FURTHER INFORMATION
FROM THE
DEPARTMENT OF
HEALTH (PEX 01B)
The Department of Health's response to 23 November
specific actions are listed below:
Q324/Q325: Examples of the sorts of social care
services that will be paid for by the £1 billion from the
NHS Resource budget
The NHS will make £798 million/£922
million available for spending on social care in 2011-12 and 2012-13.
Of this, £150 million/£300 million has been earmarked
for re-ablement, which will help people to recover their independence
after admission to hospital. This will be backed by new rules
whereby NHS Trusts, from next April, will take responsibility
for their patients for 30 days after discharge. Hospital Trusts,
PCTs and local authorities will work together in order to ensure
that avoidable readmissions do not happen within this time, and
this will include putting in place a comprehensive system of re-ablement
support.
The remainder of the funding will be transferred
to local authorities for spending on social care services to benefit
health, and improve overall health gain. PCTs will work with LAs
to agree where the money should be spent, with a shared analysis
of need and common agreement on what outcomes need to be met.
This will be a locally determined process, so that the funding
best meets local needs. However, we would expect that PCTs and
LAs would want to look at key elements on an individual's care
pathway where individuals are at risk of high cost interventions
if support were underfunded.
With that in mind, we would expect the funding
to be used to support the following social care services:
— Practical support and prevention services,
to maintain people's independence and reduce the risk of falls
or accidents. This could include, for example, befriending services
(to reduce isolation and improve mental health) and exercise and
balance services (to keep people active and reduce the risk of
falls).
— The provision of equipment and minor
adaptations (for example, grab rails or shower chairs). These
can help ensure timely discharge from hospital, and reduce the
risk of emergency admissions from falls. In 2000, the Audit Commission
found that 14% of all delayed discharges were the result of a
lack of equipment.[49]
— Integrated crisis or rapid response services—for
both frail older people, and those with mental health needs. Evidence
from the Care Services Efficiency Delivery programme suggests
that crisis response services can prevent unnecessary ambulance
call outs and hospital admissions, and reduce the need for lengthy
stays in residential care.[50]
— Supported accommodation facilities—which
can help to ensure that people are discharged from hospital or
other health services at the appropriate time, and do not have
to stay in a ward unnecessarily.
We will set out further detail in the 2011-12
NHS Operating Framework.
Q328/Q329: A note on inefficiencies/cost variations
in social care
Issue
The Spending Review will be challenging for
adult social care and we will be working closely with local authorities
and the wider sector to identify and deliver efficiency savings.
In the recently published Vision for Adult
Social Care, we set out a framework that local authorities
could use to get the best value for money from services. This
is summarised below.[51]
Helping people to stay independent for as long as
possible
Preventing people's needs from escalating will
help to delay people's need for intensive care packages, and reduce
the costs of social care for individuals at risk of increasing
levels of dependency.
One way to achieve this is through re-ablement.
Re-ablement services can help people to regain their independence
after a crisis, and can have a significant positive impact on
people's quality of life. A Retrospective Longitudinal Study
on re-ablement, published in 2007, suggested that 53% to 68%
of people left re-ablement requiring no immediate homecare package,
and 36% to 48% of those continued to require no homecare package
two years after re-ablement.
Case studies suggest that an integrated crisis
or rapid response service, that responds to people who have a
crisis within a four hour period, could save an average of £2
million per PCT and £0.5 million per local authority by reducing
ambulance call-outs, unnecessary admissions to hospital and unplanned
entry to long term nursing or residential care.[52]
Providing care and support to meet people's goals
Providing people's care and support in the most
appropriate and cost-effective way is important to ensuring that
the system is as efficient as possible.
Telecare support can help people to live at
home independently for longer by providing technologies that make
their homes more safe and secure. Self-evaluations from three
local authorities indicated that they could save around 1.5% per
annum of their home and residential care spend by introducing
integrated telecare support to people.
Personalisation, and the roll out of personal
budgets, also provides an opportunity to change the way that care
is commissioned and can help to achieve better outcomes to individuals
at the same cost. Devolving the commissioning and purchasing of
services to individuals allows many service users to use their
personal budgets or direct payments in creative ways—often
purchasing innovative local services which can cost less than
traditionally commissioned services. This approach requires wholesale
change—a change of attitude by local authorities and staff,
reform of financial and information systems, and reduction of
inflexible block contracts.
Variations in the proportion of local authority
spending on nursing and residential care was a key focus of Use
of Resources in Adult Social Care, which benchmarked performance
across local authorities.[53]
Of the total spend on services for people with learning disabilities
in 2008-09, the proportion going towards nursing and residential
care varied from 12% to 80%. For services for older people, the
proportion of spend on nursing and residential care varied from
30% to 70%.
Some of this variation may reflect local preferences
and the needs of particular populations. However, some people
are placed in residential care because there are few alternatives
to meet their needs in the community.
In its Vision for Adult Social Care, the
Government set out how supported housing and extra care housing
can offer flexible support in a community setting, which can provide
better outcomes at lower costs than traditional high cost nursing
and residential care models.[54]
Better use of community-based services (for example re-ablement
or home improvement and adaptations) can also reduce demand for
residential care.
Maximising spend on front-line services
The solid Spending Review settlement for social
care means that local authorities should rigorously prioritise
expenditure to ensure as much money as possible goes to those
most in need. Authorities must therefore ensure they minimise
spend on back office administration, sharing services with other
parts of the public sector where appropriate.
Local authorities should also look to minimise
the extent to which care is provided in-house. The following graph
demonstrates that there is significant variation in the extent
to which local authorities commission in-house service delivery
and external/independent provision. This example looks as residential
care for older people.[55]
GRAPH 1
VARIATIONS IN PROPORTION OF RESIDENTIAL CARE
EXPENDITURE FOR OLDER PEOPLE WHICH IS PROVIDED BY THE LA (OWN
PROVISION), 2008-09
There is also some evidence that in-house services
are often provided at higher cost than those from the independent
sector. The following table, from the Audit Commission report
Under Pressure, looks at the variation in unit costs between
in-house and independent residential care provision for older
people.
TABLE 1
VARIATIONS IN SOCIAL CARE UNIT COSTS FOR
RESIDENTIAL CARE[56]
Average gross weekly expenditure
| Ratio of
maximum to
average
|
Minimum
(£) |
Average
(£)
|
Maximum
(£) |
| Supporting older people in residential care provided by council
| 2.5 | 136.99 | 883.78
| 2,405.50 |
| Supporting older people in residential care provided by others (per person)
| 1.5 | 203.98 | 435.03
| 720.64 |
There are a variety of factors behind these variations, one
of which is the efficiency of the service. However, there are
a number of other factors which influence the unit cost of a service,
including:
— the supply of staff, and the terms and conditions
of staff;
— the quality of the provision offered.
Despite these limitations, such analysis provides a useful
benchmarking tool for local authorities, who should be prepared
to justify costs. As set out in the Vision for Adult Social
Care, the Government believes that local authorities with
substantial in-house provision should look to the market, including
social enterprises, mutual and voluntary organisations, to replace
them as a local service provider. There may be exceptional reasons
for authorities to retain services, but separating responsibility
for commissioning and providing services should become the norm.
Variations in unit costs
Work by the Audit Commission has found variations in the
costs paid for other services by local authorities. Examples of
cost variances are shown below.[57]
TABLE 2
VARIATIONS IN SOCIAL CARE UNIT COSTS
Average gross weekly expenditure
| Ratio of
maximum to
average
|
Minimum
(£) |
Average
(£)
|
Maximum
(£) |
| Meals per older person receiving them | 3.0
| 1.06 | 26.58 | 82.23
|
| Home care per older person receiving home care
| 2.0 | 52.29 | 143.25
| 257.57 |
| Supporting older people in nursing care (per person)
| 1.5 | 240.00 | 479.56
| 753.87 |
| Average gross expenditure per day care session for older people
| 2.5 | 4.95 | 27.35
| 72.14 |
| |
| | |
As noted above, there are a range of factors that influence
the cost of a service, of which the efficiency of the service
is one. The picture is complex and therefore it is not possible
to estimate with any certainty how much of the variation in unit
costs is related to inefficiencies. Indeed, some of the efficiency
drivers noted above may lead to increased unit costs, due to shifts
in where people are cared for. For example, reducing the number
of people in residential care may lead to higher unit costs for
residential services as the remaining users have higher needs.
In addition, these figures should be treated with caution
due to inconsistencies in the way that the data are collected
and presented. For example, some local authorities will only provide
intensive day care for people with high care needs, whereas others
will offer a range of social activities for anyone. Both would
be classified as day care, but would inevitably be delivered at
very different unit costs.
Despite these limitations, such analysis provides a useful
benchmarking tool for local authorities. Under Pressure highlighted
these large variations in unit costs and, whilst reiterating that
unit costs are subject to a range of local variations and influences,
urged local authorities to examine their data locally and conduct
a self assessment about how money is being spent.
Conclusion
We believe that there are a range of opportunities for local
authorities to make savings in adult social care over the coming
Spending Review period. Many of these will help to reduce the
numbers of people needing care in a particular area; others will
help to reduce the cost of care and limit variation between authorities.
Local authorities will need to develop plans for reform, to reassure
themselves and their communities that they are making the best
use of available resources. The Department will support the work
of authorities to deliver these efficiency savings by co-ordinating
and disseminating support tools and best practice.
3 December 2010
49
Audit Commission, Fully Equipped, (2000). Back
50
See http://www.csed.dh.gov.uk/CrisisResponse/ Back
51
A Vision for Adult Social Care: Capable Communities and Active
Citizens (Department of Health, 2010). Back
52
See http://www.csed.dh.gov.uk/CrisisResponse/ Back
53
Use of resources in adult social care: a guide for local authorities
(Department of Health 2009). Back
54
A Vision for Adult Social Care: Capable Communities and Active
Citizens (Department of Health, 2010). Back
55
Analysis of PSS Ex1 2008-09. Back
56
Audit Commission, Under Pressure, (2010). Back
57
Audit Commission, Under Pressure, (2010). Back
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