John Bolton - What Does Good Look Like When there are Scarce Resources in Social Care?


No-one doubts that social care budgets are under pressure but at CIPFA’s Annual Health and Social Care Conference Professor John Bolton said that the picture varies remarkably between councils, e.g. half the councils in England showed a growth in Adult Social Care (ASC) spend last year and half a reduction.

The Treasury, he said, know that some councils have made 30% reduction in ASC and lived to tell the tale – and so are bound to ask why others can’t, too? Yes, there is an ageing population, but there have been fewer people getting care for a decade, but this isn’t necessarily a matter of people not getting the services they need – part of the story is ASC success in reforming services to reduce demand.

On average the number of people in residential care is reducing by 3% per year. That’s good, though he noted that there is a problem in looking at the data in isolation: that doesn’t show whether (a) successful action has been taken to reduce demand by remodelling care pathways or (b) eligibility criteria are being applied more tightly to reduce access to services.

Bolton suggested that the savings achieved to date in ASC could be split broadly into four:

  • 25% from council savings from real terms reductions in the costs paid to others
  • 25% from staffing reductions 
  • 25% from cuts in Supporting People budgets
  • 25% from other factors, such as increasing income, tightening eligibility etc.

He said he would avoid looking further at procurement (as costs are already down to potentially unsafe levels) or social care staffing. He emphasised that it’s the behaviours of social workers which makes the difference in spend. Risk averse practices are expensive, and over-prescribing social care is a problem in the NHS. What happens at hospital discharge is a key issue and it seems that the more clinical involvement and the less social work involvement, there is at discharge, the higher the cost.

So what can be done? Bolton suggested that there are five areas with potential for significant savings. Some authorities have indeed progressed all of these, but many have not.

1. Personal Budgets – Direct Payments and Personal Assistants. Barking & Dagenham lead the way here, having made savings by delivering services at scale through Personal Assistants (paid at living wage, by the way) – when most authorities still tend to use comparatively conventional contracted services for Personal Budgets.

2. Community Capacity – helping people outside of the formal care system. North Tyneside have a daily graph of all the people they help, which demonstrate how 70% are not coming onto the formal social care system – and councils can help people to find solutions for themselves.

3. Integration with the NHS – getting the right care pathway for people in the NHS. This is more about better service than saving money. A recent Newton study says a possible 2% efficiency in the system would mostly benefit the NHS. Only 10% of demand in NHS could have been avoided by social care interventions – so the Better Care Fund premise – social care investment to reduce admissions – is flawed. Mostly it’s community and public health action which makes a difference. Paradoxically, though, there has been a halving in district nurses over the past decade.

4. Promoting Independence – every care plan should have an aim to help the person be more independent. In most councils, 50% of new demand comes through acute hospitals, hence the key is to control that, and recent evidence suggests we may be giving reablement support to the wrong people (those who would recover anyway) whereas those stuck in long term patterns respond better to reablement than we have supposed. It should be possible to reduce residential care by a third. Ordinarily care homes are good at settling people in to their regime, then they stay – but if commissioned to maximise discharge that can help.

5. Outcome based commissioning for population – work with Commissioners and Providers – trust them to deliver improved outcomes. This is how good practice originated in Torbay and Northumberland. Trusting the provider is potentially a lower cost model.

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