Adult social care needs radical reform not more money

Following the Government’s postponement of its green paper into overhauling social care, former social services director Chris Perry spells out a blueprint for reorganisation which he says will deliver the solutions everyone is hoping for.

Increase pension payment

The NHS and social care are in crisis. Nearly two million older people are living in poverty and more and more older people are having to sell their houses to pay for their care in this, the fifth largest economy in the world.

However, it cannot be solved by pouring more and more resources into the first aid camp at the bottom of the cliff, rather than building a fence at the top. There needs to be a whole systems approach designed to reduce demand, increase efficiency and effectiveness and find sufficient money to make health and social care free at the point of delivery of service.

Britain’s state pension is 29 per cent of national average earnings compared with 100.6 per cent in Holland, 94.9 per cent in Portugal, 93.9 per cent in Italy, 91.8 per cent in Austria and 81.8 per cent in Spain. The official definition of poverty is anything less than 60 per cent of the median household income.

Given the correlation between income and demand upon the NHS, it is hardly surprising that older people account for four-fifths of the expenditure. An estimated 1.3 million older people suffer from malnutrition, costing the NHS £19.6 billion.

There are five main causes of malnutrition: lack of money, lack of motivation, incapacity, lack of support and social isolation. A starting point may be to raise the state pension from 29 per cent of national average earnings to 60 per cent. This could be offset in part by people who go on working beyond state pension age continuing to pay National Insurance and not drawing their state pensions until they retire - with phased arrangements.

Creating a £5.5 billion surplus

The aim would be to achieve the following financial outcome:

• Cost of increasing state pension from 29 per cent to 60 per cent of national average earnings: £82.4b
• Saving on other benefits: £37.05b
• Clawed back through Income Tax: £13.79b
• Additional National Insurance from people over state pension age in work: £3.9b
• Saving on not paying state pension until retirement: £7.85b
• Saving from 90 per cent reduction in malnutrition amongst older people: £17.85b
• Reduced demand upon health and social services: £7.3b

The will produce a credit of £5.52b

The average cost of a care home is £29,270. With the increased state pension of £16,550, less the personal allowance (currently £27 per week), everyone would be able to contribute £15,092, leaving the local authority to find £14,178. There are currently 416,000 older people in care homes and it is anticipated this number would reduce, possibly by 20 per cent, as a result of this “whole systems approach”.

Therefore, the cost of providing free social care would be 332,800 x £14,178 or £4.75 billion. We were already £5.52 billion in credit and that is without all the organisational savings outlined below which will also be needed to reinforce the change and meet demand.

Organisational change

Countless enquiries into child abuse and adult abuse and neglect have criticised agencies for not working together. Successive governments have tried to encourage health and social services to work together, from Joint Funding in the 1970s to the pooling of budgets. However, no government has grasped the nettles of the differences in geographical boundaries, funding streams and lines of accountability across the two which has been the main impediment.

We are not talking about the merger of health and social care, as this would further marginalise social work. Agencies have to work together in different combinations – for example, health, adult services, leisure services and housing in respect of older people. Likewise children’s services, health, education and the police in respect of child protection.

Local government and health service re-organisations of the last 30 years have added to the cost and led to greater fragmentation. For example, Wales went from eight county councils and 37 district councils to 22 unitary authorities. Wales did have a joined up and coordinated approach between health and social services with a number of ‘All Wales Strategies’. Had the unitary authorities been based upon the existing county councils, there would have been immediate savings on the cost of democracy with the abolition of the district councils and year-on-year savings as district council departments were merged into county council departments. In England, the splitting of children’s and adult services doubled the cost of senior management in addition to that of creating unitary authorities.

During my time as a director of social services, my counterpart in health ran nine hospitals, five of which were regional, community services and the Family Practitioners Committee, responsible for general practitioners, all with a management team smaller than is now found in every hospital trust. The abolition of area health authorities has left a void of strategic planning and coordination.

The whole system approach

The answer may lie in bringing services together within county council or police authority boundaries, returning the police and health to local democratic control thereby achieving common boundaries, lines of accountability and funding streams, along with economies of scale.

There is sufficient evidence to get rid of the purchaser/provider split, introduced by Sir Roy Griffith in the mistaken belief that a mixed economy of care would force quality up and prices down. This was extended to social services by the 1990 National Health Service and Community Care Act. The increased management costs led to an army of accountants chasing the same deficit around the system.

There is just as much empirical evidence in respect of organisation, management and leadership as there is medicine and yet this is rarely applied in practice. Applying his unique “whole systems methodology” to a hospital in Holland, Christian Schumacher, author of God in Work, was able to get a 30 per cent increase in output with higher morale and lower sickness levels. However, many hospitals are still organised on the discredited “production line” model so that staff, often working in very stressful situations, do not see the outcome of their work.

Schumacher argues “functional divisions” need to be removed from “patient pathways” by creating “whole task, right-sized, multi-disciplinary teams”, able to “plan, do and evaluate” their work (which completes the learning cycle of constant improvement) with access to all the resources and expertise required. The number of tiers of management should be kept to a minimum. Appropriate levels of delegation can reduce time in meetings and employees need the “generic skills” of their profession, specialist knowledge of their area of work and to be employed on the work which interests and motivates them.

More prevention, less gatekeeping

There is a need to invest in preventative measures which keep people active, mentally and physically, and prevent social isolation, social work intervention, community development and home care. Social workers need to be freed from “care management” and the “gatekeeper” role of assessing the eligibility to specific services at a “component level”, thereby enabling them to practice their skills in using relationship to bring about change in motivation, behaviour and community support by various therapeutic techniques and counselling. Thus reverting to a “mending” rather than the current “minding” service.

Statutory agencies need to work with housing associations to develop “extra-care sheltered housing”. It is possible to put just as much nursing and social care into such developments as it is traditional residential care. The owner or tenant has their own front door, defended space and retains control over the essentials of daily living. This alleviates many of the harmful effects of traditional residential care and also reduce the risk of abuse which is greater when the victim is subservient.

Chris Perry has worked as a director of social services for South Glamorgan County Council, a non-executive director for Winchester and Eastleigh Healthcare NHS Trust and was director of Age Concern, Hampshire. A more detailed, costed, report of the above is available on his linkedIn page