Round table discussion
| Blair said the green paper addresses challenges. Does it? |
A round table discussion on the key themes within the adult green paper was hosted by www.communitycare.co.uk in London yesterday.
The debate, organised by www.communitycare.co.uk’s editor Clare Jerrom, was attended by:-
Andrew Holman Inspired Services
Cliff Prior, Rethink
Louisa Stevens, English Community Care Association
Simon Stevens Enable Enterprises
Jo Webber, NHS Confederation
Mark Ivory:- Tony Blair’s introduction to
the green paper says the green paper addresses the challenges for
social care of a changing and ageing population higher expectations
and our desire to retain control over own lives for as long as
possible and over as much as possible. Does it?
Cliff Prior:- It is a great vision but if you want to get that, you have to look at the plain logistics and I don’t think this realistically does.
| Prior: Green paper is a great vision |
The aim is that public services are more personalised but on the other hand, in other legislation, there is greater state control. People with severe mental illness are particularly exposed by the control in the Mental Health Bill which is utterly incompatible to the approach in the green paper.
Louisa Stevens:- It does in some parts but I am concerned about the cost neutral issue. I don’t know if it can be implemented if it is cost neutral. I also don’t want it to overrule any innovation that is already happening.
Jo Webber:- The vision is great – it’s good to have a long-term view of adult social care. A lot of it is reliant on partnerships. A lot has to be invested to get partnerships working well. That will be a challenge for all parties. We need to build relations to ensure we can deliver it.
Simon Stevens:- Adult social care is giving adults a double message. On one hand they are promoting independence and personal choice and on the other they are prescribing that you should get a job etc. There is also a difference between young adults and older adults.
Andrew Holman:- The green paper is packed with compromise which is why it will fall short of what it aims to do. From the government’s perspective – the notion that this can happen within existing funds is laughable although it was good to hear at Community Care Live that the new community care minister Liam Byrne will argue for more funds.
The system is crazy where you have to get assessed separately for supported living, direct payments, extra care housing, access to work and so on – you wouldn’t think that was sensible if you were starting with a clean plate. Direct payments are not grasping the nettle – it is currently only a half measure that just adds another layer of bureaucracy.
There is good stuff on early intervention [in the green paper]
but the idea that money will be saved is ludicrous.
| Holman: System is crazy |
MI There are lots of good points there. If I can turn to your point Cliff about risk and independence…
CP There are a number of issues. Firstly with
logistics – the idea that in social care that position will
save money in the long run is false. The preventive strategy will
extend life and so we will have a slightly older group with
disabilities. It is improving and extending people’s lives
and that is great. But we have to spend more money.
The logistics of the workforce, we need a skilled, empowered,
reflective workforce. Most of the current workforce are paid less
than shelf stackers at Tesco’s and these are major logistical
challenges.
There are two issues:- the pressure on people to work and we shouldn’t think that older people are exempt from this with the plans to raise pension age. There are also public safety fears. We know of people who are supported by social care and health who are subject to antisocial behaviour orders to stop them self-harming. They are subjected to harsh mental health legislation. These are real tensions but they are not addressed in here [the green paper] and there is a balance to be struck.
It is right to have this debate but it needs to be an honest debate. Let’s have an honest debate – not a pretend one.
JW We need to take measured, controlled, balanced risks to enable someone to do something. There will be situations where people will want to take more risky actions.
LS It will also be interesting to see what happens when the Commission for Social Care Inspection and the Healthcare Commission merge.
SS Direct payments are a risk. A lot of carers are non-English and immigrants. How can the government have zero tolerance on
| Stevens: Direct payments are a risk |
AH A lot of people I know run risks. A lot of risks are run because of a failure of services to support people properly. I know someone who has recently developed diabetes. For years he had a bad diet, he was not allowed to use a cooker as it was deemed too dangerous, but got no help to eat healthily. So he could only use a microwave, but has no money to afford microwave meals, resulting in a crap diet. Now he has diabetes and joins the group of people with learning difficulties more at risk of an early death. I hope desperately that this is the sort of thing early intervention strategies will start to address properly.
MI Is this where the professionals of the future will come into this? Informing service users about risks so they can make informed choices? What happens to professional roles in these contexts?
CP We need to support people from A to B. A number of organisations already do navigator roles, person-centred planning, working as advisers and supporting people. These new roles will be skilled but a different sort of professional. If I buy a flat I don’t expect the solicitor to choose a flat for me but I do expect him to advise me whether the lease is dodgy.
The green paper is not a white paper but there is developmental work to do.
LS It depends whether the professionals will be subjected to Criminal Records Bureau checks.
AH But if they had access to the Protection Of Vulnerable Adults List they would get access to people suspected of being unsuitable.
MI The risk question: If someone is on the Pova list or CRB checked, does it solve the problem?
LS It’s difficult, you need to balance the checks and risks. Interestingly, the green paper comes at the same time as the National Minimal Standards.
SS I would never employ someone who had not received care themselves as they would not know how it would work for me.
| Prior: Need to listen |
CP We have got to make people who are using services involved in training professionals. In mental health care we are constantly being told that service users’ number one priority is for someone to listen to them with respect.
MI In the green paper social care workers cease to be gatekeepers and open up services in an empowering way.
JW People who work on the frontline have been in navigating roles but it is the part of the role that has not been valued in the same way other parts of the role have. It can be split off [into a separate role] but wouldn’t it be better to value it as part of their day to day role? Why are we splitting them off? Let’s not create something that in a few months will not be flavour of the month.
AH I agree entirely that we don’t want another layer. I would have liked to have seen the green paper grasp this nettle and gone for a system where everyone has a direct payment. That would cut the rubbish around direct payments and who’s getting it and who’s not. I like the idea of one-stop-shops where people could access support to help them spend their money, including the option to buy a place in a care home or access a day centre if that was truly what was wanted. But only after having explored the alternatives.
SS What we need is assessment in one area and money in another it needs to be all separate. Assessment and money needs to be in two separate departments
CP The question here is tension. If the assessment for eligibility is separate from the commissioning service, the assessment is ill informed. If they are combined the service user doesn’t think they are on their side. I think this is absolutely dishonest, the gatekeepers exist. I do think the navigator role is very different. Social workers and care managers come from a “we control the money, we control the services” model and I do think this is different.
| Webber: Existing roles could
be strengthened |
JW I agree with you but I think there are existing roles there which could be strengthened.
CP But are the people with most care navigating role experience service users and their families? Maybe that’s more best practice.
SS Do you think you should have a choice to be in a care home?
LS As Jo says, lots of partnerships exist already. I think you should have the choice whether you can be in a care home. Care homes are part of continuing care because we don’t have enough of domiciliary care. Of course there should be a choice. It is right to request not to live in a care home but also people have got to be able to choose if they do want to go into a care home.
CP I think they spell it out differently with direct payments and individualised budgets.
LS We’d like to see it extended to care homes.
SS Commissioning won’t exist. I will be the commissioner – individuals will become the commissioner.
CP I’m not sure if it would work to use the money to buy a place in a day centre. If you look at it in terms of a situation this is more like the privatisation of directory enquiries. Some services won’t be available. You [Andrew] were talking about somebody might choose to go to a day service. It only takes a few people to choose not to have a day service and it collapses. I don’t think we should predict that any of the building based services are going to be viable if we are going to a more personalised service. For care homes, the size is such you could take a risk but the more specialised the need, the less viable it becomes. It’s better for individuals to have this advice – it’s worth the extra money. The services will be closer to what people want but they will cost more.
LS So it comes back to the cost neutral issue.
| Stevens: All comes back to
cost neutral |
CP I don’t want the government to set a noble vision – I want them to think a lot about logistics. It is a noble vision for a long jumper to jump across the Grand Canyon but you would expect them to think about the logistics before they did it.
LS: Our point of view is that independence isn’t a geographical location. In some care homes you might have more independence than you have at home.”
SS The risk is crap. Age of professionals is over. Those that don’t deliver won’t exist. Professionals need to get new jobs now. Unless social workers learn to listen to disabled people generally they won’t be around. A revolution is coming. We need compulsory direct payments that they can use for a care home or a better care home.
We need to get away from this look after the disabled attitude and become providers of an economic service.
JW There is such a range of users that we are going to have people with different needs wanting different services. But I think care homes do have a place on the spectrum of care, the aim to keep people as near to their homes is a laudable one.
We also need to look to investment in innovative technologies to go alongside this. If you do not invest in that, we are not giving people the best choice.
CP What this is offering is a choice of provider and what sort of provision. In all the studies that the King’s Fund did on long-term conditions in the US. What they came back with was not choice of provider it was choice of commissioner. But this does not allow you to say I don’t like this social services department I want to go to another one. Is a better way to balance individual choice by a choice of commissioner?
It’s like if you need a plumber in London. You may not know one so you may choose to go with British Gas who would provide you with an engineer if you needed one. They would be choosing a commissioner – someone to deliver that. Maybe we are looking at this the wrong way.
| Holman: Brokers would
release care managers' time |
AH: I don't agree with the notion that brokers would come in and release care managers time to work with the more complex cases. My experience is that authorities bring in experts because they don't have the skills in house. I think they might have got this the wrong way round and you would need to bring in experts or brokers at times rather than assume that you have skills in house.
MI: There’s a whole chapter in the green paper on strategic commissioning and what that involves and it involves the NHS as much as anybody else. I wonder if this partly solves the issue of funding more than anything else this is how the government thinks we want to keep people out of hospital. In my view PCTs commission in a weak way and just put money into hospitals. Could they not put more of that money into social care?
JW I think that partnerships have to be the way forward and if you speak to many PCTs they will says one of their key partners is the local authorities with the local voluntary community sector. PCTs have set up public and private forums. I would like to show you some of the things the PCTs are setting up from practice based commissioning.
In terms of the independent sector provision, alternative medical provision – a lot is going on in healthcare and I think that the view that PCTs are sitting on billions of pounds and all the money goes to hospitals is somewhat out of date and I think things such as practice based commissioning is providing health care services in the community. We have got areas where strategic partnerships are working really well.
MI But it is still community healthcare rather than community health and social care…
| Webber: Partners are
becoming firmer |
JW Yes but partners are becoming firmer and
firmer. In some areas these relations are really building ahead of
steam. There has to be a wider partnership at local level.
Local PSA, local public service boards bring all the statutory and
voluntary community sector bodies together. Then you can look at
where you get the best impact on health. That way, you get
different sorts of structures.
One thing frontline workers don’t want to do is write things
down 15,000 times. IT systems that talk to each other are a
prerequisite.
AH But Ebay and banks manage to do it don’t they…?
CP I’m not sure they do. If something goes wrong it’s blamed on the system. What you’ve got at the minute is compromising interests. When there are tight financial circumstances, people draw back to health, social care, employment. There is a question with health and social care. They are so inter-related, should we put them in one pot? They do work. Crisis houses to help people stay out of hospital are working. Do they save money? No. Do they provide better services for people, Yes.
There is a problem when the same person is commission and assessing.
JW But if your hip needs replacing, and I’m assessing you I see it needs replacing and agree it needs replacing. The basis is you and I have to decide what’s best for you.
CP But eligibility is still in the hands of the commissioner.
MI So we’re saying the NHS is not the solution to funding? Now the green paper is said to be cost neutral but Liam Byrne has said he will go to the chancellor and argue for more costs. How much do we need?
SS: There is a lot of waste. Why don’t we sack the people that don’t’ do any work and that might save a bit of money and if you get rid of services that don’t work you would save.
CP A lot of the Gershon approach is a smaller number of larger contracts and what this green paper is saying is a larger number of
| Prior: Contradictory approaches |
MI More than £10 billion is spent on adult social care per year so how much more would we need to make the green paper work?
AH Social care is people intensive – it has to be. Smart houses which check if you are breathing is a nice add on but there has to be a large increase in budgets to pay enough people properly.
LS We have to introduce professionalism in social care to give people a career path.
SS: But again service users need to be involved.
JW I wasn’t suggesting smart homes instead of care but there will be times when people aren’t there.
CP If there are no demographic changes we have got to see a similar above inflation increase for social care salaries as we have seen in health care. That’s probably a 20 per cent hike before anything else, like in Agenda for Change. If you look in health care and look at the difference between health provider schemes, private orders are 5 or 10 per cent higher from going into a higher transactions model…So 25 per cent is going to make sense for a higher skilled workforce. This can’t be done with the workforce being paid a minimum wage.
LS I agree. But in Hampshire there was a case of homecare provision and they decided they wanted more care homes so they built substantial beds with no regard to best value. They are planning more places and services and that would cut down budget in green paper if enough was tendered.
| Hampshire went against Best Value |
MI So through efficiency savings?
CP But 5 per cent of our turnover is spent on tendering.
LS Perhaps not that. Look at Jo’s partnerships – who can support and deliver?
CP Yes you can save some money from services people don’t want but there will be a net 15 per cent extra cost.
MI Turning to prevention…?
SS I couldn’t have been prevented. You have to look at what are you preventing?
MI So is the green paper focussed more towards older people than vulnerable adults?
CP How many needs of social care are achievable by a social care prevention strategy? It might be achievable to leisure services, health and broader social things but very difficult to see a social care response. So local authorities need to look at a broader role – what can be done across the piece to reduce needs? Even then all we will do is delay the need for services.
| Prior: Prevention not about
saving money |
LS The government’s emphasis on prevention will stop people dying but they talk about it as if you roll home one day on a skate board and die.
JW I would also say changes to health and a duty on local authorities to promote wellbeing is something partnerships need to be looking at. It is partly social services responsibility, partly health responsibility and partly education responsibility.
CP The point about prevention is a better quality of life – not very often is it about saving money. It is wrong to think prevention can save money although it is well worth doing as it improves quality of life.
MI Finally to look at direct payments before we wrap up. The take-up of direct payments is a lot lower than expected when it was introduced in 1997.
SS Direct payments are meant for independent disabled people as a pat on the back. Direct payments are wonderful but they were never ever properly implemented. It is all about implementation.
| Holman and Stevens. Holman
said direct payments were an implementation nightmare. |
CP In some areas local authorities use blocks as they don’t want people using direct payments. We sometimes act as agents because sometimes people don’t want to take on the complexity – they want an agency to do it for them.
AH Direct Payments have been an implementation
nightmare. When it was implemented the government thought the
floodgates would open so they restricted it. We had to fight for
people with learning difficulties to be included. However, after
they were included, the guidelines and regulations were already
written with other groups in mind. If they had been written with
people with learning difficulties in mind consent would never have
been in the legislation. It is, and local authorities can still use
it as an excuse. It is clear that some councils have placed
restrictions on Direct Payments because of their political views
about wanting to keep services in house. They have to be instructed
otherwise, I think the move is to have direct payments for
everyone
SS And they should be in line with national care standards
and not a postcode lottery.
To join in the debate on the adult green paper, go to the
discussion forum on the home page or
email comcare.discussion@rbi.co.uk
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