Chief executives are a resilient and optimistic species by nature, despite five years of spending cuts, but their one area of real worry is social care, not only because it represents 35% of their spend and has been cut by 12% since 2010 but because of increased risk from it failing.
The third snapshot report into the concerns of chief executives by Zurich Municipal, released at last month’s SOLACE conference, confirmed how much social care has become their number one challenge. As one respondent told the report: ‘We’ve let care of the elderly become a local issue from local taxes, irrespective of needs – how did this happen?’ The focus now is on integration and although all eyes are on the Greater Manchester Health and Social Care Integration programme the rest of the country is also moving towards closer joint working between health and social care. The trouble is that too often the emphasis is on saving the NHS budget – or reducing its overspend – rather than providing a better home-based, and less expensive, service. Cuts have put pressure on the care service, raising the risk of failure and also contributing to more complaints to the local government ombudsman especially over charges.
At a round table organised by The MJ with Zurich Municipal at the SOLACE conference, a group of local authority chief executives aired their concerns about social care, whose future is inevitably bound up with the NHS. As one said: ‘Sometimes nothing gets done unless there’s a crisis. We’re in the crisis. In fact it’s a perfect storm.’ Another agreed saying: ‘We haven’t got the luxury of time or money’. In fact one commented: ‘It won’t be long before we have an exploding platform.’ Another added: ‘I’ve got responsibility for adult care which is our biggest headache. We’ve got a health integration agenda, an outcome-based commissioning model. My health colleagues will take five years to get there and we haven’t got that time. We’ll go pop in two years.’
There was a frustration about cultural and budgetary obstacles. As one said: ‘We have the burning platform in local government but I’m not sure the NHS is experiencing it in the same way.’ Another added: ‘I got a legal letter from my clinical commissioning group saying a particular group of individuals were the responsibility of our social services not health. We should cut out these boundaries. Health and wellbeing boards should have responsibility for primary and secondary health.’ One participant said: ‘We were well ahead with integration but separate budgets don’t make integration and early intervention easy.’ Another said: ‘Local authorities are onto a hiding to nothing if they just carry on. It’s not just about the money but about culture and attitude.’ Talking of budgets one participant commented: ‘GPs are being rewarded for targets that don’t make sense.’ One said: ‘If adult care can’t meet 35% target savings in four years then we will have a massive problem.’
There was also irritation at the way the focus has been on reducing cost pressures on the NHS even though social care has faced severe cuts along with rising demand. As one said: ‘The recent party conferences were all about who puts more into health. Adult social care just doesn’t have the same status.’ Another said: ‘Adult care just doesn’t have the same impact as a child crisis.’
Participants also flagged up the impact of spending cuts even though the focus of government policy is to shift costs in the NHS acute sector to community care. As one said: ‘We’re only halfway through the cuts process. Many councils are using reserves having run out of efficiency savings. I’ve got to find £83m in savings while £48m is added annually to our costs.’ Another added: ‘The proportion of spending on care is especially acute when we’re in the middle of spending reductions. The only way we can make cuts is by making cuts in care.’ One participant pointed out: ‘We’ve got an incredibly low spend on care per head. We’re going to the lowest common denominator. We’ve had to intervene in two care homes in the past month.’
There was concern about the paradox of on the one hand councils cutting grants for voluntary groups while on the other expecting them to fill in the gaps. As one said: ‘On the one hand I was about to eradicate voluntary sector partners to save money and on the other I expected them to take on more responsibility.’ Another said: ‘Even with integration there just isn’t the money. We’re looking towards the community.’ Indeed several commented about the need for the general public – so far almost oblivious about the real parlous financial state of the NHS – to become more realistic about what they can expect. The problem is that most under-65 use the NHS only occasionally while the over-80s and those with long-term conditions use it constantly. It is usage by the latter age group which needs addressing.
There was certainly no support for care being moved into the NHS and nationalised. The NHS was universally praised for its acute sector but panned for its after care service. As one participant said: ‘My mother is in re-enablement care and she was being treated as an idiot.’ Another added: ‘We did a walk through a hospital mimicking an old person’s journey through the wards. We came out confused. If we moved care into health it would be even worse. The NHS is there as an acute service. It’s not good at the after-care bit.’
But there are solutions. One said: ‘We’re exploring the idea of “community wraps”, the devolution of core functions to local community groups dealing with those who don’t have complex needs.’ Another added: ‘We need to move away from targets of four hours waiting in A and E and go further down the food chain.’ One participant said: ‘We’re also looking at more community re-enablement and also at smart cities for digital health solutions’. Another noted: ‘We’ve got one GP practice dealing with all the care homes so there’s consistency’. Other comments were: ‘Better data sharing would make a big difference’ and ‘You could adopt a “troubled families” approach to palliative care.’ Business, with its rate going to local government from 2020, also needs to have a greater involvement. As one said: ‘We need a narrative now with the business community as they will effectively be funding social care. But if I told business I was increasing their business rate to help the elderly I’d get short thrift.’
Round table participants:
Ruth Bagley, chief executive, Slough BC
Richard Crouch, group director of operations, Somerset CC
Michael King, chief executive, the Local Government Ombudsman
Sander Kristel, director of commercial and change, Worcestershire CC
Melanie Laws, chief executive, Association of North East Councils
Michael Lockwood, chief executive, Harrow LBC
Robert Tinlin, chief executive, Southend-on-Sea BC
Tom Whiting, corporate director of resources, Harrow LBC
Phoebe Morris-Jones, policy officer, Lewes DC
David Forster, Zurich Municipal
Paul Tombs, Zurich Municipal
Heather Jameson, The MJ (chair)
