Rethinking Care Funding

An interesting headline in the Independent caught my attention  this morning.

‘Affordable old age – U-turn on money for elderly care’

So the  story develops, in the Independent, along with other papers that the government (via a ‘senior sources within both coalition parties) that the Dilnot proposals to fund adult (note – adult, not ‘elderly’) social care in England.

Dilnot’s ‘headline’ proposal was that there should be a cap on the limit of personal liability for the cost of care fees and this development suggests that that limit may well be set at £35000.

The article explains

A Whitehall source said: “They’ve come to the conclusion they’d be mad not to do it. It’s all about the legacy. It means both the Conservatives and Liberal Democrats can turn round in 2015 and say: ‘We sorted out social care. Because of what we did no one will have to lose their homes to pay for nursing home care any more.’ That’s a pretty big achievement – and would appeal to both sets of voters.”

Now this narrative of ‘losing homes to pay for nursing care’ is a basically incredibly simplistic for a start as it doesn’t really take into account the conditions that currently exist about when that may or may not happen. It does, however, grasp on the ‘tabloid narrative’ of the terror of the home owning generation that they might actually have to use some of their assets to pay for the high cost of care.

You see, I have a problem with Dilnot and care caps while seeing it is politically pleasant. Care has a significant cost.  Caps are good politically but there will need to be significant investment of money and the ‘cap’ is solely in terms of ‘care costs’ and wouldn’t cover the ‘hotel costs’ of residential care.

Protecting inheritances though, fits well into the coalition narrative and without doubt, there’s a need for the basis of social care funding to be rationalised. I hope the coalition move beyond the ‘selling homes to pay for care’ narrative that’s overplayed and under-understood.

See, the other interesting little tidbit of information in this report from the Independent is that

The Treasury is expected to argue that the plan should be paid for out of the general NHS budget. But that could create problems for Mr Cameron, as Labour could argue that funding care was robbing hospitals and frontline services of cash.

This will add significant pressure on the NHS – however it does potentially free up the local authorities from some funding responsibilities that they already have. This remains a worry. What I need to see to be satisfied with this proposal is detail about where and how the money is going to be made up when the cap is in place.

A move on Dilnot though (which is about more than caps – believe it or not and you wouldn’t necessarily if you just read the headlines) would be a definite positive so I’m not knocking it.

I just wonder about headlines that talk about ‘affordable old age’ – affordable to whom? Sometimes affordability comes at a cost. I want us to achieve quality care for all those who need social care input and it will cost. It’s a matter to consider where the burden of that cost will lie. As long as the money is extracted from a stretched NHS budget without further injections of cash, I can’t be as overjoyed as I would like to be about this u-turn.

I’ll retain my sliver of cynicism until we have more details.

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Reforming Care

There’s a good piece today in the Telegraph by Liz Kendall the Shadow Minister for Care and Older People about the need for the government to push through reforms to the system of funding (and provision) of social care in this country.

The timing is pertinent of course although the message seems to have been around for decades. Tomorrow will be the Queen’s Speech and the government will set out its legislative programme for the next year. With the Dilnot Commission reporting last year it seems that the need for changing the means of funding social care support would be something that may appear tomorrow. My own gut feeling is that it won’t but I’m happy to be wrong on this.

There are two connected but separate issues to the ‘care reform’ debate. One relates to the way that care is funded and that is the issue that Dilnot specifically refers to.

Currently, each Local Authority has it’s own ways and means of determining charges although there is a threshold capital limit of £23,500 above which a person may be liable for charges. There are various computations and methods that these levels and charges are managed but the fact is that means testing is by no means consistent across England – nor is quality and level of provision.

£5000 towards care in Manchester may buy something very different to the same in Chester or Westminster or Norfolk.

There is anger about the ‘working hard all their lives to buy a house and then needing to sell it instead of leaving it to the kids’ argument that I have less time for as I think the exponential rise in property values is less about working hard and more about luck, employment opportunities and an odd housing market but if you are going to deprive people of assets which by default is going to happen as social care won’t be fully funded, it should be done in a fair, equitable and transparent manner.

Currently, I find it almost impossible to explain to someone what charges they may be liable for and it shouldn’t be like that.

Dilnot proposes a cap (which may be changed according to the government) on the amount that would be charged to the individual needing care and I can appreciate that. It is a sum which could be insured against and it is a sum which can be planned for.  However, it would need increased capital funding from central government and there’s the rub.

As for the process of improving quality of care and choice in care. it’s separate but linked. The ‘system’ is starved of cash injection at the moment. Cost has overtaken quality in terms of contracts being meted out by local authorities and choice is a luxury for the few rather than an option for the majority.

The government has been ruthless in their decimation of budgets to local authorities and while we’d all like to think the NHS and local social care budgets are intrinsically linked – the reality is different and the shifting of cost and responsibility between health and social care ‘pots’ is damaging to those who need to use these services.

Work has to be done on the fundamental basis of the way that social care is delivered in terms of ensuring that rights and particularly the right of access to well funded care is open to all. While money will always buy more choice and better facilities (that’s the point of ‘working hard all your life’ if you want to follow that argument) – the provisions meted out to those who are unable to pay ‘top ups’ or arrange their care independently cannot lag behind.

There has to be a more cooperative flow of budgets between health and social care and they have a symbiotic partnership and while there is division, there will be increased costs.

Integration is seen as a ‘watch word’ but to date there has been little in terms of actually working on it in a practical and innovative manner from bottom up.

It becomes an easy word to through around and everyone around the table can nod and smile and say ‘yes, we need to do that’ but what is needed is solutions not a continual detailing of problems (although problems do need to be identified of course – but sometimes I feel that’s all that happens!).

So let’s watch and see if the government do pick up the challenge tomorrow – I suspect we won’t see any changes but I hope to be pleasantly surprised..

It is worth remembering though that the provision of Dilnot would appeal to the demographic the government wants to attract but it would be at a considerable cost.

I will watch with interest.

Researching and Improving Dementia Services

Memory

Today the government has announced an increase in funding for dementia research, indeed, the figures given by the BBC talks about raising the money put into dementia research from £26.6m to £66.6m by 2015.

Great news, really it is. I think it’s essential that there is a focus on dementia and what can prevent and assist those who suffer from and potentially suffer from dementia in the future.

As well as research though there were other strands to the government’s announcements about dementia.

Mr Cameron will set out plans to step up research into cures and treatments and to ensure that the health and social care systems are equipped to deal with the problem.

The highlighted part is the area that sticks a little in my throat as I read it. I do wonder how much the government and ministers are aware of the services that have been decimated (probably more than decimated if we are going to be talking literally) over the last couple of years and the disinterest shown by the general public in terms of improving both health and social care outcomes for those who have dementias.

Money into research and cure is a hopeful statement  – it looks forward and it helps us who are the electors of today have more hope for our future with the fear of losing cognitive functioning in our later (or not so later) years.

Money into equipping health and social care systems to ‘deal with the problem’ of dementia are altogether something else because it isn’t ‘us’ who will benefit – we, todays electors, are the ones who will pay and experience (or at least, the lack of political will on all sides)  shows that no-one wants to pay for the true costs of providing good quality care for older people with dementia in real terms.

I’ve seen a lot of simplistic talk about dementia over the past weeks, months, years. It is not a single diagnosis and it does not affect people in a single way. People with dementia walk and function among us and they are not all older people sitting alone in bungalows waiting for pity – although it’s important to remember that some do live alone without sufficient support or interaction. They are not all people who want or need pity – there is hope for positive life experiences even when ones cognitive functioning is impaired.  We infantilise the process of ageing and those who merely have a diagnosis of dementia and it says far more about those who are speaking and talking in those terms that those who may be bearing the progress of their diagnoses in as many different ways as there are people.

However one thing does need to be addressed and I hope it is addressed by the government today – with money. That is the issue of treatment and assumptions made about people with dementias in institutional care settings. We have had talk about ‘dignity in care’  – particularly in hospital and residential care. This must be approached and tackled in the ways I have previously discussed by putting more people on the ground in terms of nurses in hospitals and increasing staffing levels in residential and nursing homes. We need to back up a determination to provide better care for some of those people who won’t be ‘shouting loudly’ or have families to ‘shout’ for them by placing independent visitors and advocates in these institutional settings and improving regulation and quality control for those who need these services.

As for changes in home care – we need to embrace truly personalised care and the ‘personalisation’ agenda beyond managed budgets of block contract agencies providing 15 min ‘spot checks’ to put a microwave meal in the oven for older adults with dementia in their home. This is not dignified and it is not cost effective. Over time, putting more good quality and accessible care into people’s homes will keep people out of residential and hospital settings over the longer term but it will cost.

So I hope these announcements the government makes will look at quality of care and will look at funding of care over the long term for people with dementias who live both in the community and in residential settings.

I hope to see, alongside better funding for research

1) Better support for family/friends as carers

2) Proposals to make personal budgets work well and for different support to be used for those who are not able to engage in the process of choice themselves either because they don’t wish to or don’t have the mental capacity (or family) to do so.

3) More thought put into the funding mechanisms of care for people with dementia both at home and in residential settings. Dilnot or not Dilnot. I’m not in agreement with all the tenets of Dilnot (I’d favour the so-called ‘death tax’ to be honest) but its better than that awful hotch-potch that we have now and what we can’t afford is to allow things to continue and to leave matters up to different local authorities to manage in their own different ways and at different levels.

4) Better non-directed advocacy with muscle for those who don’t have family/friends/community around them (by non-directed advocacy, I mean advocates who specialise and are trained in working with people who may lack mental capacity to ‘direct’ or instruct their advocates)

5) Robust regulation of dementia nursing and residential homes and wards in hospital with random spot checks and high standards.

I’ll be back tomorrow and see how the government does on this announcement.

One day though, I’d like to see a government of any political flavour that truly does look at national interest and not political expediency in terms of policy making.

The triumph of hope over experience.

photo by Ruth Flickr

Is Adult Social Care Broken? And what can and will fix it.

FIX

Over the past few weeks, oh, who am I kidding, over the past few years, I’ve been pondering the way that adult social care is structured in this country from the position of having worked in this area over a number of years. I have seen many changes but anyone who has been involved in social care for more than a year could probably say the same. If there’s one thing that is sure about statutory social work/social care, it’s that the next reconfiguration or improvement is just around the corner.

In my renewed spirit of positivity though, I thought it would be worth reflecting personally on some of the changes I have worked through and look at some of the directions we are going with a thought to what I would do if I were in a policy-making position rather than the position of a front-line practitioner.

So I entered social work in the shadow of the changes pushed through by the NHS and Community Care Act (1990). We were moving from ‘social work’ into care management and this was going to be an improvement for those who used the services as local authorities were going to be contracting out/selling off their own centrally run and ‘inflexible’ services to new, private and voluntary sector providers who would be far more flexible about meeting the needs of individuals.

When I think back to those heady days, the ideas weren’t so different to the ways that the personalisation agenda was presented. Direct Payments were just about to start but the idea was that care would be planned by a care manager to put the service user at the heart of the process and more interesting, more exciting and more specialist services would be commissioned for the same ‘pot of money’.

We were also sold talk of community involvement rather than segregration – gyms instead of day centres –  but the day centres remained and the processes weren’t flexible enough to allow the choices that should have been there.

So Direct Payments were introduced, first as an option and then as a right. They led from the ILF (Independent Living Fund) model of giving mostly younger adults (because you had to be under 65 to qualify for ILF) with physical disabilities a pot of money and a choice of employing a PA directly.

Quite rightly, this model was seen as positive and there were attempts to spread this more widely to all user groups. The take up was much higher in some user groups than others, strangely (I’m being ironic – bear with me) related to access to greater ‘pots’ of money or more informal support.

There has also been a massive push and development of carer services. It might not seem it to those who devote themselves to caring for family members or friends but there are now statutory rights to assessments and increasingly service provisions directly for carers.

And so we moved through to the Putting People First agenda of pushing the right to a personal budget for care services to everyone who uses and is eligible to support.

It is the right direction absolutely. Increasingly choice and control for social care packages is and must remain at the heart of social care provision for adults in the UK but there are genuine practical problems.

Firstly that too often councils have just shifted people who have been more difficult to engage in the process of choosing in the way the LAs want them to choose onto ‘managed’ budgets where the LA implements the care for the user and essentially makes the choices for them leaving very little different.

Secondly, the provision of 24 hour residential and nursing care has been lost in the push towards choice. It feels a lot like an poorly regulated afterthought when actually provision of residential and nursing care can be the most important decision in someone’s life and affects life quality absolutely.

Thirdly and by no means lastly, funding issues.

There is not enough money to pay for good quality care services for all who need it so the decisions are made about who will pay and how they will pay. The Dilnot report offers some potential solutions, personally, I don’t think it goes far enough.

The fact is that people don’t want to pay for care. They don’t want to pay for care related to health needs. People believe it is a right to receive care free. But that isn’t the case. Care costs and it is means-tested.

The postcode lottery comes into its own here with charging policies varying massively. On the ‘ground level’ I know people I assess and review are increasingly refusing care I feel they desperately need purely on the basis of cost. This shifts costs from self and social care onto health in the future, but at least health costs are free to the individual.

The Future

Personal budgets are not going anywhere and must be embraced and embraced positively as they are supposed to be. We must look past some of the cynical ‘target fixing’ of the local authorities who want to prove they are doing better on ‘choice’ and really adopt a strong advocacy role in using them the way they were intended to do and keep pushing and pushing until they deliver the promised change in terms of outcomes for all users of adult social care rather than relying on a few old examples. They must work but they also must work better.

Charging policies must change and this is in the offing. While I don’t agree 100% with the Dilnot recommendations, it is better than what we have. We need transparent and equitable methods to fund social care that don’t regard the sector as an afterthought.

Promotion of advocacy to all user groups who don’t have informal networks and particularly to those who may have issues with capacity is essential to back up and check on progress of professionals and local authorities who have different budgetary agendas. We have to offer support to challenge on an equitable basis.

Our systems have to be more flexible, as professionals within local authorities we have to have access to different styles of commissioning that include micro-providers. We have to have access to different communication formats and promote more interactive feedback using more technology to those who find it more useful while backing up with face to face contact, discussion and feedback for those who don’t.

Our world is becoming more fragmented as we have more access to information sources and accept that people cannot be defined merely by needs identified in traditional style assessments. We have self assessments now but they are more similar to DLA forms based on ability to wash and dress rather than building holistic pictures of who and what someone is. That is what is needed. Yes, it will be labour intensive but we need to find more value in quality and more value in the individual.

Where will be money come from to do this and to make these changes? Well, I think that better quality and treating people as human beings has so many longer term benefits regarding outcomes that it will be a saving and not   just in value but in quality of life.

Is the system broken? In parts. But the people who work in the system aren’t and nor are the people who use and need it. We need to build it back up together. Co-production has to be the answer.

These are exciting times for adult social care – lets build a positive from too many negatives and make things better.

Photo by Amanky/Flickr

Burstow’s Bluster

I, like many others in the sector, no doubt, were perplexed by the headline as I read it yesterday on the Guardian website that Paul Burstow, the Minister of State for Care Services, claimed there was ‘no funding crisis in social care’.

Although I follow Burstow fairly regularly and have a good idea of his rhetoric, I thought it was worth checking to see if a quotation or ‘soundbite’ had been taken out of context.

Indeed, he concedes that there needs to be a push of money from the private sector into the care sector – I’m not sure how exactly he intends for this to happen because unlike in the health sector, there’s not much left to privatise in adult social care.
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