Responding to COVID-19: insight, support and guidance
The annual conference was well attended, and covered a wide range of issues relevant to health, social care, their integration, and the wider system. Read below for an overview of the topics discussed by our speakers and download their presentation slides.
Surveying the state of social care and its implications for the NHS, keynote speaker Richard Humphries (Senior Fellow, Social Care, the King’s Fund) warned against the tendency in some quarters to present social care as a supportive adjunct to the NHS – Simon Stevens is the first national NHS Chief Executive to say that social care should be the priority – and attribute NHS problems to social care’s funding challenges. Social care is also a critical service in its own right, he said, and "the NHS is quite capable of getting into trouble without any help". The question could equally be put the other way round, to look at the effect of health changes on social care; for example, there were 40,000 long-term beds in the NHS 25 years ago which are now in the social care sector, and domiciliary carers now do tasks which nurses undertook 25 years ago.
Looking at the spend on older people, which is dominated by the NHS, he suggested a designed system would end up with the split we have between keeping people in good health and dealing with them when they’re ill. The CQC Report on the State of Health and Social Care, issued on the day of the conference, points out pressures, as does the King’s Fund’s recent Home Truths report on all dimensions of care for older people. Even allowing for the Better Care Fund, he said, there has been a 9% real terms cut in social care spend since 2009 – against the flow of demography. Likewise key NHS services for older people have reduced, and there is considerable concern for the viability of local authority reliant residential care, and especially home care, where market exits are occurring.
Delayed transfers of care due to awaiting a social care package are up 165% in the last five years, though there are still more delays. But there are fewer delays than those involving other reasons, primarily awaiting further NHS care. Austerity has focused the mind, but savings actions can’t fully explain the reductions: 26% fewer people in receipt of social care now than five years ago; carers are feeling less satisfied; and there are more complaints to the ombudsman. The last five years have seen social care funding cut by 2% per year in real terms, and even if 100% use of the precept is assumed, the average real terms increase will be 0.6% annually when probably 4% is needed to maintain the service offer. The King’s Fund believes the current £1.2bn social care shortfall will rise to £3.5bn by 2020. Naturally, Richard Humphries said social care needs to carry on trying to get more with less, but the government may also need to revisit the Care Act’s ambitions, and take notice of the rising crescendo for fundamental change.
Download the presentation (PDF, 969 KB)
John Jackson, who has been ADASS’s Resource Policy lead since 2009, backed up the picture of social care finances painted by Richard, stressing how hard it was proving to carry on generating £1bn a year of savings in social care – the more so when it was no longer feasible to hold provider prices down further: rather, what local authorities have to remember now is that if the market falls over it will cost massively more than at present. The starkest fact is that there are 1.6 million people over 85 now, but by 2035 there will be 3.5 million.
Would sustainability and transformation plans (STPs) solve the problem? It is unlikely that they will deliver the savings plans required by the Five Year Forward View, for two reasons. First, political deliverability is likely to be a big issue. Second, the NHS doesn’t have a history of long-term planning, and had never had less than 4% growth per year prior to 2010, so this is new territory and a struggle is likely – the more so when lack of coterminosity between local authorities and STPs is problematic, and A&E performance is at its worst since 2003.
Download the presentation (PDF, 448 KB)
Elizabetta Zannon (Director of the NHS European Office, NHS Confederation) explained that, as the first full member to leave the EU, Britain couldn’t really tell what to expect from Brexit, but that there are two main models:
What options lie between these extremes? Hard to say, but EU leaders say Britain can’t separate movement of people from movement of goods, services and capital – no ‘cherry picking’. Trade deals are very complex, she warned, and tend to take a long time to settle.
Turning to health specifically, 10% of doctors, 5% of nurses and 6% of social carers are from the EU, but the distribution is uneven, so there could be particular problems in some regions. ‘Brexit’ can be used as an acronym of the areas of potential impact on the NHS:
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Christine McLaughlin (Director for Health Finance, Scottish Government) and Mark Ash (Assistant Director of Finance, Velindre NHS Trust) outlined how somewhat different arrangements have emerged in Scotland and Wales, from which England might draw lessons.
The Scottish system, said Christine, is 10% of the size, and interestingly different from the English one. There are 14 NHS boards, 32 local authorities, but a single commissioner and budget for health and social care – with a ‘structure in the middle’ – integrated joint boards (IJB) which are made up 50/50 of councillors and NHS non-execs. The integrated joint board is a legal entity with a set of accounts, but doesn’t hold the finances, and has no workforce. It therefore relies on good partnership working, including with other sectors. The details vary, for example whether children’s social care is included, but ‘variations to suit local circumstance’ is preferred to ‘consistency’ as a goal. Winter planning, for example, sits with the joint boards rather than being nationally led. The national level concentrates on outcomes, not targets – local decisions are made on what indicators and targets to adopt.
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The Welsh, said Mark Ash, "pinch with pride" by renaming English initiatives (eg the Better Care Fund is the Intermediate Care Fund), but more substantively have combined health and social care budgets and a director general overseeing health and social care together – though there are no bodies with joint formal powers. The 1997 local government reorganisation led to 22 unitary authorities and 22 local health boards (with no purchaser-provider split) – which proved helpfully coterminous but too small. The health side has been rationalised to seven boards, but though the Williams Review recommended matching seven local authorities, that didn’t happen, so local authorities were asked to merge voluntarily but also with little result. Local examples of integration such as the Gwent Frailty Programme, present a potential way forward, with the health board and five local authorities pooling their budgets.
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Andrew van Doorn (Deputy Chief Executive, Housing Associations' Charitable Trust) looked at the potential contribution of housing to health. He emphasised the need for providers – more importantly than commissioners – to integrate services, including with housing. Its importance to wellbeing is clear: most health management takes place in the home, and one study has shown that poor housing costs the NHS £1.4bn per year.
Housing associations are now the main providers of social housing. Andrew asked: how can they help with health’s priorities? Most obvious are specifics around leaving hospital, for which assistive technology offers should increasingly become the norm. But Andrew also recommended using NHS land to develop step-down accommodation and housing for the NHS workforce, and suggested that – with property management not a core expertise for the NHS – it would make sense to give housing associations the chance to manage the NHS estate.
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Matthew Cripps (National Director, NHS RightCare) explained how atlases of variation have proved how not all hospitals are following evidence-based best practice. Tackling the previous ‘invisibility of variation’ is proving an extremely valuable driver for improvement, and Matthew provided several compelling examples. Some areas could halve the incidence of limb amputations due to diabetes, for instance, while saving substantial money at the same time.
From an integrated point of view, it would make great sense, he said, to pull social care data into the approach to enable a deeper comparison between the services provided in a particular area across the whole pathway. This hasn’t been possible yet, but is something Matthew is keen to take forward.
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Kevin Stewart (Local Taxation and Benefits Manager, Wealden District Council) considered how Attendance Allowance (AA) (of around £4.75bn annually) would fit in were it transferred to local government though, as he noted, the DWP seem to have pulled back from hoping to transfer attendance allowance to be met from retained business rates in its entirety, to seeking to transfer new cases only.
Kevin argued if the aim is to pass across this universally available, disability-related cash payment so that local authorities could end it and plough the money into better targeted support, the local political realities would most likely result in maintaining the status quo.
Download the presentation (PDF, 253 KB)