Memorandum by the Association of Directors
of Social Services (DD 33)
SUMMARY
1. The Association of Directors of Social
Service represent all Social Services in England and Wales. Social
Services are key partners in working with the national, regional
and local Health communities to support people through the winter
pressures and reduce delayed discharges. Through the winter of
2000-01 there were 10 per cent fewer delayed transfers of care
than 1999-2000. There is therefore much clear evidence of good
inter-agency working. Our history and experience leads us to a
view that it is a mistake to look at delayed discharge in isolation.
Rather the pressures seen in this part of the acute health system
are part of the pressures across related areas, and the solutionms
can only come from a whole system approach. We support the aspirations
of the National Service framework for Older People and would wish
to see a stronger focus on better services for older people.
2. Evidence is presented from three key
areas—from the monitoring of Social Services performance,
from the use of non-recurrent and earmarked grants, and from budget
pressures. These indicate areas of improvement and highlight initiatives
that have made a difference in facilitating good discharges. However,
it is clear that this is limited, and that relieving pressure
in this one area is having a detrimental effect on social care
budgets. The financial pressures are being borne by the Local
Authorities and by the Independent Sector providers. A case is
made for a more fundamental review of government spending across
social care.
3. The recommendations arising from this
evidence are as follows:
(a) Re-consider urgently, as a matter of
short, medium and long term financial planning, the proper fit
between health funding and local authority funding for social
care. There is no equivalent to the NHS Plan in the social care
environment which would enable the comprehensive spending review
to create a funding environment to support joint plans.
(b) Work to be undertaken as a matter of
urgency to ensure that a robust monitoring system is introduced
incorporating agreed and aconsistent definitions of services,
or pressures and a whole system data monitoring base.
(c) Consideration to be given to establishing
an agreed programme management system for delayed discharge and
to be established across the whole system involved in providing
better services for older people.
System Redisign Recommendations:
(a) Joint Commission plans to demonstrate
a wider range of interventions to support the prevention of admission,
safe discharge schems and care at home schemes and to clearly
demonstrate whole system targets.
(b) Refocus health planning around 24/7 primary
care services. This to include new working partnerships, for example,
around community triage with Social Services involvement; community
outreach from acute care for consultations, advice, and testing;
and a focus on community capacity to care, pre and post admission.
Evidence should be provided to clinicians illustrating positive
outcomes from community based interventions with funding to pilot
changed approaches to delivery.
(c) Refocus services on non-acute hospital
rehabilitation capacity for occupational therapy, physiotherapy,
speech therapy, and the development of a reablement work force.
Community based rehabilitation workers should be established to
work with Social Services, specialist home care workers and Primary
Care Teams to support care at home services.
(d) Workforce development is a critical component
of community care sustainability and a whole community approach
should be establshed. The NHS training confederation and TOPSS
should agree a joint training strategy to cover the public and
independent sector. The strategy should be underpinned by
a joint workforce plan that includes a broader skill mix. Employment
protocols should be established locally to prevent poaching of
scarce staff scross interdependent sectors.
1. INTRODUCTION
1.1 This submission is from the Association
of Directors of Social Services who represent all Directors in
England and Wales. Social Services have been committed to working
with our health care partners over many years and we have a common
understanding of the pressures leading to delayed discharges.
We prepare joint plans and undertake joint action to address these
pressures. Action to relieve pressures on this area has been prioritised
by Social Services, often at considerable cost to Local Authority
budgets. We have, therefore, at times been dismayed at the attempt
to consider delayed discharge as a failure of the social care
sector. Consider the more detailed analysis of delayed discharge
indicates a whole system failure and the need to re-examine fundamental
health practices as well as the challenges this pressure poses
for social care.
1.2 Social Services have taken a consistent
approach in our consideration of health pressures, including delayed
discharge, and this informed our evidence to the National Beds
Enquiry when we supported the recommendation that considered the
re-balancing of health resources towards a broader spread of community
resources. We believe the debate should focus more directly on
how to develop health and social care systems which result in
better services for older people and is more responsive to meeting
their needs. We fully support the aspirations, aims and objectives
of the National Service Framework for Older People and consider
that work to implement this, adequately fund this, and fast track
this is essential to address delayed discharge.
2. Social Services are intimately involved
in working with the health community to manage health pressures
including delayed discharge. This joint work includes the following:
2.1 The production of local joint capacity
plans to identify and manage health pressures over the winter
months. These are signed by Directors of Social Services and the
Chief Executives of Health Authorities and Trusts.
2.2 Engagement in the local Situation Reporting
process which monitors hospital pressures on a weekly basis throughout
the winter months. At a national level we work with the Local
Government Association and the Department of Health in monitoring
capacity pressures over the winter.
2.3 Engagement in the health and social
care planning and commissioning process through membership of
local, regional and national Task Groups, Modernisation Groups
and Local Implementation Teams, in particular the National Service
Framework for Older People.
2.4 Through work with the Primary Care Groups/Trusts
and Health Authorities on the development of joint agreements
for intermediate care plans and joint funding.
2.5 Through the mainstream activity of Social
Services:
— With social work and care assessment
teams, often based in hospitals, land inked to primary care teams
and accessible to local communities.
— Through Social Services care management
linked to vulnerable people receiving long and short-term care.
— Through offering support to carers
and through services developed by the Carers Grant.
— Through commissioning, purchasing
and monitoring a wide range of public and independent sector direct
services including home care, day care, respite care, rehabilitation
services particularly occupational therapy.
— Through direct access and provision
of specialist equipment, housing adaptations and specialist housing.
— Through commissioning a wide range
of preventative and advocacy services through partnerships with
user and carer groups and the voluntary sector.
2.6 Through the emerging use of Health Act
Flexibilities, the piloting of Care Trusts and the development
of jointly managed, jointly funded health and social care services.
2.7 Through membership of Primary Care Groups
/Trusts.
2.8 Engagement in Building Capacity for
Partnership in Care at the national level and in establishing
local partnerships and forums with the independent sector residential
and nursing care, housing and care at home services.
2.9 Through experience of accessing health
winter pressures money and recent building capacity grants to
develop initiatives to address health pressures around delayed
discharge.
2.10 Through local work on continuing health
care agreements and local policies and protocols for assessment,
the operation of the directive on choice and good discharge practice.
2.11 Through the national monitoring of
performance which includes Social Services indicators directly
affecting delayed discharge as well as crossover indicators.
2.12 Through delivering national priorities
for Social Services which includes the promotion of independence.
3. Factual Information
This is presented from three areas:
3.1 Evidence from Performance Indicators
as reported in the Social Services Inspectorate Autumn 2001 Monitoring
Report
3.2 Evidence from the use of grants—ADSS
Survey
3.3 Evidence from Budget Pressures —ADSS
Survey
3.4 Evidence from Performance Indicators
as reported in the Social Services Inspectorate Autumn 2001 Monitoring
Report.
(a) This reflects the evidence of two market
factors -the decline in the market through the loss of 35000 beds
over the last year, and the lack of capacity in the market with
residential, and nursing home beds in many areas being full. In
addition there are major problems in agreeing a sound funding
base for the independent sector markets, and recruitment and retention
problems, particularly of qualified nurses, is effecting the sustainability
of this market.
(b) It is considered that this may deteriorate
as a result of the £42m reported overspend in Social Services
budgets for older peoples services. The gap between the increased
health activity levels and health funding to support this, and
the capacity of social care to fund discharge care will widen.
(c) Most Acute Trusts are now implementing
joint protocols on the Directive on Choice.
(d) There are be joint agreements on intermediate
care helped by transparent funding streams, however there remains
a lack of access to a range of appropriate health care services.
(e) Delays accessing home care reflect many
of the same market pressures as that in a) above and problems
of recruitment are acute in many areas. The funding of equipment
and adaptations has not kept pace with the volume of health activity.
In general housing plans have not yet been flexible enough to
develop a wider range of housing options to support hospital discharge,
although Supporting People will offer greater opportunities for
this.
(f) There have been major problems recruiting
social workers, and other assessment staff in social care. The
national recruitment campaign and training strategy will eventually
address this.
Related significant Performance Indicators
(i) Admissions of supported residents
aged over 65. The national average level of supported admissions
of older people to residential and nursing care was seen as relatively
stable.
(ii) Provision of intensive home care.
The national level of provision of intensive home care across
all adult groups has continued to rise steadily.
(iii) Older people helped to live at home.
Slight reductions in 1999/2000 but rise projected in 2000/2001.
(iv) Delayed Transfers of Care. 9.1%
of people aged over 75 had delayed transfer by April 2001 however
there where wide regional variations. The collation of this information
had been difficult and revisions in definitions had not been fully
implemented. More accurate reporting is expected in 2001/02.
(v) Key Facts on capacity planning and
transfer management.
— The main delay in facilitating safe
and timely discharge of patients from an acute hospital setting
was in time awaiting residential or nursing home placement (33
per cent of councils); delays waiting public funding (24 per cent
of councils). Whilst 23% of councils had no agreed increase in
supported placements over winter, the majority had planned increases
agreed.
— There was a similar pattern in the
time taken to assess and arrange the provision of care to facilitate
discharge, (38 days for residential and 15 for a home care package).
90 per cent of councils had agreed protocols for assessment and
69 per cent protocols on the Direction of choice.
— Market capacity was seen as insufficient
by over half of all authorities in the provision of residential
and nursing care for older people.
— Intermediate care was only just emerging
but nearly all Social Services were planning for developments
in partnership with health colleagues.
Comment: The social care sector in working
to prevent delayed discharge is dependent on many factors over
which it has little control. Key amongst these is the reliance
on the independent, mainly the "for profit", sector
for the delivery of care at home services, residential and nursing
care. Social Services contributes to the purchasing of this care
from a capped budget which has no connection to the actual or
projected activity budget of the acute sector. The impact of this
has been to keep market prices depressed in an attempt to sustain
a volume of activity. This is not a sustainable position for public
sector commissioners or for the providers. A national survey from
Laing Buisson indicated that providers are looking for a 16.7
per cent increase on their capital return which would be a £110
a week average increase in fees for nursing home care. Small,
time limited grants, while helpful to fast track initiatives,
do little to address this fundamental weakness in the social care
funding formulas.
3.5 Evidence from use of grants—ADSS
survey
(i) The ADSS conducted a brief survey in
Spring 2001 to ascertain the evidence of the use of the non recurrent
money allocated to health (£50m) for joint planning to address
winter pressures and to facilitate the start of intermediate care.
Of the 63 returns the main frustrations lay in the non-recurrent
nature of this funding and the lack of transparency in the tracking
of additional funding pots. This had resulted in some instances
in the failure to share or transfer funding to social care partners.
When money had transferred it had been focussed upon attempts
to relieve discharge pressures through additional residential
and nursing home beds, the development of rehabilitation and recuperation
schemes, rapid response services, and the increase in home care
and respite care.
(ii) Of the services that were thought to
have made the biggest impact on managing the winter pressures
included the following—50 per cent thought this was the
expanded care at home packages, including night care and hospital
from home schemes; 40 per cent considered rehabilitation and intermediate
care developments; 29 per cent the development of rapid response
services and 21 per cent additional residential and nursing care
places. It can be seen that the capacity to expand existing community
based services to cover 24/7 periods and to react quickly were
key indicators of success. While re-thinking about the focus of
rehabilitation work is fundamental to intermediate care developments.
(iii) ADSS welcomes the £300 million
grant to support building capacity as it will enable the fast
tracking of patients, and Social Services are on target to meet
the 20 per cent reduction of delayed discharges from the September
2001 baseline. This will build on the proven successes of many
of the earlier initiatives and support independent sector partnerships.
There are however concerns that the money is distributed in a
formula that could appears to reward poor practices. In addition
there remains the concerns that the money is time limited and
it does not address some of the more fundamental funding deficits.
3.6 Evidence from budget pressures—ADSS
Survey
(i) The ADSS conducted a survey of the funding
pressures on Social Services in 2000. This found that older people
make up approximately 62 per cent of Social Services clients and
account for 47 per cent of current Social Services spending. Gross
expenditure by Social Services on older people in 1999-2000 was
£5.640 million and net expenditure following fees and charges
was £4.160 million. Local Authorities were spending significantly
above their standard spending assessment on Social Services, an
average of 8.9 per cent for 2000-01 and this is set to rise to
9.7 per cent in 2001-02. This impacts on other Council Departments
which are subsidising their own Social Services Departments from
other budgets. Social Services have continued to run with overspend
budgets, by 64 per cent overspending on Children's Services and
21 per cent on Older Peoples' Services. Social Services budgets
are already almost £1 billion above government provision
even without the additional overspend pressures around £200
million this year. Councils are spending more than 10 per cent
above government guidelines and almost 6 per cent over last year's
budget plans. The data suggests an overspend of £210 million
above the government grant and for older people £42 million
above locally set budgets.
(ii) Social Services funding has therefore
not kept pace with increased demand for more intensive
services for the most vulnerable or with the increased volume
of the demand. The impact of this has been highlighted by
ADSS and reinforced by the recent SPAIN Group (a consortium of
30 voluntary organisations of and for older people) who reported
on the consequences for older people of the under-funding of Social
Care. The gap between Health Care funding and Social Care funding
continues to widen. This leads to a vicious circle in which delayed
discharge pressure is passported from Health to the Social Care
sector, and then across this sector to the care market, where
funding pressures effect capacity, which leads to the back—up
on health pressures. Social Care under-funding therefore directly
contributes to health pressures. In addition these pressures limit
the overall capacity of social are to promote independence in
the following areas. (a) There continues to be waiting lists for
critical Social Care Services such as equipment and adaptations.
(b) There is a general withdrawal from investing in preventative
Social Care Services. (c) There is an increased pressure on self-funding
routes such as new charges and the increased use of top up payments
for residential care. (d) This also results in an increase in
rationing systems which impact on the quality of life of some
of the most vulnerable people in our society. e) It also widens
the gap between those who can partially self fund and those who
cannot. Under-funding of social care is resulting in practices
towards older people that are in danger of reinforcing social
exclusion which is contrary to the aspirations of the National
service Framework.
(iii) Under-funding on Social Care impacts
on the acute difficulties that are currently being experienced
in recruitment and retention of Social Care staff across the public
and independent sector. The local Health Services are paying more
and aggressively recruiting from the nursing home market, with
dramatic consequences on the sustainability of that market. The
Social Care market suffers from widening pay differentials across
comparable public sector employment with subsequent recruitment
and retention difficulties. The workforce pressures for the existing
Social Services workforce are heavy and cannot keep pace with
the increased volume of older people referred for help. The focus
on the existing workforce pressures and the lack of financial
capacity in social care limits many opportunities for joint training
and the development of a new, and possibly different workforce,
such as reablement workers.
(iv) The budget settlement for Social Services
for 2002-03 remains disappointing and has not addressed the fundamental
issues raised above. Rather some new financial distortions are
apparent in that the Preserved Rights grant is unlikely to cover
the actual activity required of this funding which has transferred
responsibility from the Benefits Agency to the Local Authority.
It is also clear that the grants regime is subject to various
"ins and outs", the SSA formula for personal social
services is no longer "fit for purpose" and propped
up by the floors and ceilings rules. In undertaking long term
plans to address national priorities this places Social Services
in an invidious position.
4. RECOMMENDATIONS
4.1 Fundamental proposals:
(a) Re-consider urgently, as a matter of
short, medium and long term financial planning, the proper fit
between health funding and local authority funding for social
care.
(b) Work to be undertaken as a matter of
urgency to ensure that a robust monitoring system is introduced
incorporating agreed and consistent definitions of services, of
pressures and a whole system data monitoring.
(c) An agreed programme management system
be established across the whole systems involved in providing
better services for older people.
4.2 System Redesign Recommendations
(a) Joint Commissioning plans to demonstrate
a wider range of interventions to support the prevention of admission,
safe discharge schemes and care at home schemes and to clearly
demonstrate whole system targets.
(b) Refocus health planning around 24/7 primary
care services. This to include new working partnerships, for example,
around community triage with Social Services involvement; community
outreach from acute care for consultation, advice, and testing;
and a focus on community capacity to care, pre and post admission.
Evidence should be provided to clinicians illustrating positive
outcomes from community based interventions with funding to pilot
changed approaches to delivery.
(c) Refocus services on non-acute hospital
rehabilitation capacity for occupational therapy, physiotherapy,
speech therapy, and the development of a reablement work force.
Community based rehabilitation workers should be established to
work with Social Services, specialist home care workers and Primary
Care Teams to support care at home services.
(d) Workforce development is a critical component
of community care sustainability and a whole community approach
should be established. The NHS Training Confederation and TOPSS
should agree to a joint training strategy to cover the public
and independent sector. The strategy should be underpinned
by a joint workforce plan that includes a broader skill mix. Employment
protocols should be established locally to prevent poaching of
scarce staff across interdependent sectors.
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