Lesley Dixon is Chief Executive of PSS (Person Shaped Support) which has a long history of social care innovation and is one of the leading independent providers of Shared Lives services. PSS has just published a report on the outcomes and costs of its Shared Lives support, which includes powerful personal stories alongside data which should interest many people working in the sector. Lesley writes:
Social Impact Reporting is a big priority for us. At the end of each year, we make it our business to take a detailed look at what works, what difference our services make, what is cost-effective and ultimately whether we are doing any good for the people we work with.
We recently published our first Social Impact Report for Shared Lives and TRIO, which looks at the fantastic achievements made by our Shared Lives schemes across the UK; in Merseyside, Wirral, Manchester, Wales and the Midlands. The report includes information on the people we work with, the pathway they follow when they come to the service, the outcomes we support people to achieve (including case studies) and what our service-users think about the service. It outlines some cost-benefit analysis information, looking at the value of our Shared Lives projects when compared with other, costlier forms of care in the areas we work in, and also looks at some of the innovative work being done with our TRIO project in Wales, the hospital-to-home work we are trialling in some of the schemes, and our work with Shared Lives Plus on the My Shared Life tool.
Perhaps our biggest finding from this report is around the savings our scheme can make to the public sector. We found that Shared Lives is 51% cheaper than residential care and 35% cheaper than supported living. This means that on average, a Shared Lives Placement at PSS would represent an annual saving of £23,491 per person, compared to if they were to be placed in residential care, or an annual saving of £11,922 if they were placed in Supported Living.
Whilst there are some really good findings and inspiring case studies in the report, we know there is more we can do to keep getting better. We plan to use the My Shared Life tool from Shared Lives Plus to help us manage impact on an ongoing basis, as opposed to a reflective report at the end of each year. This will help us ‘course correct’ where we know that some of the things we are doing could be more effective or where they aren’t working. We also really want to embed some measures which can help us demonstrate that what we are doing is high quality (such as some of the NICE Quality Standard measures), as well as some other tools which can help us establish baselines and demonstrate an emotional impact – such as people no longer feeling socially isolated or lonely.
In its Pre-Budget report for their Adult Social Care inquiry today, the Communities and Local Government select committee calls for The Chancellor to bring forward £1.5bn funding from the ‘Better Care Fund’ to plug the hole in social care funding in the year ahead (2017/18). The Better Care Fund is a national funding pot which was intended to be spent on improving adult social care and bringing social care and health together, easing pressure on hospitals and the NHS. It has been announced but is not due to be released until 2019-20, despite the current crisis in social care funding which is seeing care homes and home care businesses closing and worrying signs of quality and safety dropping. The Committee also calls on the Government to commit to closing the funding gap for the rest of the Parliament through to 2020.
We gave written and oral evidence to the Select Committee about the role which innovations like Shared Lives and Homeshare could play in transforming social care. I agree with the committee that the Better Care Fund should be brought forward. But this would be to plug a current gap between what is being spent and what would be needed to achieve anything approaching minimum standards. It would not result in ‘Better Care’, but a slightly eased crisis. For better care, we also need a national vision for social care which has real ambition, which is prepared to take some sensible risks in scaling up the most promising models and significant additional investment. Programmes like Nesta’s Realising the Value and our work with SCIE and PPL on Total Transformation point the way towards a health and social care system which would work and be affordable long term, rather than relying on crisis handouts year after year. We all deserve better than that.
A letter to the Prime Minister from the chairs for three select committees calls for cross party talks and consensus on a long term settlement for social care. Having given evidence to the recent Communities and Local Government Committee on this issue, I ‘m heartened to see the three committees coming together to call for positive change.
We have been here before of course. There have been cross party talks and the beginnings of consensus, but they have either gone nowhere or unravelled as pre-election party politics put point-scoring ahead of doing the right thing by older and disabled people. The Dilnot reforms gained cross-party support but were an early victim of austerity.
The temptation will be to aim for big, simple, government-sized announcements, like the complete integration of heath and social care. These will not solve the issue, and could even do more harm than good if, for instance, the whole system is integrated around the power bases of the big local hospitals, at a time when we need desperately to shift power and resources into the community. There is clearly a need for a big injection of funding to avoid widespread catastrophe and whole care industries such as home care collapsing completely. But again, short term funding is necessary but not sufficient, if it is spent only on the things we spend it on now.
So by all means let this lead to more money and more joined up health and care systems, but the more important and much trickier challenge is to use this moment not simply to shore up today’s approaches, but to invest in scaling up the most promising community and family based initiatives. The goal should not be integrated bureaucracies but unified goals: a health and wellbeing system which aims to create and sustain wellbeing, which connects people and supports family carers, which values resilience. It has never been more appropriate to take some risks. We have of course been calling for ambitious investment in initiatives like Shared Lives and Homeshare which have demonstrated they work. But we also need to be prepared to scale down bureaucracies and organisations whose unresponsiveness demonstrates they are too big, through accelerating approaches like personal budgets, personal health budgets and the involvement of voluntary, community and social enterprise organisations in designing and delivering interventions in people’s lives which are focused on health, not just illness and which are social as well as genuinely caring.
I’ve been in a couple of roundtables recently in which the Labour party has outlined their plans for integrated care. It’s fairly broad and high level stuff at the moment, but a key part of their proposal is that health, care and perhaps other aspects of the welfare and support system will be integrated with a single budget, with, as I understand it, councils in the lead on commissioning (presumably using the new Health and Wellbeing Board structures) and NHS organisations acting as delivery bodies, with less emphasis on increasing competition from independent providers.
It’s an alluring idea, which addresses a split between health and social care which has never ‘worked’ and was hotly debated when the NHS was created in 1948. Back then, the NHS could focus on illness treatment and most people got any ‘social care’ they received from their families, not the state. Now the NHS and social care need to be effective and sustainable for massively increased numbers of people with manageable long term conditions, not short illnesses likely to be either treated or fatal.
I’ve blogged before about the need to integrate not just services, but the informal/unpaid support system and the formal/ paid service system. An integration of health and care will not automatically achieve this. A recurring phrase in today’s discussion, for instance, was ‘patient rights’. There was a little, but much less, about citizens (not patients) and shared responsibilities. It would be easy to integrate around the existing public services power bases of hospitals and professionals, not around individuals, families and communities. This would be to integrate illness treatment services, not health and well being (eco)systems.
The language of rights in relation to health and well being is interesting. Charities and politicians alike are more comfortable talking about rights and entitlements than about responsibilities. This can mean that charities contribute to ‘clientism’ and that politicians can’t deliver on promises. Continue reading
Update to the original text: I’d read “We agree” in paragraph 29 as referring to all the points made earlier in the paragraph where it is reported that the law commission and others argued for a statutory footing for resource allocation systems. In fact, the commitee agreed only with Richard Humphries’ point in that paragraph about a muddled of picture of 152 allocation systems as is clear from the later recommendation in bold. Paul Burstow MP, the committee’s Chair, kindly clarified this: “we only recommend placing RAS on a statutory basis for the purpose of arriving at notional costs [for Dilnot care accounts – see below], not for determining the amount in a personal budget. On the more general use of RAS we recommend in para 204 that the “Government should review the efficacy of RAS and ensure that the code of practice or guidance makes clear that the development and application of any methodology for calculating the cost of meeting eligible needs is transparent, has regard for the well-being principle, and is subject to the duty to meet eligible needs.”” Some text below amended accordingly.
The Joint Committee chaired by Paul Burstow MP which has been examining the draft Care and Support Bill has reported today.
One of the most interesting aspects of the report is what it has to say about Resource Allocation Systems, which are the complex sets of calculations (algorithms) which turn an assessment of need into a cash amount to pay for an individual’s services. The recommendations taken individually are very sensible. For instance, the committee urges the government to put beyond any doubt that nobody’s resource allocation should be reduced because of the presence of a carer, without having gained that carer’s consent to carry out the caring which is seen as reducing the need for state funded support.
The committee identifies the fairness and transparency of Resource Allocation Systems as a crucial part of the delivery of personal budgets and Direct Payments and suggests that a RAS will be just as crucial to developing the “care account” by which the amount and individual is seen as having spent on care will be totted up under the new Dilnot system of capping the maximum amount anyone has to spend on care. The Dilnot system will not add up what a person actually spends, which could vary according to the care provider they choose to use, but will instead be based on a notional spend, proportionate to their level of need and typical or expected support costs for someone with their level of need.
The committee agrees that having 152 different resource allocation systems is “muddled”. This is part of the current “Ordinary Residence” problem, in which non-transferable care packages can stop people from moving from one council area to another for fear of losing an existing care package and the committee notes that this challenge will extend to those with a “care account” unless there is a national system.
This shows how far away from the original brief the reform of care laws has come. When the Law Commission was charged with tidying up and modernising social care law, it was very clear that it had not been given a brief to draw up a law for personalisation. Of course, sweeping away all existing social care law, was an opportunity for precisely that – why would we just tidy up a law which fits badly with the vision for a personalised social care system? – and the committee are calling for the new system to be built around personalisation.
Personal budgets and Direct Payments are of course just one aspect of personalisation. I can see a risk with establishing RAS Continue reading
I spoke at GovToday’s Social Care conference yesterday on ‘rethinking personalisation.’ My argument you won’t be surprised to hear was not that we should re-think whether personalisation is a good idea, but that we still have more to do in really understanding what good care and support as part of living a good life really looks like. I started by suggesting that when I talk to policy makers and when I talk to people who use services and front line workers it can seem like there are two different worlds. In one world, anything is possible. We can make savings whilst tailoring support to what people want and helping people find good lives. The other world feels at times like it’s full of cuts, gaps, unmet need and failures in even basic care and safety. You could say that just shows how out of touch with reality the people dreaming of personalisation are, but you can find real people living real lives in both worlds.
I believe that a lot of the people living in the world full of possibility and who have found many of the resources they need, get to live in that better world not because they live in an area where there is endless public money (not sure where that would be these days), but because they have found other kinds of resources, including being supported to find and build their own resourcefulness. Often when people are able to live lives which feel whole and not fractured, another pair of very different realms – the realm of services and the realm of families and friendships – have found a way of complementing each other, rather than ignoring or fighting against each other.
The Joint Committee which looked at the draft Care and Support Bill reports next Tuesday. I’m hopeful that it will recommend that the Bill does more to create that alignment between paid and unpaid, formal and informal. If it does, I think that the Bill and last year’s White Paper could be seen in future years as a turning point for social care, and perhaps for attitudes to public services more generally. This won’t be about cutting existing services and hoping for the best. But it will be about a system which Continue reading
I was part of another discussion about the development of NICE quality standards for social care services the other day. I’m heartened that NICE are talking to the social care sector and seem keen to fit their work around the needs of people using social care, rather than just trying to fit social care into their existing health-focused model of quality standards and guidance.
It’s dry, but important, stuff: where NICE recommends, commissioners (ie public money) follows. NICE is all about ‘evidence-based’ practice, which is very sensible, but also worrying for a sector with no real culture of measuring the outcomes of its work. We need to address this, but if we rush into it, we may end up measuring the wrong things in the wrong ways, with all the perverse incentives that can entail, and which are evident in some NHS health commissioning.
As I’ve been thinking through these issues, I’ve come up with some tricky questions which are all linked, and to which I’m not sure I know, or have yet heard, convincing answers:
- Social care outcomes are not exclusively delivered by interventions which we would normally label as ‘social care services’. For instance, many of our members’ most creative micro-enterprises look nothing like a social care service and people have bought all sorts of things (season tickets to a football club etc) with Direct Payments. So to which services do social care Quality Standards apply?
- How will Quality Standards avoid creating one system (high quality, expensive) which applies to people whose personal budgets remain managed by councils, with another system (unregulated, cheaper) for those who have the freedom to spend a cash Direct Payment more or less as they please?
- NICE quality standards for NHS services are used in a traditional commissioning environment, in which local planners of one kind or another purchase services as part of large contracts, mainly from large organisations. Social care is increasingly purchased by individuals using Direct Payments or their own money (self-funders) and sometimes from very small providers, so how will quality standards be useful for individuals making their own spending decisions?
- Social care is in transition, moving (uncertainly, patchily) Continue reading