REFORM OF THE NHS AND SOCIAL CARE
The NHS and Social Care are in crisis. 1.9m older people are living in poverty and more and more older people are having to sell their houses to pay for their care in this the fifth largest economy in the world. So what can be done?
Clearly it cannot be solved at a “component level” by pouring more and more resources into the first aid camp at the bottom of the cliff, rather than building a fence at the top. More of the same, only more so will not work. There needs to be a “whole systems approach” and radical reform returning to the Beveridge principles of health and social care being free at the point of delivery of service. The total package needs to be designed to reduce demand, increase both efficiency and effectiveness, move from a “minding” to a “mending” service in respect of social care and find sufficient money to make health and social care (not living costs) free at the point of delivery of service. Change needs to be based upon empirical evidence of cause and effect rather than hypothesis.
The NHS costs £116.4b of which 4/5th or £93,12b is spent on older people. There is a correlation between income and demand upon the NHS and with 1.9m older people living in poverty there is little wonder that they make such demands upon the NHS.
Latest estimates suggest 1.3 million people over 65 (almost 1 in 10) suffer from malnutrition or are at risk of malnutrition, but this number could be much higher. Nearly one third of all older people admitted to hospital are at risk of malnutrition. 50% of older people admitted to hospital from care homes are at risk of malnutrition. Malnutrition increases healthcare use, including hospital admissions, increases length of hospital stay, and risk of becoming a permanent resident of a care home. The cost of malnutrition in England in 2011-12 was estimated to be £19.6 billion per year, or more than 15% of the total public expenditure on health and social care. The treatment cost per patient with malnutrition or risk of malnutrition (£7,408 per person per year) is two to three times greater than that for a non-malnourished patient (£2,155 per person per year). Therefore just to do something about malnutrition would enhance the lives of older people and save the NHS considerable money - £19.6b per year or 15% of the total expenditure.
There are five main causes of malnutrition, lack of money, lack of motivation, incapacity, lack of support and social isolation.
Britain’s State Pension is 29% of National Average Earnings compared with 100.6% in Holland, 94.9% in Portugal, 93.9% in Italy, 91.8% in Austria and 81.8% in Spain. The official definition of poverty is anything less than 60%.
If the State Pension was increased to 60% of National Average Earnings it would take 1.9m older people out of poverty. A cheaper option would be to increase “pension credit” to this level but the take up of “means tested” benefit is low and older people who have worked all their lives find it humiliating. However it would not cost as much as one might think as the increased State Pension would use up more of the “personal allowance” of those with other income thereby clawing back some of the cost through income tax and there would be a saving on other benefits. So how is it to be paid for?
It is hard to believe that less than ten years ago people could be excluded from employment on grounds of age alone. There was no other group of people who could be excluded in this way. Imagine the outcry if someone was denied employment or sacked because of their gender, race, religion or disability and yet until the abolition of the “default retirement age” it was perfectly legal to refuse employment or “sack” people on grounds of their age. Research has shown that redundancy has a more lasting debilitating effect than either divorce or bereavement and enforced retirement was like redundancy only more so as there was little hope of further employment. Therefore there was little wonder that there was so much depression among older people and clearly the benefits of this “watershed” acknowledgement of discrimination are yet to be fully felt. The American experience was that legislation came first followed by attitudinal change.
However now that people can no longer be forced into retirement and, in many cases, condemned to spending the rest of their lives in poverty, there is a case for linking the eligibility to the State Pension to retirement, and not age. People who go on working beyond the age at which they could draw their State Pension would continue to pay National Insurance (they are currently exempt) and not draw their State Pensions until they retire (with phased arrangements e.g. dropping to three days and drawing 2/5th of one’s pension etc). This might produce sufficient money to both leave the minimum age of entitlement at 65 and pump prime the raising of the basic State Pension to 60% of national average earning (which would still be amongst the lowest in Europe) and lift all older people out of poverty. Given the correlation between income and demand upon the NHS and the likely impact on malnutrition this would reduce demand on both health and social services.
The State Pension currently costs £77,088,000,000 (77.08b) per year. To increase it (from 29%) to 60 % of average national earnings would cost an additional £82,404,413,793 (£82.4b). However the following savings would partly offset the cost:
i) Pension Credit and other benefits £32b
ii) Winter Fuel Allowance £3b
iii) TV Licences £0.55b
iv) Bus Passess £1.5b
There are 11.68m people aged over 65 of whom 1.9m are in poverty therefore it is likely that at least 9.78m people would pay more income tax at a minimum of 20% (possibly higher) The additional pension would be £9,960, taxed at 20% for 9.78m people would produce £13,799,178,808 (£13.79b)
Therefore the actual net cost of increasing the State Pension to 60% of national average earnings would be £82.4b less the consequential savings above of £37.05b and the additional income tax of £13.79b which leaves £31.56b to find.
There are currently 1.19m people over the age of 65 years in work. If one assumes the average earnings of £27,600 (although many will earn higher than this) the additional income were they to go on paying National Insurance would be £3,941,280,000 (£3.9b). And savings on not paying their State Pension of £6,600 would be £7,854,000,000 (£7.85b). Therefore this reduces the amount to be found by a further £11.75b to £19.81b.
As mentioned above, and from an independent study, it is thought that malnutrition costs the NHS £19.6b per year. Although lack of income is perhaps the major cause of malnutrition among older people, depression (often brought on by retirement and lack of income), lack of motivation, bereavement and social isolation can also be contributory factors. Assuming the increased pension and social work input, to be described later, is able to reduce malnutrition by 90% it would both enhance the quality of life of older people and save £17.82b leaving just £1.78b to find.
Older people currently cost the NHS £93.12b per year and £73.52b without the total cost (not 90%) of malnutrition. There is a correlation between income and demand upon the NHS in all age groups and therefore if the increased pension and measures to reduce social isolation brought about a 10% reduction (it is likely to be higher) that would produce an additional £7.3b. Therefore the package is already (£7.3b - £1.78b) £5.52b in credit towards the cost of free social care (the definition of which will be clarified later).
The total Social Care Budget is £50b of which 51% or £25.4b is spent on older people and increased pensions are likely to reduce demand here also. There is a need to invest in preventative measures (which keep people active, mentally and physically, and prevent social isolation), social work intervention, community development and home care. The majority of caring is quite spontaneous and voluntary and yet many older people do not have these support networks. Social workers need to be freed from “care management” and the “gate keeper” role of assessing the eligibility to specific services at a “component level” thereby enabling them to practice their skills in using relationship to bring about change (in motivation, behaviour, inter-personal relationships and community support) by various therapeutic techniques and counselling – thereby reverting to a “mending” rather than the current “minding” service which is a consequence of the purchaser / provider split and which encourages dependency, accelerates decline and adds to the workload. Community Social Work can develop the kind of self-supporting community activities in which people can be involved to combat social isolation. Social Isolation, often brought about through lack of income, is as detrimental as poverty. Befriending schemes were an attempt to combat social isolation. However these are both costly and artificial. The role of the social worker is to try to re-establish contact with relatives, rekindle old friendships, forge links with neighbours or create situations whereby people might make new friends.
There is also a need to work with housing associations to develop “extra-care sheltered housing”, both to buy and rent, as a direct alternative to traditional residential care. It is possible to put just as much nursing and social care into such developments, as it is traditional residential care, and the owner / tenant has his/her own front door, defended space and retains control over the essentials of daily living. And every day housing and living costs are met by the older person as they would be if they were at home. Extra Care Sheltered Houses alleviates many of the harmful effects of traditional residential care and reduces dependency and thereby the risk of abuse due to the victim being subservient. It should be possible to greatly reduce the number of older people in both “care homes” and “nursing homes”.
Charging for residential care provided under Pt 3 of the 1948 National Assistance Act has remained almost unchanged since that time. People hand over their income up to the cost of the home, less a small personal allowance The first £14,250 of capital is disregarded after which the person is deemed to have £1 per week income for every £250 capital up to £23,250 after which they are expected to pay the full cost. In 1948 very few people owned their own homes now the majority do. In 1948 everything, including clothes, was included in the charge but the more enlightened Local Authorities, seeing this as a throwback to the days of the Poor Law, gave residents back a clothing allowance to choose their own clothes. This was misunderstood by the majority of Local Authorities who began to expect older people to buy their own clothing out of the personal allowance, which was never the intention. And more recently many Local Authorities have been further abusing the Personal Allowance and the notion of third party top ups whereby relatives can, if they chose, meet the cost over and above the Local Authority’s contract price for their loved one to go into a more expensive home. However the Local Authority, having identified the need, must either provide a place within their contract price or meet the difference.
There was always a mixed economy of care, although until the 1980s private homes were only available to the well off. When Margaret Thatcher became Prime Minister she decided to extend choice by allowing people who were on Supplementary Benefit to have their fees made up by the Benefits Agency subject only to the availability of a place and a means test. As a consequence public financial support for people in private and voluntary residential home rocketed to tens of billions.
Sir Roy Griffiths was asked to look at the situation which he termed the “perverse incentive” as the same money was not available for home care. He was also concerned that there was no assessment of need or verification of wishes and it was thought there were people in residential care who neither needed or wanted to be. He therefore recommended that the money which had been, a rapidly growing, open ended entitlement be transferred to Local Authority Social Services Departments as a “cash limited” allocation available for both residential and home care and that Local Authorities had a duty to carry out an assessment of need and verification of wishes. For some reason he included Nursing Homes, which had previously been a Health responsibility, and remained so for registration and inspection purposes, so that for the first time people in nursing homes were “means tested” under CRAG (Charging for Residential Accommodation Guide) and social workers required to assess the need for nursing home care.
This was implemented by the 1990 National Health Service and Community Care Act. However despite Sir Roy’s unshakable belief in market forces Local Authorities were expected to fix their contract price and “manage the market”. Most Local Authorities fixed their contract prices below the cost of their own in house provision - so much for Sir Roy’s “level playing field” and there is little wonder that in some areas as many as 50% of Care Homes have been found to be below standard by the Care Quality Commission.
It is very difficult to get figures on just how much is collected from older people towards their long term care as many local authorities, particularly in England, “wave away” those they regard as “self-funders” to make their own provision which is contra to the spirit of the 1990 legislation which assumed a verification of wishes and assessment of need with some people paying the full cost (not self-funding – an English term) with the local authority gradually picking up the cost as their money ran out.
The measures above should greatly reduce the number of people in residential accommodation (care homes) and nursing homes. And the increased State Pension will give everyone sufficient income to meet their living costs. Therefore everyone will be able to pay £16,550 (60% of National Average Earnings – currently £27,600) less their personal allowance (currently £27 per week) or £15,092 per year – which should be adequate to meet the hotel or living costs. The intention is that nursing and social care should be free at the point of delivery.
In order to ensure adequate care Local Authorities should be required to fix their contract fees at the cost of their own in-house provision less the share of the overheads of local democracy. And third party top ups, which have been abused should no longer be an option. Therefore people could either be placed via the local authority and get their nursing and social care free or meet the full cost in a more expensive private home. They would, of course, still have the higher state pension as a contribution towards the cost.
The average cost of a care home is £29,270 (Nursing Costs in Nursing Homes are already met) and under the proposed State Pension of 60% of national average earnings people would be able to contribute £15,093 leaving the Local Authority to find £14,178 per placement. There are currently 416,000 older people in Care Homes and it is anticipation this number would reduce substantially, as a percentage of older people, as a result of this “whole systems review”. Assuming a 20% reduction the cost of providing free nursing and personal care under this scenario would be 332,800 X £14,178 or £4,718,438,400 (£4.75b) And we were £5.52b in credit.
Successive government have tried to encourage health and social services to work together from Joint Funding in the 1970s, whereby health was given money which could only be spent by social services with tapering arrangements, to the pooling of budgets.
However no Government has dealt with the real issue: that of lack of coterminosity of boundary and different funding streams and lines of accountability which has been the main impediment.
This does not amount to the merger of Health and Social Care as a different combination of agencies is required for different outcomes. For example Child Protection needs Social Services (now children’s services in England), Health, Education and the Police to work closely together. A doctor can exercise judgement as to whether or not a child’s injury is accidental or not and treat the injury. The social workers role is to try to understand why the perpetrator caused the injury, what might be done to prevent it recurring by bringing about change through counselling or safe guarding measures, or, depending upon prognosis re-home the child. Education is in daily contact with many children for surveillance purposes and the police need to consider whether prosecution is appropriate. Various voluntary agencies are also involved. As far as older people are concerned the key players are Health, Social Services, Housing and Leisure Services.
Successive reforms of health and social services since the 1970s have added to the cost and led to greater fragmentation, reduced effectiveness and have led to a “process” rather than an “outcome” orientated service. They have been done at a “component” rather than a “whole systems” level. Often the tools used are those that identify that something is wrong and not how to put it right. In consequence changes are made which still do not work and yet more costly and time consuming re-organisation takes place.
There is just as much empirical evidence as to what works in respect of organisation, management and leadership as there is medicine and social work and yet there is little evidence of it being applied in practice.
People working in health and social services are dealing with some very distressing situations although it is very rewarding to see the improvement, how ever small, that they have been able to bring about in people’s lives. Unfortunately many hospitals are still organised on the discredited “production line” model so that staff do not see the outcome of their work. And there appears to be an underlying assumption that people are motivated by, and can be controlled by, money: when there is no evidence to substantiate this. People may be attracted to a particular post by the salary but once in post they are motivated by job satisfaction and recognition.
Reform of the public sector (railways, health and social services) and many of the principals underlying subsequent changes can be traced to Margaret Thatcher’s premiership when a purchaser / provider split was introduced by Sir Roy Griffiths in the mistaken belief that it would force quality up and prices down through a mixed economy of care. Clearly this has been proven not to be the case and it has doubled management costs and led to an army of accountants chasing the same deficit around the system.
There is therefore sufficient evidence to get rid of the purchaser / provider split which was extended to social services by the 1990 National Health Service and Community Care Act and resulted in social workers being predominantly employed on the purchasing side undertaking assessment and care management rather than being seen as agents of change. A consequence of this has been that social services have moved from a “mending” to a “minding” service.
During my time as a Director of Social Services, services were run jointly with Health and my counterpart in health ran nine hospitals, five of which were regional, community services and the Family Practitioners Committee (GPs) all with a management team smaller than is now found in every Hospital Trust. The abolition of Area Health Authorities has left a void of strategic planning and co-ordination and the creation of trusts almost a throwback to the pre-National Health Service structures.
Local Government re-organisation during the 1990s which created unitary authorities also added considerable cost. For example in Wales it went from 8 County Councils and 37 District Councils to 22 Unitary Authorities at considerable cost. Up until that time Wales had been the envy of England as it had coterminosity of boundary between health and social services with a number of All Wales combined health and social service strategies. Had the Government of the time decided to go for Unitary Authorities based upon the existing County Councils there would have been savings all the way. Immediate savings on the cost of democracy with the abolition of the District Councils and year on year savings as District Council Departments were merged into County Council Departments as staff left through natural turn-over. There would have been no need for any redundancies.
In England the creation of Unitary Authorities resulted in twice the number of Social Service Authorities and the splitting of children's and adult services doubled senior management costs again. Social Service Departments lost responsibility for homelessness in 1974 and have subsequently lost responsibility for Youth Justice, despite their considerable success, and “registration and inspection” which went to the Care Quality Commission. So responsibilities and geography have got smaller and salaries gone up.
To take social care away from Local Government and amalgamate with Health would be more of the same and would further marginalize Social Work and reinforce the “minding” service creating an ever increasing number of dependent older people. Although the Seebohm Report which led to the 1970 Social Services Act and the creation of Social Services Departments could never have led to the “one door to knock on”, he envisaged, he was never fully understood. The term “generic” was confused with “generalist” in implementation leading to “jacks of all trade and masters of none”. However what Seebohn did was to recognize the unique contribution of social work and the “generic skills” required to use relationship to bring about change via various therapeutic skills and counselling – the recognition and understanding of which has been all but lost. Social Workers needed these skills together with specialist knowledge of the area they were working in and to be employed on the work which interested and motivated them and which was why they chose the vocation.
Many local authority areas are considered to be not financially viable and already, in Wales in particular, shared services are being developed. Therefore the answer may lie in bringing all these services together at County Council or Police Authority geography, thereby returning the Police and Health to local democratic control and creating coterminosity of boundary with common funding streams and lines of accountability.
Perhaps Government should consider the reinstatement of Social Service Departments in England (they still exist in Wales), re-designated as Social Work Departments to mirror the Scottish experience, to imply “mending” and not “minding”. Responsibility for “registration and inspection”, homelessness (this was transferred to housing in 1974, as they had the houses, which was responding to the “presenting problem” and not addressing the causes or providing the necessary help) and youth justice could be returned to them
Between 1971 and 1974 Directors of Social Services had to be both qualified Social Workers and approved by the Department of Health and Social Security, as it was then. And there may be a case for reinstating this requirement and adding one of management training and qualification so that chief officers might bring the body of knowledge derived from their professional backgrounds to strategic planning and advising the County Councils on policy within the legislative framework of Central Government.
The trend over recent years, and since the purchaser / provider split, has been to separate out “planning” from “doing” and from “evaluating” which leads to more of the same only more so and leads to the demoralisation of staff. Applying his unique “whole systems methodology” (tied analysis”, “transformation analysis”, “team size” “non-delegatable tasks etc) to a hospital in Holland Christian Schumacher was able to get a 30% increase in output with higher morale and lower sickness levels. It is also important to reduce the number of tiers of management to ensure a one stratum gap between manager and subordinate (Stratification of Work and Organisation Design – Ralf Rowbottom and David Billis – Brunel University – disciples of Elliott Jaques). Less than a one stratum gap leads to perceived “personality clashes", as the manager and subordinate are probably doing the same job, and the more levels of management the more difficult that communication becomes as per the party game of whispers. And more than a one stratum gap leads to problems in understanding communication due to differing levels of abstraction required of the roles. Training is crucial if one is to match the capacity of the individual to the complexity of work and employ people on the work which motivates and interests them.
Having brought all the relevant players together into the same chief officer’s management team, with coterminosity of boundary and common funding streams and lines of accountability there is a need to regroup services from the point of delivery of service and align them behind desired outcome. “Functional divisions” need to be removed from “patient pathways” by creating “whole task, right sized teams” able to “plan, do and evaluate” their work (which completes the learning cycle of constant improvement ) with access to all the resources and expertise to complete the task.
Services could then be delivered via “inter-agency, multidisciplinary, outcome orientated, whole task, right sized teams” aligned behind outcome with access to all the resources and expertise to complete the task. A local manager would be accountable to the “lead agency” in each case to determine the "why", "what" and "when". Staff would remain accountable within their professional disciplines for the "how" with representation in the County Council Management team for strategic planning and the non-delegateable tasks of management – i.e i) negotiating common policies within legislative frameworks and advising the County Council ii) painting the vision and giving strategic direction; iii) devising strategies for their implementation; iv) monitoring and evaluation; v) high level co-ordination; vi) managing the external environment, and; vii) leadership and people development.
Meetings which are essential to disseminate information, involve staff in decision taking and co-ordinate activity between departments, should be kept to a minimum. For example during my time as a Non-Executive Director of an NHS Trust all hospitals had to introduce what were called “Integrated Governance Committees” which were actually about “risk management”. The Integrated Governance Committee consisting of 24 people, including the Chief Executive on £140,000 per year and Consultants whose time would have been better spent seeing patients, spent two hours each month pouring over the “risk register” which consisted in the main of equipment which was wearing out. Not once was anything removed from the register or the risks prioritised. The report then went to the “Capital Prioritising Committee” and from there to the Audit Committee where twelve people, including the Chief Executive and several others who had already considered it in the larger group spent a further hour discussing the same report. From there it went to the Management Team and then to the full Trust Board which spent a further hour on the same report. The cost of the staff time was such that if the system were abolished all the equipment on the “risk register” could have been purchased in three months! The Director of Finance said this was an “opportunity saving” implying that the staff would still have to be paid. However at the time the Trust was making ground staff and auxiliary nurses redundant!
As a Director of Social Services it was always of concern to me if more than one member of staff from the same department attended an inter-departmental or inter-agency meeting in that it implied the levels of delegation were wrong.
Hospitals are very expensive and unhealthy places are more use needs to be made of day surgery and hospital at home. There are frequent references in the media to the shortage of Doctors and Nurses and the consequential use of agency staff. However if there are sufficient agency staff there is no shortage; they are simply employed in the wrong pace. Agency staff are paid more than permanent staff, often receive their accommodation and travel expenses and the agency gets a fee. If the NHS did not use them there would be no work for them to do and they might consider applying for permanent positions. It should not be beyond the whit of management to reach agreement with the unions to bring this about given the money it would free up for redeployment or higher salaries.
The NHS and Social Care are in crisis. There needs to be a “whole systems” review leading to radical reform to reduce demand and improve effectiveness and efficiency. “More of the same” will not work. .
This paper has suggested how this could be achieved whilst staying true to the Beveridge principle of being available to all and free at the point of delivery.
It has argued that:
i) increasing the State Pension to at least 60% of national average earnings, to lift older people out of poverty and reduce demand upon the NHS, is key;
ii) people who work beyond eligibility to the state pension should continue to pay National Insurance and not draw their State Pension until they retire
iii) the purchaser / provider split should be removed as it has not forced prices down and quality up as envisaged but doubled management costs;
iv) social workers need freeing up to do the job they were trained to do
v) The cost of health and local government re-organisation of the last thirty years should be reversed;
vi) coterminosity of boundary, common funding streams and common democratic accountability of all the statutory agencies and departments involved, bringing them together at the lowest possible cross over point (likely to be within County Council or Police Authority areas) is paramount;
vii) functional divisions need to be removed along patient pathways by creating “whole task right sized teams” aligned behind outcome, able to “plan, do and evaluate” their own work with access to all the expertise and resources needed to complete the task;
viii) front line staff need confidence to take decisions up to the extent of their discretion with the capacity (intellect X knowledge X experience) to match the complexity of work through improved training, and engaged on the activities which interest and motivate them
All the evidence is that all that is outlined in this paper could be achieved within per capita budgets (i.e only increasing in line with population growth) whilst increasing the basic state pension to 60% of national average earnings and making health and social care (not living costs) free at the point of delivery of service, paid for by income tax and National Insurance as originally envisaged.