Health CommitteeWritten evidence from the Association of Directors of Adult Social Services and the Local Government Association (LTC 26)
Background
ADASS
The Association of Directors of Adult Social Services (ADASS) represents Directors of Adult Social Services in Local Authorities in England. As well as having statutory responsibilities for the commissioning and provision of social care, ADASS members often also share a number of responsibilities for the commissioning and provision of housing, leisure, library, culture, arts, community services and increasingly, Children’s Social Care within their Councils.
LGA
The Local Government Association (LGA) is the national voice of local government. We work with and on behalf of our membership to promote support and improve local government. The 422 authorities that make up the LGA cover every part of England and Wales. Together, they represent over 50 million people. They include county councils, metropolitan district councils, English unitary authorities, London boroughs, shire district councils and Welsh unitary authorities, along with fire authorities, police authorities, national park authorities and passenger transport authorities.
Responses
The scope for varying the current mix of service responsibilities so that more people are treated outside hospital and the consequences of such service re-design for costs and effectiveness
There are strong and widely acknowledged arguments for disinvesting from acute services and reinvesting into community settings. However, a number of barriers restrict these opportunities. The financial models of Payment by Results and the tariff system, which reward acute activity, actually incentivise hospital trusts to maximise service take-up.
More fundamentally, it is beginning to be accepted that there are too many hospitals now, particularly those based on the traditional District General Hospital model, given the developments in primary, community and social care. The challenges to resolving this are considerable; simply downsizing a hospital’s activity in order to reduce acute funding is rarely an option, as issues of clinical safety and the required staffing levels for accreditation of services rapidly emerge. The real alternatives of reconfiguration and changing the roles of local groups of hospitals have always proved immensely difficult to engineer against public resistance.
These barriers are further heightened by significant budget pressures within the whole system, limiting the opportunity to switch funding or develop community based facilities in advance of reducing acute demand.
One way forward would be to create a tariff system for acute care which included the full end-to-end care pathway, pre-admission and post discharge, in order to incentivise a more holistic approach to clinical commissioning and service development.
Supporting this, reforms of health and social care are pushing for greater integration, placing a stronger emphasis on prevention and early intervention and promoting a system-wide focus on improved outcomes for the individual set with an individual and local community asset based approach.
The emphasis over the past period has been on speedier discharge, but as set out above this needs to shift to prevent unnecessary admissions, sign posting people to other services, plus providing a range of “off the shelf” services which would potentially support people to avoid unnecessary admissions to in-patient care ie 24/7 access to telehealthcare, homecare, respite etc, without requiring in depth and bureaucratic assessments.
The Community Budget areas have shown us that this will require a joined up approach to leadership and shared cultures across the health and care system as well as sharing of individual data records so that people can be tracked and supported across the system.
In addition to improved tariff and incentive mechanisms, local areas will need to take a joint approach to the use of resources and develop joined up commissioning arrangements and to make sure that resources are shifted from acute to preventative and community based services. Health and Wellbeing Boards (HWBs), as the body with statutory responsibility to promote integration, will be crucial in holding the system together locally, promoting joined up working and enabling the best use of resources locally.
The LGA strongly supports this issue being addressed. It also features strongly in emerging Health and Wellbeing Boards’ priorities. We recognise too the political impact for councillors, MPs, Scrutiny and Healthwatch partners.
The readiness of local NHS and social care services to treat patients with long-term conditions (including multiple conditions) within the community
Social care and the NHS have been working closely over a long period of time and there are many examples of integrated community based services and support. These models and variations can readily be adapted to suit the management of long term conditions. The current reforms are helping to accelerate the pace and scale of these approaches with the Health and Wellbeing Boards being a new element in bringing local partners together to address local need. The shift of Public Health responsibilities to councils alongside the development of an integrated Outcomes Framework are catalysts to making community based integrated approaches the norm.
ADASS and the LGA are currently working closely with five other national partners (NHS England/DH/PHE/Monitor/ADCS) through an Integrated Care Working Group (ICWG) to support the acceleration of the pace and scale of integrated community based preventative and early intervention services and support. This work is reporting directly to the Care Services Minister and the partnership is considered a significant step.
Equally, the development of Personal Health Budgets for all those with Continuing Healthcare funding provides an opportunity for personal budgets to be developed jointly with social care, pooling resources based on an individual need, which potentially could lead to the development of more clinical support, which may be more appropriate, deliver better outcomes and at reduced cost—arguably this is already happening in many areas. The real benefits will come by extending this approach beyond CHC eg mental health needs and support provided by local community groups or third sector organisations rather than medically led psychiatric services.
One of the key messages for the NHS and social care working together to support those with long-term conditions is that integrated services must be designed from the bottom up, designed around integrated health and social care personal support plans and the pathways of people through a local health and social care system.
It is not sufficient to develop joint services based purely upon organisational, managerial or structural integration. There needs to be a holistic and whole-system approach.
Successful and sustainable re-design requires the full engagement of front-line staff, managers, people who use services and their carers. There also has to be cultural change across organisations, facilitating multi-disciplinary working.
The practical assistance offered to commissioners to support the design of services which promote community-based care and provide for the integration of health and social care in the management of long-term conditions
The ICWG is setting a “Common Purpose Framework” (CPF) to describe the barriers to integration and establish national and local enablers to overcome these barriers. This will include commissioning guidance. ADASS is working with the Kings Fund to produce guidance for Health and Wellbeing Boards in integrating commissioning activity. ADASS is also supporting and promoting a leadership programme to help Directors in their role in taking forward integration of commissioning and service provision.
Arguably much of the work already being progressed with Personalisation and Think Local Act Personal(TLAP) promotes an approach which moves away the “professional gift” model—diagnosis and labels, to service users determining their needs and priorities, based on the outcomes they want to achieve and arranging the support that they require and how it is provided. There are many major national, regional or local third sector organisations working with people with long term conditions and they will no doubt make their own submissions. Particularly at national level, they can be a valuable source of research into service integration, improved outcomes and examples of best practice from across the country.
The numbers of people dying in hospital has continued to rise whilst a number of surveys indicate that, given a choice, a large majority of people would choose to be cared for at home. Recent research by the Nuffield Trust reaffirmed the inter-relation of health and social care at the end of life and the need to provide a holistic approach focused around the individual and their needs and wishes. Social services have access to and make best use of local intelligence (health and social care data sets) to focus on the design and delivery of end of life care improvements in all sectors. Engagement with the emerging clinical consortia, commissioning support organisations and health providers across acute and primary care settings, local hospices and local authorities is well developed to ensure the effective pooling of resources to facilitate the commissioning and design of new services with a clear understanding of the shared service improvement agenda.
Finally, however, as noted above, the real-life experience of staff, patients and carers is an essential element of service re-designs and commissioners must access this experience as much as possible.
The ability of NHS and social care providers to treat multi-morbidities and the patient as a person rather than focusing on individual conditions
ADASS and the LGA have the longest history of promoting personalisation within the public sector, which considers “outcomes” over treatment, conditions and models of service. This is reflected in the three outcomes for the NHS, Public Health and Adult Social Care, which can guide providers. Personalisation is being complemented by outcome-based commissioning and more recently by the development of payment by results. These are driving a person centred approach.
Both the LGA and ADASS have supported National Voices and “Think Local Act Personal” in the development of a narrative for integrated care an support, driven by patients and service users, that will help commissioners and providers to understand and respond to the needs of real people.
The ability to treat patients as people first is critically dependent upon the quality, skills and stability of the health and social care workforce. In respect of supporting people with long term conditions in the community, there is a great deal of guidance available for staff involved in personal care of any kind. One example would be the “Common Care Principles for Self-Care” developed by Skills for Health and Skills for Care, supported by ADASS through the Workforce Development Network. Alongside the Workforce Development Strategies of the Department of Health and Skills for Care, ADASS has prompted the development of integrated workforce strategies at a local level (initially known as Integrated Local Area Workforce Strategies). Minimisation of staff turnover, as one example of a benefit, promotes continuity of carers on teams of carers for people, which in turn promotes greater dignity in the care arrangements.
Taking a truly person centred approach to LTCs means changing the paradigm, so that people who use services are given more control of co-ordination and are expected and helped to take more responsibility for self-management. Coordinate My Care for end of life care seems a good example and has led to real shifts in practice and better outcomes. Alongside this, there are some real opportunities to use technology to help manage LTCs more effectively. This includes some of the “diagnostics” in telehealth but also some simple ways of being able to communicate regularly and frequently with people who use services. The infrastructure of telecare has a lot to offer here.
The concept of “pathways” can be as much of a hindrance as a help. By definition many people who use of adult social care have several conditions, so then flooding them with specialists each with their own pathway to follow just makes life more complicated. ADASS and the LGA would suggest that, we keep the core benefit of a “pathway” which is consistent and evidence based decision making but have health and support plans much more based on the person.
Finally it is important to recognize the psychological aspects of these (long term) conditions and to ensure that a support plan takes account of this: depression for example is a major determinant of how an out of hospital support plan works.
Obesity as a contributory factor to conditions including diabetes, heart failure and coronary heart disease and how it might be addressed
The movement of Public Health to local councils alongside the adult social care focus upon wellbeing is creating the right conditions to bring the totality of local resources to bear upon health inequalities and its causes. DASSs and Lead Members have generally a broad portfolio of services (often including leisure, housing and others) to draw upon and deal with these challenges, particularly around prevention and social inclusion.
Social care services can support the reduction of obesity by always having regard to good nutritional advice and the benefits of any level of physical exercise or activity in both care planning and in service delivery. Awareness of nutritional issues is particularly important where a person may have some degree of restricted mobility. Training in these areas for personal support planners would be beneficial, as would access for people with LTCs to local health promotion services. There have also been many examples across the country of councils working with the former Primary Care Trusts to develop “Leisure Centre Prescription Schemes”, and tackling obesity should be a shared prevention priority between councils and Clinical Commissioning Groups.
Obesity certainly features in Joint Strategic Needs Assessments, and is likely to be a priority in the Joint Health and Wellbeing Strategies which have been developed. These will in future be supported and monitored by the HWBs.
Current examples of effective integration of services across health, social care and other services which treat and manage long-term conditions
There are multiple examples within social care where personalisation and use of personal budgets has led to a significant change both in improving the outcomes people are achieving, changes in the services and support they are accessing and the positive impact it has had upon their perceptions and experience. The Personal Budget Outcome Evaluation Tool (POET) survey 2011 and associated report (attached in a link at the end of this submission) provides significant evidence based on individuals’ experiences and examples.
Best practice in end of life care within local authority services includes working with a wide range of stake holders such as hospices local colleges, social care providers including care homes, extra care schemes, domiciliary providers and supported living establishments. These networks have allowed commissioners to develop innovative approaches and interventions to support a range of service user groups. The recent publication of the National End of Life programme “Sharing successful strategies for implementing supporting people to live and die well” highlights good practice across England demonstrates how effective integration can be to support people with long term conditions and in particular those people nearing the end of their life.
There is a 30 year tradition of multi-disciplinary working in the Community Mental Health Teams and Community Learning Disability Teams developed initially to support the closures of long-stay hospitals from the late 1970s, early 1980s and beyond. Much of the learning from these teams, in terms of differing professional cultures, the need for joint training, addressing different assessment systems and processes, is still relevant today in developing integrated working.
In general terms, there are many current examples of integrated working, which will include services for people with LTC’s. Torbay has often been cited for its integrated community health and social care services, and North East Lincolnshire remained the only “Care Trust Plus” in the county, with adult social care services delivered within the NHS on behalf of the council. In Greenwich, the Royal Borough has developed award-winning integrated services with the community health services of the Oxleas Foundation Trust. These are based on a single point of access, a joint emergency response, integrated hospital discharge teams, community assessment and rehabilitation teams and intermediate care at home teams. In respect of long-term conditions, there is clear evidence of improved quality of life, with reductions in emergency admissions and outpatient appointments (as well as significant financial gains).
The implications of an ageing population for the prevalence and type of long term conditions, together with evidence about the extent to which existing services will have the capacity to meet future demand
The ADASS Budget survey shows 3% demographic pressures (about £400 million pa), with services being stretched, with fewer people receiving services but at higher cost and intensity. This points to an urgency to consider a whole system approach facilitating switching resources from acute to primary preventative services. Unlike when the NHS was set up 65 years ago, now more than half of GP appointments and two-thirds of outpatient Accident and Emergency visits are for people with long-term illnesses and conditions.
This group, many of whom are older people, are now responsible for 70% of the total health and care budget, over £70 billion every year and that number is growing. Equally, when discussing the aging population we naturally concentrate on the older age group, but there are also similar issues with substantial growth in younger people with significant disabilities living much longer, which is fantastic, but presents equally significant challenges in the support they require.
A major element of the growing demand for services to older people is the increased prevalence of dementia. This need and the necessary response are comprehensively covered in the National Dementia Strategy, to which ADASS and LGA contributed. It is clear that the progression of dementia can be slowed and early diagnosis magnifies the benefits of any subsequent intervention. The National Dementia Strategy takes a social model of disability: so “living well” does not really rely over much on health services and recognises the importance of housing, technology, combating stigma, dementia friendly communities, asking the wider community what it can do. Another proposal would be to involve the Design Council in innovation.
Finally, there is a need to recognise increases in demand for services for people who suffer strokes, diabetes and cardiovascular conditions. Timely and expert treatment can increase longevity, limit disability and promote quality of life.
The interaction between mental health conditions and long-term physical health conditions
The correlations between long-term and various aspects of mental health, particularly depressive illnesses are well-known. This can lead to a self-perpetrating set of interactions such as social withdrawal and reduced mobility, self-neglect, poor nutrition or increasing problems with smoking, drugs or alcohol.
The interaction of mental health conditions and long-term physical health conditions is well evidenced and reflected in the mental health strategy “No health without mental health”. Poor mental health has a negative impact on people’s long term health care needs and it is estimated that people with long term conditions are two to three times more likely to experience mental health problems than the general population.
Evidence suggests that there is a strong negative impact on recovery and management of long term conditions for those people who also have mental health needs. This manifests itself in longer periods of time spent in hospital, poor outcomes and lower quality of life. If mental health problems are left untreated, this will also impact negatively on people’s ability to self-manage their long term condition (such as diabetes) with people lacking the motivation and ability to do this.
What is needed is strong collaboration between primary and mental health care with services wrapped around the person rather than conditions. ADASS has worked with the Royal College of Psychiatrists to produce a position paper calling for pooled personal budgets alongside integrated assessments across NHS and social care, and integrated support plans. Ideally this could support both the mental health and physical health needs of individuals.
The extent to which patients are being offered personalised services (including evidence of their contribution to better outcomes)
In many respects, the introduction of the Independent Living Fund (ILF) in 1988 could be seen as a major early milestone in the development of a personalised approach to supporting disabled people. Well ahead of the community care reforms, the introduction of Direct Payments and a commitment to universal availability of personal budgets, the ILF allowed people to create their own personalised care arrangements using direct purchasing power. The ILF has contributed to major developments such as the support for employment of Personal Assistants, and the role of user-led organisations in advocating for, supporting and providing local services.
The personal budgets approach is ideal for support for people with LTCs, allowing greater choice and control of care arrangements. Long-term conditions were a natural focus for the piloting of Personal Health Budgets.
It is arguable that the recent review of ILF has concluded that given the progress of personalisation and prevalence of personal budgets in adult social care, ILF Funding should transfer to LAs to be managed in a single approach based around the individual. Arguably this would also provide LAs the opportunity to review and revise the allocation of such resources based on need.
Attached to this response is a link to the 2011 National Personal Budget Survey published by TLAP.
The 2012 version will be published at the end of May. Below is an excerpt from the executive summary for the 2012 National Personal Budget Survey:
“There is an increasing body of evidence across health and social care that personal budgets have the potential to improve social care and well-being outcomes, for people with long term conditions. This was the clear conclusion of the Personal Health Budgets pilot independent evaluation published in late 2012 and is consistently demonstrated in social care by councils using the Personal Budgets Outcomes Evaluation tool (POET). It will be important to take personal budgets forward across health and social care as a key element of the integration agenda in support of people with long term conditions”.
8 May 2013