHS £3bn a year to care for people in hospital who are fit enough to be sent home but haven’t got sufficient support, and free services for people with “critical” or “substantial” needs would help.

Elderly people in residential accommodation would still be expected to pay their own housing costs if they can afford to, as at present.

The report sets out how the NHS and social care system could deliver productivity savings which they claim, combined with the extra funding, would release resources to meet the rising needs of an ageing population and enable it to embrace medical and technical advances.

Their plan, compiled with think tank the Institute for Public Policy Research (IPPR), suggests streamlining the NHS by replacing 244 commissioning bodies and other organisations with up to 10 new Health and Care Authorities

It also puts forward the case for a long-term funding settlement which guarantees NHS funding will grow at its historic annual rate of 1.5% above overall economic growth, for a total of around 3.5% a year.

Reform would require annual spending on social care to double, from its current level of around £17 billion to £36 billion, by 2030.

The report recommends funding this during the current parliament by putting a penny on National Insurance Contributions (NICs) for employers, employees and the self-employed, as part of a wider settlement for the NHS.

They suggest the creation of up to 10 new Health and Care Authorities (HCAs), to replace the current 195 Clinical Commissioning Groups (CCGs) and five NHS England regions.

This would mean undoing some of the Lansley reforms, which separated acute and community care commissioning – undertaken by CCGs – and primary care and specialised commissioning – undertaken by NHS England.

The number of national NHS leadership bodies would also be cut from six to three, by merging NHS Improvement, Health Education England and Public Health England with NHS England.

They also suggest the obligation to competitively tender for services – internally or externally – should be scrapped, arguing that the constant churn generated by this process is costly and disruptive to care, with limited evidence that it has improved quality or efficiency.

Lord Darzi said: “The NHS and social care have done well to improve or maintain quality over the last decade. But the cracks are now showing.

“We need bold action to ensure that the NHS is fit for the 21st century. This will mean caring as much about social care and public health as the NHS and embracing reform as much as additional funding.

“The gift the NHS needs on its 70th birthday is a pragmatic plan to secure it for future generations.”

Lord Prior said: “Simply putting more money into the NHS and hoping for the best will not work. With funding must come radical reform. We need a shift from ‘diagnose and treat’ to ‘predict and prevent’.

“Care must be joined up around – and tailored to – the patient. A universal service should be there for everyone, not the same for everyone.

“At the heart of our plan for reform is a radical simplification of the NHS and a properly funded social care system to make this happen.”

It is disgusting that people were misled into believing that the insurance payments they made to government – which are compulsory – would cover the cost of care in their old age have been ripped-off – with many being left without proper care.

Summary

The Lords David Prior and Lord Ara Darzi proposals to reform the NHS and to make social care free at the point of entry are designed to stimulate the debate on the way forward for these services which are critical to the population of the UK.

Whether making social care free would take the pressure off the NHS is debatable. It could be argued that it will only encourage greater use of social care. Those who work in the NHS will dread the thought of another reorganisation, and there is no mention of how much this would cost. I guess we will need to wait for the publication on the Green Paper on social care which has now been delayed, to see if any account has been taken of the proposals made by the lords.

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

NHS Community Services Providers: Take Centre Stage


A report from NHS community services providers suggests that their services are at the point of taking centre stage. For many years now, successive national NHS policies have stated that community services should play a more central role in the future health and care system than they do at present. The most recent iteration of this ambition was the Five year forward view (FYFV) (NHS England, October 2014), but this initiative was only the latest in a long line of NHS strategic plans that sought to strengthen the position of the community sector and deliver care closer to people’s homes.

This argument in favour of stronger, expanded community services has been made for three overarching reasons:

  1. The NHS must radically improve its ability to prevent illness and support people to ensure their own wellbeing if it is going to be financially sustainable. Strengthened community services are crucial to bringing the right focus on preventing ill health, improving the population’s health and wellbeing, and tackling health inequalities.
  2. The disease burden is shifting as people are living much longer with multiple long-term conditions that cannot be permanently cured by hospital intervention. Conditions such as diabetes and hypertension require a very different type of interaction with patients and the public than, for example, a traumatic injury. Community services offer the most appropriate way to promote good health and prevention and provide joined-up care for an ageing population.
  3. Acute inpatient services, in both hospitals and mental health services, are under huge pressure and they are currently being used unnecessarily and inappropriately for patients who could and should be treated closer to home. It is better for patient care, better for performance outcomes, and better for the NHS budget to treat as many patients as close to home as possible, with community services once again at the heart of provision.

However, while the burning platform for this shift in the provision of care is the financial and operational pressures in the acute sector, the real driver for community services lies in good population health and prevention at scale. Too much time has been spent making the case for community services in relation to “moving care closer to home”, when it is the combination of all three reasons that makes the case. Concentrating solely on this defines community services in relation to what they are not, rather than what they are. This then colours the debate around community services, which continues to be acute-focused and about shifting services between settings rather than acknowledging the positive reasons for strengthening community services.

The analysis for this report is informed by an online survey of NHS trust chairs and chief executives representing 51 trusts that provided community services and 20 that did not. The contribution of these 51 trusts. This means over half of all trusts that we are currently providing a substantial amount of community services.

To complement the survey a number of interviews were carried out to gain a richer understanding of the issues facing community providers.

Despite the potential of community services, the survey and analysis found seven reasons why ambitions for the community sector have not yet been realised. And, in doing so, the report provides a clear manifesto for what needs to change if community services are going to take up a more important role: The seven reasons are:

  1. There is insufficient understanding of community services and the community provider sector among the national bodies, the Department of Health and Social Care, commissioners, politicians, patients and the public.
  2. Community services have been, and continue to be, an inconsistent national and local priority.
  3. There needs to be greater financial investment in community services.
  4. Demand for community services is outstripping capacity and supply.
  5. Structural inequity means that competition and procurement disproportionately affect community service providers.
  6. There are worrying staff shortages in key roles.
  7. There is a lack of national-level data and a national focus on an improvement approach for community services.

Summary

The report from NHS community services providers puts clearly the overarching reasons for more investment in community services. However, change is unlikely to come about unless there is a major shift in the policy of NHS to recognise the value and contribution of community services, who will then move more closer towards centre stage

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

 

The seven key principles to reform social care

Jeremy Hunt speaking at BASW’s World Social Work Day event. Picture: Joe Newman

The social care industry has been looking for some time to gain an insight into the governments thinking on the future of social care. It may well be that this week we were given some insight.

Jeremy Hunt, Health and Social Care Secretary speaking to the British Association of Social Workers conference in Westminster, said we need a relentless and unswerving focus on providing the highest standards of care – whatever a person’s age or condition.

Too many people experience care that is not of the quality we would all want for our own Mum or Dad. “We need a relentless and unswerving focus on providing the highest standards of care – whatever a person’s age or condition. This means a commitment to tackle poor care with minimum standards enforced throughout the system, so that those using social care services are always kept safe and treated with the highest standards of dignity and compassion.”

He went on to say that fixing the broken social care system “will take time” and acknowledged there had been “stalled reform programmes” in the past as he set out plans for reform. Giving his first speech since his department was given full responsibility for social care in January, Mr Hunt said the solution will be found in embracing the “changes in technology and medicine that are profoundly reshaping our world.” Setting out the seven key principles to reform social care which will be detailed in a Green Paper to be published in the summer.

Seven key principles

One of the Green Paper’s key principles will be a sustainable funding model. Other principles set out in the Green Paper include: the quality and safety of services, the integration of the health and social care systems, control for those receiving support, valuing the workforce, providing better practical support for families and carers and ensuring greater security for all. The new system of funding social care will be capped. Asked directly if that meant there would be a cap on what any individual had to pay, he replied: “Yes.” But his remarks disappointed those who had hoped for a tax-funded system that would give social care parity with the NHS. He insisted the element of personal responsibility envisaged in the original National Assistance Act 70 years ago would stay.

The health and social care secretary said: “The way that our current charging system operates is far from fair.” This is particularly true for families faced with the randomness and unpredictability of care, and the punitive consequences that come from developing certain conditions over others.

“If you develop dementia and require long-term residential care you are likely to have to use a significant chunk of your savings and the equity in your home to pay for that care. But if you require long-term treatment for cancer you won’t find anything like the same cost.”

Hunt acknowledges that the principles will not succeed unless the systems we establish embrace the changes in technology and medicine that are profoundly reshaping our world, he said. “By reforming the system in line with these principles everyone – whatever their age – can be confident in our care and support system. Confident that they will be in control, confident that they will have quality care and confident that wider society will support them.”

The need for action now

Hunt is under pressure to do something now. This month Sir Stephen Houghton, the leader of Barnsley council in South Yorkshire, said the postcode lottery was turning a historic economic divide into a serious social one. “If you happen to live in a poorer area you’re more likely to receive lower-quality care in old age or if you suffer from a long-term disability. People should be entitled to the same quality of service no matter where they live,” he said.

Hunt acknowledged “the daily pressure” faced by local authorities and said: “We need to recognise that with 1 million more over-75s in 10 years’ time they are going to need more money, and we are going to have to find a way of helping them to source it.”

Niall Dickson, chief executive of the NHS Confederation, which represents organisations across the healthcare sector, said: “Warm words are always welcome but let us hope this speech represents new thinking in a government which like the rest of the political class has been understandably distracted by Brexit. The signs are that the Secretary of State understands what is needed – but the challenge of convincing his cabinet colleagues remains.”

Jeremy Hughes, Alzheimer’s Society chief executive, said: “Jeremy Hunt’s seven principles must not be wishful thinking for those impoverished by having dementia. The Government must now commit the funding to make good on these principles. “Without the necessary funding, vulnerable people will continue to struggle needlessly. By 2021, a million people in the UK will have dementia, and we need urgent action to create a system that can meet that challenge.”

Summary

The seven key principles that will form the framework of the Green Paper due to be published in the summer of 2018 should be given a cautious welcome. After all, it could be argued that the reneged promised cap on social care frees cost this government a large majority at the last election. However, it is just possible that the pressure of the Government to deliver on these principles this time may result in a solution to the problems of social care for fear of losing the next election. I have no doubt that Jeremy Hunt is sincere in trying to achieve change, but he cannot do anything without the support of the Prime Minister and her colleagues. This issue should be above party politics. Let us hope that the Jeremy Hunt principles lead to much needed action.

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

Is the new Government cash injection for social care just another stop gap measure?


Local Authority Councils have welcomed the government’s decision to give them an extra £150m in funding for social care over the next financial year, but warned it was a temporary measure that would not alleviate wider pressures.

The cash injection was announced by Sajid Javid, the community’s secretary, in a written ministerial statement outlining the local government finance settlement for 2018-19.

After “listening to representations”, Javid said, he was committing an extra £150m over the year for social care, to be allocated on the basis of relative needs. The money will come from an expected underspend elsewhere in his department.

It is hard not to see the money as a response to the actions that are now being taken by Councils that in order to provide social care they are having to massively control their spending on other services.

It follows the decision last week by the Conservative-run Northamptonshire county council to signal it as near to effective bankruptcy after admitting “severe financial challenges”, particularly over social care.

The council issued a section 114 notice imposing financial controls and banning spending on all services except statutory obligations to safeguard vulnerable people.

The government has also faced pressure from some of its MPs to boost funding. The Shrewsbury and Atcham MP, Daniel Kawczynski, tweeted on Monday that he was having “difficult discussions” over the local government finance settlement.

The new cash means the government has given councils £9.4bn in dedicated funding for adult social care over three years, the statement said. The wider issue of social care needed “a sustainable settlement for the future”, Javid said, adding that a long-planned green paper on the subject due this summer would set out further plans.

Responding to the settlement, Gary Porter, the Conservative peer who chairs the Local Government Association (LGA), said the £150m “is recognition of the LGA’s warning about the urgent need for the government to further try and help councils tackle some of the immediate social care pressures they face”.

The money was, however, “a temporary measure and needs to be compared against an annual social care funding gap of £2.3bn by 2020”, Lord Porter said.

He added: “Core central government funding to councils will be further reduced by half over the next two years and almost phased out completely by the end of the decade.

“We have warned that councils also face an unprecedented surge in demand for children’s services and homelessness support. This is leaving increasingly less money for councils to fund other services, like fixing potholes, cleaning streets and running leisure centers and libraries.”

This financial year, Porter said, some councils were “perilously close to the financial edge”, even with the possibility of raising some extra council tax revenue.

Paul Carter, the leader of Conservative-run Kent council, and chair of the County Councils Network, said his organisation welcomed the extra money in the funding settlement.

He said: “While this funding provides some new resource for this coming financial year we must continue to work with ministers, who understand the enormity of the financial challenges facing counties, to deliver a long-term sustainable and fair funding solution to meet the estimated £2.54bn funding gap for counties.”

Councils have repeatedly warned that they face an increasing financial crisis caused by a combination of a significant reduction since 2010 of their support from central government and an increase in their statutory obligations, notably on providing social care to an ageing population.

Longer-term plans to tackle the crisis over funding social care were delayed after Theresa May swiftly ditched an election manifesto proposal to increase the amount people would have to contribute themselves.

In November, it was announced that the green paper outlining plans for the sector would be published this summer.

Summary

The cash injection of £150 million although given a cautious welcome by councils does little to address the funding gap in Local Authority funding. It can be seen more or less as a response to prevent some councils from declaring themselves bankrupt and unable to provide services for vulnerable people. It is one of a number of stop gap measures introduced by the Government to give it time to prepare the green paper outlining plans for the social care sector due to be published this summer. In the meantime, the rationing of social care will continue.

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

Care Quality Commission is seeking more transparency in care services ownership

In the light of the recent BBC Panorama Report on the so-called Paradise Papers that raised concern about tax avoidance through offshore accounts of large companies, seems to have alerted the Care Quality Commission.

An investigation by the Financial Mail has found that some firms involved in the care industry – many of which receive public money directly from local authorities to pay for residents’ care – have links to offshore tax-haven territories including the Cayman Islands, Luxembourg, Gibraltar and the Channel Islands.

The revelations coincide with a battle for control of the country’s second biggest care home provider, Four Seasons, controlled by Guernsey-based tycoon Guy Hands.

The company has until December 15 to satisfy a £26 million interest payment on its enormous debts.

The Care Quality Commission are to clampdown on large companies and in future Britain’s care home providers will be forced to declare their links to offshore tax havens. The clampdown comes amid growing concerns over the future of Four Seasons, one of the biggest operators in the market.

The CQC have said that from April it will ask firms to lift the lid on what are in some cases highly complex ownership structures – and to reveal the identities of the moneymen behind them.

A spokeswoman for the Care Quality Commission said the care market is ‘much more global than it was ten years ago and we need to be more transparent. We need to develop regulatory policies and want to get a better oversight of providers.’

She added that the CQC wanted to know who are the ultimate owners, and ‘who has influence and control. We need a better understanding of the ownership, of the investors and directors, and to make that public.’

The ownership of some groups passes through multiple layers of bizarrely named companies before ending up with a business or trust in a tax haven.

Among the so-called Big Five, Barchester is owned by a Jersey-based company. Four Seasons is owned by Hands’ Terra Firma, with an office in Guernsey. HC-One has links to the Cayman Isles. Its chairman Dr Chai Patel is director of a Cayman-domiciled FC Skyfall Topco Ltd.

In addition, second-tier groups, including Akari and Orchard Care, which own more than 100 homes between them, operate through a labyrinth of companies. Akari’s ownership funnels through a dizzying array of firms before resting with Caymans-based Csp Iv LP.

Orchard is controlled by a Guernsey-registered outfit along with ASO LUX 3 S.A.R.L, a mysterious Luxembourg-based enterprise.

And some care homes under the Bondcare and Care Worldwide brands are controlled by Gibraltar-based trustees.

Is the CQC right to be concerned about care home ownership?

Currently the Care Quality Commission as part of the registration and inspection process requires providers to have in place, a business plan and evidence on how the service is to be funded. This is to ensure that the service has enough capital to run the business for a considerable time, and to protect the wellbeing of residents from risk should the company become bankrupt. In which case, they will have to move.

The problem with larger companies is much more serious. It is obviously more difficult to establish the financial credibility of some larger providers. Otherwise we are left to conclude they would have done something about it by now. What is even more concerning is given the state of the care industry at this point in time, it would be extremely difficult to relocate such large numbers of residents, and the resulting upheaval to people’s lives

Moral issues

I work from the standpoint that most management and staff in the care sector give their best to residents, and do not receive financial rewards that equate with their level of commitment and effort.

It is morally indefensible for larger companies to take advantage of the offshore tax system when the care industry is suffering as a result of underfunding.

Summary

BBC Panorama Report on the so-called Paradise Papers and the Daily Mail Report on some larger home owners who use offshore accounts has raised the alarm bell with the care Quality Commission.

CQC has a right to be concerned. It is very much a safeguarding and risk issue. Given the overall position and reducing profitability of the care home industry. It may be difficult to relocate large numbers of residents, should any of the bigger companies go bust. It is imperative that the CQC establishes the financial credibility of these larger companies who use offshore accounts.

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