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Find out about the people behind Royal Voluntary Service in our series of guest stories from our volunteers, staff and partners.
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Tuesday’s report from the National Audit Office on Planning for the Better Care Fund painted a disappointing picture of plans containing misplaced assumptions not backed up with evidence through a lack of engagement with important stakeholders.
As a result, during the summer the process was placed on hold and targets and incentives were redesigned. Plans were not put to Ministers in April as intended because the financial risk to the NHS was regarded as far too great.
Plans have been reworked and last month we learned that 146 of the plans, the vast majority, have been approved, including those requiring further support (91) and some with certain conditions attached (49).
The Better Care Fund now contains some £5.3 billion in funding and exceeds the minimum contribution by £1.5 billion. The amount of credible savings has been adjusted down from £1billion to £532 million made up of reduced emergency admissions (£283 million), reduced delayed transfers of care (£31 million) and increased effectiveness of reablement (£30 million). The vast majority of savings appear to accrue to the NHS.
The main change was to the framework for the £1 billion payment-for-performance part of the Fund. The proportion of the £1 billion linked to performance now depends on the level of the local target for reducing total emergency admissions to hospitals.
We know all too well that there are far too many people being admitted and readmitted into hospital unnecessarily. Over 200,000 older people are readmitted into hospital within a month of discharge. Together the plans aim to deliver over one year an overall reduction in non-elective activity (general and acute) of 163,162 stays. In addition over 2 years the Fund aims to deliver 100,962 fewer unnecessary days spent in hospital, 11,860 older people remaining at home 3 months after discharge and 1,948 more people supported to live independently.
This process has been tough on local authorities. In the past few months local areas would have been preparing to implement the Fund. Instead they were reviewing and resubmitting their plans. This may impact on their performance and therefore ability to hit targets in the early stages of the Better Care Fund which may have a knock on effect on resources.
Joined up health and social care is a laudable and necessary ambition given tight funding and an increasingly ageing population. With the emphasis so strong on reducing hospital admissions, local government believes that the resources to support wider local initiatives to promote integration and prevention will be reduced. Reducing admissions by over 3% when they have risen by 47% over the past 15 years is a very ambitious target.
Providing a degree of focus and direction is a good thing and is an improvement on a vague call to pool budgets. But we must not lose the good initiatives that already exist. The dust is now settling and it is hoped that lessons have been learned and that that the Fund can deliver on its core undertaking “to give elderly and vulnerable an improved health and social system and to join up health and care services around the needs of patients, so that people can stay at home more and be in hospital less”.
This week saw the publication of a report from The Commission on Residential Care which is chaired by former Care Minister Paul Burstow MP and has over the past year explored the future of residential care– from care homes to extra care villages and supported living, for older and disabled people. You can read a copy of the report by following this link to demos.co.uk
The Commission had two main objectives. First, to create a vision of ‘housing with care’, not bound by existing definitions, but based on the outcomes that people want and value. And second, to set out how the existing offer could change to deliver this vision, across financial, operational, governance and cultural aspects of care.
The Commission found that despite there being many examples of good care, it is surrounded by negative perceptions fuelled by the headline cases that make the headlines.
The Commission made a number of recommendations to embed good practice and challenge public perceptions. These included enshrining a broader, more accurate definition of ‘housing with care’ throughout government policy; greater co-location of care settings with other community services; expanding CQC’s role in inspecting commissioning practices; and promoting excellence in the profession through the introduction of a license to practice and a living wage. The Commission concluded that these measures, among others, could help build a housing with care sector fit for the twenty-first century.
September 4 saw the long anticipated final report of the independent Commission on the Future of Health and Social Care in England (Barker Commission) by the Kings Fund. You can read a copy of the report by following this link to kingsfund.org.uk
This report examines the current health and social care system and proposes a new approach that redesigns care around individual needs. The Commission concludes that this vision for a health and care system fit for the 21st century is affordable and sustainable if a phased approach is taken and hard choices are made about taxation. We still under spend a number of other European nations when it comes to healthcare and the Commission believes it is feasible to be able to spend between 11-12% of GDP by 2025 to meet the inevitable rising demands on an ageing population.
It has recommended that health and social care should have a single ring fenced budget with central commissioning. Not many will argue with ring fenced budgets for social care and bringing both together might speed up efforts towards integrated care. But this does require yet another reorganisation which won’t be welcome. Clinical Commissioning Groups have not been in existence for long and some will say that they have not had the opportunity to develop and deliver well coordinated care.
The Commission wants those with critical needs to receive free care at the point of use and believes this should also be extended to substantial need when then economic situation allows. By 2025 those whose needs are moderate should also receive free care. Pathways should be simplified to respond to changes in need. It wants to see a new “care and support allowance” and personal budgets to give individuals more control over the support they receive.
The Commission has made some radical and controversial proposals on how to raise £5 billion to pay for this expansion. Proposals include removing exemptions on free prescriptions and means testing TV licences and the winter fuel allowance. Also suggested is requiring those over 40, in retirement and high earners to pay more in national insurance. These proposals may prove unpopular especially those which involve means testing of the vulnerable.
But firstly, politicians of all parties need to agree that more money needs to be spent. Whether it is paying decent wages and providing better training for care staff or to providing free care for those with most critical needs more funding is essential. It is not possible to meet rising demands purely by efficiencies. More funding needs to come from somewhere and this primarily equates to increased charges or taxes. It could of course come from making other choices around scaling down other big ticket projects. But with elections just 9 months away and older voters more likely to take part in a general election than other age groups, are any parties brave enough to bite the bullet?
In response to the release of the Kings Fund report A new settlement for health and Social Care, published today 4 September 2014. The report recommends that some benefits should only be given to those older people most in need, and that those savings and increased taxation should be used to fund the inevitable increased cost in social care. Follow this link to read the full report A new settlement for health and Social Care
Britain is facing an ageing population, which along with many positives, also brings challenges. To allow a truly preventative and personalised approach to care for older people, which should be our focus when looking to reduce costs, it is essential that health and social care budgets are unified and integrated. The voluntary sector has an important role to play in bringing down the costs of care and ensuring the individual needs of older people are met.
David McCullough, Chief Executive
Posted by David McCullough at 13:49
Thursday, 04 September 2014.
On Thursday 13 March the National Audit Office (NAO) published its Adult Social Care in England report.
Much of the content of the report will come as no surprise to many who follow the health and social care agenda. It includes much talk about integration and social care being 'joined up'. In particular the finding the older people have experienced the greatest spending reduction in their care, down 12% between 2010/11 and 2012/13, is a stark one. Over the last four years, the number of adults receiving individual packages of state-funded services has fallen. But with 87% of local authorities having set their eligibility threshold to only provide support to those with substantial or critical needs paints a consistent and disappointing picture, especially with a growing government focus on prevention being the best and cheapest way to look after older people. Around a third of adults aged 65 and over report a need for help with at least one activity of daily living. Without this help they are at further risk of having a poor quality of life and becoming socially isolated with all of the negative health implications that brings.
The NAO indicates that greater spending on social care is related to lower delayed hospital discharge rates and fewer emergency admissions. At a time when A&E and other services are under severe pressure the continuing cuts in funding of front line support services does seem counter-productive. We know from Royal Voluntary Service research that a Home from Hospital scheme can reduce hospital readmissions by 50%.
Indeed, voluntary organisations are filling a much needed gap. In 2010-11 the NAO showed that the voluntary sector spent £2.9 billion from its own fundraising on care and provided a further £6.2 billion of care commissioned mainly by local authorities. This represents nearly a quarter of voluntary sector activity.
Self funders of care contribute 13% towards a total adult social care budget of £19 billion. There are fears expressed by the NAO that Councils know little about this group of service users and will struggle to plan for them. There are also criticisms that the commissioning and providing services which are the most cost-effective is based on weak evidence. The NAO concludes that national and local government do not know whether the care and health systems can continue to absorb the cumulative pressures, which includes increased demands of an ageing population, and how long they can carry on doing so.
The Public Accounts Committee chair Margaret Hodge MP, has been swift to swoop on the report findings. "The result is unnecessary stress and an unfair financial burden on those who need care and the 5.4m unofficial carers who already contribute £55bn worth of care every year.
"The fact the departments do not know how much longer the entire care system can cope under the mounting pressure makes for a worrying picture.” The MP meets with Government departments on 26 March when this will be discussed.
The delivery of health and social care has undergone major change to its core structures. Many of the changes have already taken place, but most took effect on 1 April 2013. These changes will have an impact on who makes decisions about NHS services, how these services are commissioned, and the way money is spent.
Primary care trusts and strategic health authorities have been abolished, and other new organisations such as clinical commissioning groups (CCGs) have taken their place. As of this week a total of 211 CCGs are responsible for £65 billion of the £95 billion NHS commissioning budget. All 8,000-plus GP practices in England are members of a CCG, putting the majority of the NHS budget in the control of frontline clinicians for the first time. The groups will include other health professionals, such as nurses.
CCGs will commission most services, including, planned hospital care, rehabilitative care, urgent and emergency care, most community health services and mental health and learning disability services. CCGs can commission any service provider that meets NHS standards and costs. These can be NHS hospitals, social enterprises, charities, or private sector providers.
To add to the mix are health and wellbeing boards; a new forum where leaders from the health and care system work together to improve the health and wellbeing of their local population and reduce health inequalities. Each top tier and unitary authority has its own health and wellbeing board. Board members will work together to understand their local community’s needs, agree priorities and encourage commissioners to work in an integrated way. The intention is that as a result, patients and the public should experience more joined-up services from the NHS and local councils in the future. Local boards are free to expand their membership to include a wide range of perspectives and expertise, such as representatives from the charity or voluntary sectors.
In addition each local authority will have a local Healthwatch organisation in their area. The aim of local Healthwatch will be to give citizens and communities a stronger voice to influence and challenge how health and social care services are provided within their locality. Local Healthwatch will also provide or signpost people to information to help them make choices about health and care services.
Add to this other bodies such as the NHS Commissioning Board, Public Health England and Healthwatch England to name but a few, and it becomes a complex maze to work oneself through. The intention is the make health and social care more integrated and responsive to the needs of the local community. Support for older people such as that provided by organisations like WRVS has never been more necessary given the constraints on central and local Government spending. It is in everyone’s interest to work towards making sure this new system delivers. Time will tell whether the changes bring about the transformation that is urgently required.
A year ago the House of Lords decided that the social changes that were being experienced with many more people living longer needed investigating as they couldn’t find evidence that it had been looked at comprehensively by Government before. Today the Lords Select Committee on Public Service and Demographic Change published its highly anticipated report. The key message is that are as a nation we are “woefully underprepared for ageing”.
Many of us will be living 10 years longer than we were expected to when we were born. Whilst there is a very real issue now, we don't have to look that far forward to the change accelerates. For example, by 2030 the number of people aged over 85 will have doubled.
The key message from
the report is that are
as a nation we are
We know that this creates opportunities. WRVS' own research shows that older people generate some £40billion to the UK economy, and this will rise
. But at the same time this brings about its own challenges.
The Committee is concerned about how older people will support themselves and has highlighted three key areas that need addressing. The first is around pensions and encouraging saving, the second around working past traditional retirement age and lastly around unlocking assets within their own homes.
On health and social care the Committee believes that the system is not designed to deal with long term chronic conditions, but more acute conditions and therefore it will need radical change. It argues that there needs to be a shift in focus and vision in England to improve integration and prevention, with an aim of keeping older people safe in their own homes rather than in hospitals. It suggests looking at merging health and social care budgets and providing care 24hours a day, 7 days a week for 365 days of the year. The Committee recognises the valuable contribution that voluntary organisations such as WRVS already make, but recommends that central and local government work with the third sector to increase volunteering especially by older people to support older people.
Ageing is a huge social change that will impact on everyone. Government therefore needs to have a firm understanding of what this means in terms of the UK’s population, society and public policies and develop a coherent strategy going forward. The Committee is critical of the current and previous Governments over many years that have failed the grasp the enormity and urgency of the situation. The Committee calls for the issuing of a White Paper before the next general election setting out the issues and how we should prepare for longer life. All parties should consider an ageing society in their manifestos for the next election.
The Committee also recommends that whoever is successful after the election should establish two cross party commissions to respond to the ageing society; one would look at finance and the other health and social care.
This report offers a unique opportunity to tackle some difficult issues and to bring about real change. Let us hope that this opportunity is grasped by all parties as we head towards the next election. Read the full Ready for Ageing report.
Yesterday’s confirmation by the Health Secretary revealed that the cap on social care will be set at £75,000 in England. This headline has received a cautious welcome from most quarters. However, the cap cannot be looked at in isolation and at the moment it is still difficult to see how many older people and those entering old age in the coming years will be affected as there are still a number of unknown factors. In addition, boarding and food costs are not included in the cap. The objective is to try and ensure that people living in their own home are not penalised unfairly as they are still responsible for paying their housing costs. These so called “hotel” costs will be capped at £12,000 a year.
The cap won’t take effect until April 2017 and the Government has stated that £75,000 in 2017 is in effect worth the equivalent of £61,000 in today’s prices. The current threshold over which support is not provided is rising from £23,250 to £123,000, a rise of nearly £100,000. This means that more people will be entitled to receive some support for their care albeit on a sliding scale.
The big element missing in all of this is at what level the national “eligibility criteria” will be established. At the moment councils are free to set the criteria at low, moderate, substantial or critical. This perpetuates something of a postcode lottery. As funding has become tighter, an increasing number of local authorities have set their criteria at substantial. At the last count well cover 82% of England’s local authorities were at a substantial level or higher. The level at which this is set will be important calculating how many people will be supported. The higher the eligibility criteria bar is set means that those with lower needs which may prevent or delay more intensive and expensive interventions may miss out.
But the response to Dilnot is not the full answer. Implementation of these changes and those proposed in the Care and Support Bill won’t take effect for over 5 year’s and there is already a shortfall in the funding of adult social care that will increase during this time as local authorities make further savings.
All of this goes to demonstrate that volunteers working within organisations such as WRVS are key in delivering the practical support that older people want, but without the huge bills attached, not just for now, but for the long term.
Paying for care in old age is a significant worry for many people. However, for a large number of people going into a care home is the last resort and most older people would rather live independently in their own homes for as long as possible. Supporting them to do this doesn’t have to have a large bill attached. Practical support provided by volunteers at crucial times, such as settling people back into their homes after a major operation, will be central to us managing demand for health services in lean times. WRVS volunteers bridge that gap through a whole range of practical services, such as supporting older people to continue do food shopping; making sure their houses are warm and cupboards well stocked when they are discharged from hospital or just a friendly face popping in to see them regularly. This support is relatively inexpensive but the rewards are considerable.
The focus of the older people debate centred this week was on the Government’s plans to radically reform pension provision and provide a flat rate pension of £144 a week by 2017. This announcement by the Pensions Minister Steve Webb MP completely overshadowed figures published on the same day by the Department of Health showing that over a ten year period emergency readmissions for the total population had increased from 370,940 in 2000/1 to 648,147 in 2010/11. When taking a closer look at the 75 and over age group, the figures are even more worrying. The raw data shows that in 2000/01 the numbers of emergency readmissions for the older age group were just under 100,000, but by 2010/11 had doubled to just over 200,000 a year. This equates to a rise in emergency readmissions for the older people from 11.04% to 15.69%. One can ponder why this is the case, an increase in the numbers of older people, changes in counting methodology, definitions and various other possible changes in circumstances, but nevertheless the rise is still significant.
There is a crucial role for the emerging Clinical Commissioning Groups to play in ensuring that the support and the services that keep people safe at home are made available. Over recent years money has been transferred from the mainstream NHS to local authorities for the purposes of reablement and post discharge support in addition to more general social care.
There is a growing consensus that low level social care that provides vital practical support is preferable to them returning to hospital shortly after discharge when it is not necessary. During Health oral questions on Tuesday, Stephen Dorrell MP, Chair of the Health Select Committee, quizzed the Minister saying that one of the most effective things to do to improve the patient experience of health and care is to improve the co-ordination, not just between the hospital service and community-based health services, but between the NHS and social care.
However, WRVS research into the relationships that are being formed at a local level are not as advanced as one would like to see at this stage. Of the 98 PCTs that responded to a WRVS FOI enquiry into relationships with the local authority, 20 had pooled budgets, and 3 had informal regular meetings. Just a single PCT had established a joint working group with representatives from local authorities specifically for commissioning services related to admissions/discharges.
On Monday the Guardian published data from its survey in which professionals working in local government said they did not have the knowledge and expertise to commission services. The vast majority (77%) said they needed more training to do the job of commissioning well, while 14% said they were already being expected to perform jobs without the necessary skills. Just 8% said they felt fully equipped to take on the job of commissioning. Almost half of those surveyed admitted they had not heard of the Social Value Act, which requires public bodies including councils to consider the social value of a contract when procuring services and goods.
Penalties on readmission rates were introduced to improve clinical practice and it is estimated that the cost to the NHS of patients being readmitted to hospital within a month following discharge is £2.2bn. It is clear that the increase in unnecessary emergency readmissions of older people is unsustainable and takes up valuable resource which could be more effectively used elsewhere in the healthcare system. It is still early days, and it may take some further steps and time but there are cost effective solutions that exist for example, Home from Hospital services, that can deliver better outcomes on the ground. It is time that more use is made of these types of service.
Posted by Steve Smith at 00:00
Friday, 18 January 2013.
As we enter 2013, the many issues that come with an ageing population have never been more centre stage. Keeping with the theatrical theme, even the film industry is getting in on the act with Dustin Hoffman making his directorial debut at the age of 75 with “Quartet”, a film about four friends who reside at home for retired opera singers.
The draft Care and Support Bill published in July 2012 proposes a single, modern law for adult care and support that replaces existing outdated and complex legislation. Comments were requested by the Government by 19 October and a summary of responses was published just before Christmas. The Joint Committee on the Draft Care and Support Bill has already begun to take evidence from experts and has invited written submissions by 11 January as part of this work.
In yesterday’s report by think-tank Centre Forum, Paul Burstow sets out some ideas of how the funding of future care could be achieved by linking winter fuel payments with Pension Credit, reducing the number of recipients from over 12 million to around 3 million, saving £1.5 billion annually. The idea is welcomed by some, but criticised by others and is likely to be controversial. But it does set down an early marker for the ensuing comprehensive spending review that will begin shortly.
In December local clinicians were given the green light to take control of the NHS budget in 34 areas of England shaping the way in which care is delivered for millions of older people in the coming months and years.
The House of Lords Select Committee on Public Service and Demographic Change hold their final evidence session on 9 January, where they will put the questions that have emerged over the course of their inquiry to Ministers Jeremy Hunt MP, Norman Lamb MP and Steve Webb MP. WRVS has been one of a number of organisations that have given oral evidence at hearings over the past few months. The inquiry is the first by Parliament to assess if our society, policies and public services are really ready for the ageing population. The evidence that the Committee has received so far suggests that we are worryingly underprepared.
The outgoing Archbishop of Canterbury Rowan Williams in his final New Year Message centred on the crucial role of volunteers. He said that anyone who had seen the London Games “will have been made aware of the army of volunteers who cheerfully gave up their free time and worked away, without complaint, all hours of the day and night to make these great events happen. They were the key people who translated the Olympic vision into reality for the rest of us.” He recognised that similar acts are happening in many other communities around the country in far less glamorous circumstances. But he also asked the tougher question: what can we all do to join this silent conspiracy of generous dedication?
It is clear that urgent action is required by Government to put in place the adult social care framework that older people deserve and that will be necessary to meet the demands of the 21st century. It has also become clear that Government cannot do this alone.
Earlier this week building on the comments made by Williams, social care minister Norman Lamb said that friends, family and neighbours should all do more to prevent older people going into care unnecessarily. Just before Christmas it was announced that volunteers will soon benefit from a free service which will allow them to re-use criminal records checks time and time again. The move to cut red-tape and reduce the burden on those who give up their time to work with older people is a welcome step. The many tens of thousands that give up their time on a regular basis with WRVS and other organisations to help in their local communities are an essential part of the solution. So not only do we need a new legal framework, but also to devise new and innovative ways to encourage more people, especially those reaching retirement, to continue to contribute. At the same time movement to ensure cooperation and coordination between organisations and authorities is necessary, if we are to be in better shape at the end of 2013.