Round-table discussion on the adult green paper

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

Chair:- Mark Ivory, managing editor of Community Care
Reported by Clare Jerrom, editor of www.communitycare.co.uk
and Amy Taylor, senior reporter at www.communitycare.co.uk

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

immigration when I need immigrants to get me up in the morning? On
one hand the government urges “yes, yes that’s
wonderful” and on the other hand it’s too risky.

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

small contracts. Both have got a lot of logic but are
contradictory. Individualised approach is inherently more costly.
Is it so valuable and if so cost it.

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

If you look at a frail and confused older person all you can do is
extend their life. You’ve still got cost but you spend more
money on it.

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