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

Are we any nearer a political consensus on paying for social care

home-help-domiciliary-care

Since the seasonal break the media has once again turned its sights to what they perceive to be a health service that is at breaking point and A&E departments turning people away. The situation has become so grave that Joyce Robins, from Patient Concern, said: “I don’t think the NHS will be able to spin their way out of this crisis. The public deserves honesty about the state of the services on which they rely – I would simply not want to be in hospital right now.” Her comments come as the British Red Cross – which has been called in to prop up struggling services – described the overcrowding in Britain’s A&E units as a “humanitarian crisis”.

As long ago as January 2016 the boss of NHS England was arguing for a new political consensus on paying for elderly and social care, and the funding debate should consider the value of pensions and homes, the boss of the NHS has said.

Simon Stevens argued that one of the main questions in tackling the challenge of how to pay for and look after an ageing population was whether some of the money spent on increasing state pensions should instead be allocated for social care.

“What are the pros and cons of dedicating some of the proceeds of the triple lock to older people’s social care?” he asked. The triple lock promises to raise the state pension every year by the higher of inflation, the increase in average earnings or 2.5%.

Social care is funded by cash-strapped local councils, who have had their budgets cut by 40% over the past five years. It includes services such as help for people at home with basic tasks such as washing and eating as well as adjustments to homes to reduce the risk of a frail, elderly person falling, such as grab-rails.

NHS England’s chief executive feared the service would be unable to cope if the recent decline in help received by older people from social care services, especially in their own homes, continues to increase demand for medical care and problems of hospitals becoming overcrowded.
He wanted the government at that time to rescue social care services from their downward spiral of funding cuts and increasing unmet need by reaching a political consensus on the payment for social care by 2018, to coincide with the NHS turning 70.

Some 12 months on it would seem that Stevens predictions are being realised, with further reports of an NHS in crisis. The new Conservative Government since coming to power have done little to seek a political consensus but rather choose to pass the buck to Local Authorities by allowing them to increase rates to provide more services.

In December 2016 Jane Cummings of Chief Nursing Officer NHS England said too much cash was being pumped into caring for patients in “old and expensive” hospitals, rather in a more efficient domiciliary setting.

In a letter to the Telegraph, Cummings said a greater emphasis on home care would result in a service that was better catered to a patient’s individual needs.

She said: “With more care provided at home, the NHS can spend more cash on patients rather than maintaining old and expensive buildings. And more people can be better looked after, with care personalised to their needs.”

She said refocusing the spending priorities towards domiciliary care would be controversial, but were necessary for the benefit of patients. In her letter, she said: “Whatever the merits of these plans, choices like these will always be controversial because we are talking about changes to strongly supported services that have served communities well for years.

“So this is not a moment to sit on our hands, nor to instigate big-bang changes. What we need is decisive but well-debated, locally owned improvements, doing things for which nurses, doctors and other health and care workers have argued for years.”

She said there was a real need to change “outdated models of care” so patients “don’t fall into the cracks between different parts of the system and ensuring that we provide care based around their needs, and not those of NHS organisations”.

It would seem then there a great deal of consensus that more care should be provided at home through domiciliary care agencies which would free up much needed hospital bed space and nursing time. This consensus however is not matched in the political arena, and we would seem to be light years away from gaining a political consensus and agreement to the payment for social care.

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

Addressing the uncertainty surrounding end of life care interventions in care homes

end-of-life-care-for-people-with-dementia

If you ask them, care home staff, healthcare professionals, residents and their families would all wish for and want to achieve the same outcome: a good death. But how can that be managed with all the uncertainties at play and with so many people and points of view to consider?

What people want, their care needs, how to interpret and treat symptoms, and who becomes involved in the decision making when someone with dementia is dying can become a source of anxiety, upset and frustration for everyone involved.

What’s been missing until now is a way of framing those uncertainties that can help make sense of the challenges, acknowledge them and have productive and helpful discussions that bring about the best decisions.

Research carried out by Claire Goodman has found that care home staff, healthcare professionals, Residents and their families may not always agree on the best approach to end-of-life care.

Using three different studies, the research – presented at the Economic and Social Research Council’s National Centre for Research Methods Festival – tracked the care of older people in 29 care homes over a 12-month period. Altogether, 528 residents, 205 care home staff and 44 healthcare professionals took part in the research.

The research found that end-of-life interventions were characterised by uncertainty in three key areas:

  1. Which is the “right” treatment?
  2. Who should do what and when?
  3. In which setting should end-of-life care be delivered and by whom?

Treatment uncertainty was an issue when a resident had been stable with no signs of decline, who had previously recovered from a similar episode of ill health or when deterioration was protracted with periods of good health between episodes of ill health.

It was further complicated by how quality of life was defined. care home staff, residents and family members said it was about residents’ ability to respond, engage with others and appreciate the home environment. For visiting primary care staff, it was linked to whether the intervention would lead to recovery of function or improvement.

Even where an advance care plan had been put in place, these competing narratives of what a good outcome looked like could not always be resolved.

When it came to who should do what when someone was dying, there was uncertainty about roles and responsibilities at both an organisational and an individual level.

Decisions to treat were GP-led, but this was a complex process between care home staff, visiting healthcare professionals and families. Visiting GPs had the (clinical) authority to make key decisions about hospitalisation or treatments, but this was undermined by infrequent contact with, and partial knowledge of, residents. Healthcare professionals providing urgent or emergency care found navigating these relationships even more problematic.

Care home staff often lacked confidence, concerned that relatives might be upset and lodge a complaint, and that this could lead to issues with the regulator.

Even where working relationships were robust and treatment was clear, end-of-life care could still be adversely affected by the way services were organised and resourced.

There was a lack of confidence among staff about their ability to deliver proper end-of-life care if promises of services and resources from the NHS did not materialise.

From all these insights, the outcome of the research concluded that uncertainty is an inevitable and integral part of end-of-life care for people with dementia. Residents’ characteristics, the protracted period of dying, multiple and changing personnel involved, different definitions of quality of life and the realities of working across health and social care mean uncertainties cannot always be resolved.

In simple terms, even with access to evidence-based guidance on how to support people at the end of life in care homes, there are times when it will not always be clear if palliative care is the right treatment, who should do what and when, and if the person can be supported to die in the care home.

The acknowledgement of these uncertainties according to Claire Goodman should not be seen as a failure, but as something that has to be worked at over a period of time by all those involved. There needs to be opportunities for conversations between care home staff and NHS practitioners to work through the options available to them.

Although uncertainty is an inevitable and integral part of end-of-life care, it is of paramount importance that care home staff can demonstrate the continual involvement of those nearest to the person. Clear communication between the perspective parties involved in the end-of life care plan, and care staff learning from their experience, may help to address the uncertainty.

Claire Goodman is professor of healthcare research at the Centre for Research in Primary and Community Care at the University of Hertfordshire

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute

Managing Director

Bettal Quality Consultancy