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    Joint Authors:

    Colin Slasberg Consultant in Social Care

    Peter Beresford visiting Professor University of East Anglia

    Last September, spurred into action by what the pandemic told her about the state of social care, Nicola Sturgeon announced an independent review of adult social care to ‘build a service fit for the future’ in Scotland. She invoked the spirit of 1948 for social care to experience the same transformation post Covid as the NHS did post war. The review was led by Derek Feeley, President and Chief Executive of the Institute for Healthcare Improvement.

    With remarkable speed, based on extensive public engagement the review has now reported. The headlines are likely to be dominated by calls for a National Care Service. Responsibility for funding will become centralised and new joint Boards with the NHS will be responsible for commissioning and procurement, not the local authorities. The latter will retain delivery of the ‘social work’ function, which means the great majority of current function given the infrastructure required to support and direct the field work role which identifies need and allocates resources to individuals.

    Cultural change must precede structural change.

    The report’s authors believe that structural change without cultural change does nothing more than re-arrange the furniture. This leads them to the view that it is their first recommendation, which transcends structural concerns to address cultural concerns, that is the real key to delivering what the First Minister wants. The report recommends a system is built from and driven by a ‘human rights approach’, such that ‘Human rights, equity and equality must be placed at the very heart of social care and be mainstreamed and embedded’. It would be ‘further enabled by incorporation of human rights conventions’ with particular reference to Independent Living.

    Facing up to the resource consequences

    It will not, of course, be the first time a review or commission has sought such high minded ideals. Nor would it be the first time a government has signed up to them, but without a serious plan to deliver. What is new in the Scotland review is that it has grappled with how those ideals engage with the question of resources. This raises genuine hope the ideals will for the first time get beyond ‘blue horizon’ managerial pleadings.

    The review makes the following three recommendations;

    1. ‘People should understand better what their rights are to social care and supports, and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
    1. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
    1. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’

     The first two recommendation give practical expression to what a system built to deliver human rights looks like. The third offers a practical way forward to realising it.

    The transformation process – from what to what?

    The recommendations above also give expression to what a system not built to deliver human rights looks like. Neither the person nor the social worker has any power. Decisions are taken ‘above their heads’. The social worker is rendered merely piggy in the middle. They take information from the individual and give it to the decision maker and then feed the decision maker’s decisions back to the individual. The situation is further damaged by the social worker being ‘hampered’ by having to think first about resources, eligibility and cost.

    These first two recommendations make clear that a human rights based approach means that the individual and the social worker must be free to work in authentic partnership to work out the best way to give the individual the best quality of life their circumstances allows without regard to availability of resource.

    If these two recommendations were to be delivered, the role of the social worker would be transformed. They will, at long last, be the social care equivalent of the clinician in the NHS. People are generally confident that if they need a diagnosis and treatment from an NHS clinician that the clinician will make their best judgement as to what modern medicine will make possible.  Patients are aware, however, they may subsequently have a wait depending on availability of resources.

    Managing the resource consequence

    For such a positive practice process to ever become a reality in social care, the resource consequences have to be managed. To base a strategy on thinking otherwise, perhaps on the premise that society and their political leaders should fund all the needs of older and disabled people however much it costs, is very high risk. Social care would have to be delivered outside of a budget. Proponents will have to persuade political leaders and the public why social care should have a guarantee of all their responsibilities being funded while no other public service does, not even the NHS. Failure of such a strategy will mean the status quo will not change.

    The pragmatic approach is to accept that social care will continue to be delivered within a budget determined by the democratic process, national or local.

    The Feeley review addresses this reality in the third recommendation above. If need is to be identified without regard to resource availability, there is no arithmetic prospect that the resources required will coincide with the resources available with the precision required to match spend to budget. The system must allow for need to exceed resource.

    The political consequence

    The current, eligibility based system does the exact opposite – it does not allow for need to exceed resources. It actually forbids it. The system delivers the imperative to spend within budget by ensuring the flow of needs it meets is determined by the budget. This is made evident in Scotland by the scale of the post code lottery despite all councils ostensibly working to the same eligibility criteria. Because ‘need’ is determined by resources, it is a system that never recognises there is any unmet need. Whatever budget is provided is always enough.

    That, of course, is music to the ears of political leaders with other priorities on their minds. But if the Scottish government adopts the recommendations of this report, that comfort will have been given up. Councils will know the true cost of delivering on political leaders’ commitments to the human rights of their older and disabled citizens. The commissioners will have the information to tell them.

    Implications for England

    We have to wait and see how Holyrood responds. But however it does, perhaps this review’s thinking can influence the debate in England where the same eligibility based system is in place The debate in England has yet to get beyond the funding questions. Absent is any thought of vision. But only with vision can we know what we want for our money. And only with vision can we ensure we are spending our money well, achieving the results we want, and how far we are falling short.

    The Scotland review’s third recommendation as above is a remarkably simple idea. Eligibility of need must be replaced with affordability of need to control spending. Those responsible for the system will need to be prepared for transparency and honesty about any gap between needs and resources. Unmet need in social care should replicate the functions waiting times have in the NHS. Firstly they are a ‘safety valve’ at the front line when resources lag behind need. Secondly they act as a weather vane so political leaders know what way the wind is blowing when the time comes round to make political decisions about the funding requirements for social care.

    The Scottish review recommendations resonate powerfully with the view about the transformation change required in England set out by Barry Rawlings, leader of the Labour opposition in Barnet. Barry’s blog places the agenda in the English context.

    Whether or not the Scottish government lights this beacon, hopefully leaders in England will open their minds to the possibilities opened up.

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    In September 2020 the Welsh Government invited comments on the draft regulations, code of practice and statutory guidance from local authorities, local health boards, and other organisations or sectors which are represented on Regional Partnership Boards (RPBs) or have an interest in the provision of care and support to the local population. RPBs are the main Welsh platforms of collaboration between health, social care, the Third Sector and a range of other key stakeholders.

    The Socialist Health Association – Cymru agreed its repose to the consultation questions as follows:-


    Question 1 Do you agree that market stability reports should be prepared on a regional basis, by local authorities and local health boards through the regional partnership boards? If not, please give your reasons.

    The Socialist Health Association Cymru believes that the business model underpinning our social care service in Wales is no longer sustainable and we need to be planning for a National Care Service.

    The independent sector continues to express concern about its marginal viability with residential care providers requiring levels of bed occupancy that go against the Welsh Government’s policy of more care in a domestic and homely community environment.

    There is a recruitment and retention crisis which is worse in the independent sector due to poorer pay and conditions, less training and fewer opportunities for career progression.

    Within this context we believe there is an urgent need to undertake regular assessments of the continuing viability of the current model of provision.

    While the consultation document proposes reports on a regional basis, it important that the geographical spread of provision in mapped at a more local level.


    Question 2 Do you agree that market stability reports should be produced on a five yearly cycle alongside the population needs assessments? If not, what alternative arrangements would you propose, and why?

    We note that the proposals recommend that a five year assessment cycle with at least a mid-cycle interim review.

    We believe that the overall fragility of the sector requires a three yearly overall assessment with a yearly review.


    Question 3 Have we specified all the key matters that need to be included in market stability reports? If there are other matters you think should be included, please specify.
    While we are fully aware of the sector’s legacy of being heavily dependent on for-profit providers, we are surprised at the failure of the consultation document to consider what role public bodies might play in service provision. This is only briefly mentioned in the context of a sudden closure of an established private sector provider.

    The omission is all the more surprising as it recommended that the assessments should be linked the to Regional Partnership Board needs assessment.

    The implicit assumption is that local authorities will have no role in the management or shaping of the market beyond its present contract compliance assessments. This means that it will be for others to address gaps in service provision.

    The variation in local authority fees across is Wales in considerable. It is far from clear why this is the case though these fees are at the heart of any assessment of the viability of the sector.

    Question 4 Do you agree that market stability reports should be kept under regular review and revised as necessary, but at least at the mid-way point of the five year cycle? If not, what other monitoring and review arrangements would you propose, and why?

    See reply to Q2


    Question 5 In your opinion, does the draft code of practice strike the right balance between what is required of local authorities and what is left to their discretion? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    The document urges “reasonable” efforts for community engagement. This is a rather elastic requirement which could result in a minimum level of engagement. It would be useful to be more specific that efforts should be made to engage with organisations such as the CarersUK, Stroke Association, Alzheimer’s Society, Mind as well as any successor organisation to Community Health Councils.

    There should be a specific reference made to any community councils in the Regional Partnership Board area.

    There only the most fleeting reference to engagement with care staff and other support / partnership professional groups. There should be a clear requirement to engage with local trade unions involved in the Education, Health & Care Sectors e.g. Unison, GMB Unite the Union, RCN, NEU and Local Medical Committee. In some areas, where there may be low levels of trade union membership, the local trades union council ( if it exists) should be consulted.

    Local groups of faith should also be specifically included in any engagement. They provide comfort and support to many of our citizens in times of difficulty and they can have important insights into the needs for particular communities.

    Question 6 In your opinion, does the draft statutory guidance set out clearly the partnership approach that local authorities and local health boards should take in preparing their market stability reports? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    See replies already given.
    The document mentions the need to anticipate trends but is rather limited in the scope of the horizon scanning it envisages. This is a vulnerable sector underpinned by a fragile business model. It follows that more vision is required in looking at delivery models of care e.g. more in-house provision by public bodies, the NHS or the Third Sector.

    Question 7 What impacts do you think our proposals will have on the duties of public bodies under the Equality Act 2010, or upon a local authority’s duty under the 2014 Act to have due regard to the United Nations Convention on the Rights of the Child, the United Nations Convention on the Rights of People with Disabilities, or the United Nations Principles for Older People?

    This is a timely document and Welsh Government is to be commended in initiating this legislation. Not withstanding the attitude of the Westminster Government to international agreements the Welsh Government has always used best international standards to drive policy.

    A citizen focused, responsive, stable and caring service needs to be in place to meet international standards. This must include provision that is based on the needs and wishes of its users. The workforce must be well trained and valued.

    None of this will be possible if overall business model of care is not longer fit for purpose for the challenges of the 21 Century.

    Question 8 We would like to know your views on the effects that our proposals with regard to market stability reports would have on the Welsh language, specifically on opportunities for people to use Welsh and on treating the Welsh language no less favourably than English. What effects do you think there would be? How could positive effects be increased, or negative effects be mitigated?

    This is particularly important. Bigger, footloose corporate bodies have a smaller footprint in Wales which is generally a good thing. Smaller, local providers with a local workforce are more likely to be culturally sensitive to their needs of citizens.

    In many parts of Wales the local population will include people who have spent most of their lives in an area and others who have moved in at various stages of their life cycle. Our providers must respond to this diversity.

    Many vulnerable users would wish to engage with services in their first language. The planning and service delivery process must be responsive to this need.

    The Welsh language is an important part of Welsh life. As well, individual communities have other cultural attributes which can provide support and comfort to local service users which should also be factored into a citizen centred service.

    Question 9 Please also explain how you believe the proposed policy around market stability reports could be formulated or changed so as to have positive effects or increased positive effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language, and no adverse effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language.

    See Q8.

    Market stability reports should include a specific section demonstrating how the needs of Welsh speakers and other sensitive cultural dimensions are taken into account.


    Question 10 Under the Well-being of Future Generations (Wales) Act 2015, public bodies have a duty to consider the long-term impact of their decisions. We would like to know to what extent you think our proposals will support the principle of sustainable development set out in that Act. Further information on the Well-being of Future Generations (Wales) Act 2015 may be found here: https://www.futuregenerations.wales/about-us/futuregenerations-act/

    Our health and care service is still too illness and crisis orientated. It needs to be more pro-active and enabling for all our citizens.

    Beyond the immediate pressures of Covid-19 and the longer term legacy we have inherited, the Welsh Government needs actively to promote a policy of prevention and early intervention to create a more equal and socially just society that is at ease with itself.

    This includes providing our young people with the best start in life, providing all citizens with the opportunity to live full and enjoyable lives and providing a healthy ageing strategy including tacking loneliness and social isolation for citizens as they progress through life.

    Question 11 We have asked a number of specific questions. If you have any related issues which we have not specifically addressed, please use this space to report them. Please enter here.

    SHA Cymru welcomes this proposal to assess the inputs into service provision other than in crude quantitative ways. This approach could be extended to other field of policy e.g. to assess the scope and scale of service provision in different communities and localities.

    Our Chief Medical Officer has often pointed out that “one size does not fit all”. Different communities have different needs. If we are to address these varying needs at a community level we need to develop processes which could be informed by the lessons learned from implementing this legislation.

    October 2020

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    Cllr Barry Rawlings, Leader of the Barnet Labour Group

    Particularly since the pandemic, public attention to social care has focussed on the fragility and impoverishment of the major services, residential and domiciliary care, that provide the direct care and support to older and disabled people. However, less visible is the beating heart of social care, which is the way councils identify need, plan support and allocate resources. This is the process that determines the fate of each individual.

    Over the past 18 months, as the Labour opposition to a Tory controlled Council, we have been forensically testing how that system works. We have found its nothing like the claims being made for it. We have been giving a great deal of thought to what is wrong and how it can be put right. We have come to a number of key conclusions.

    The first conclusion is that the UN definition of Independent Living is beyond question the right vision for social care. We believe all Barnet residents who rely on social care, whether in their own home or living communally, should have control over their lives with ‘choices equal to others’ with ‘full inclusion and participation in the community’.

    We have to make this a practical reality, not just a pipe dream and not just yet more rhetoric. This means addressing the resource question. So, our second key conclusion is that the UN approach to the resource consequences is also the right one. States are not expected to have all the resources immediately available but are expected to take ‘concrete steps’ to embark on a process of ‘progressive realisation’ of the resources required.

    So, instead we are looking at the feasibility of a new model of working. That model is:

      • First: To empower our social workers to work in real partnership with our service users to identify and cost all their needs for Independent Living.
      • Second: To put a stop to the miserable, minimalist ‘eligibility’ practices.
      • Third: To ask budget holders to be transparent about what their budgets can afford and what they cannot.
      • Fourth: To expect the Director to explain what is needed for all to have Independent Living, not to reduce ‘need’ to whatever budget is provided.
      • And then to do everything in our power to secure the resources required by using the evidence we have gathered to ask Government for the funds Barnet needs.

     

    That brings me to our third key conclusion. The Care Act already provides the primary legislation to make this happen. Its central concept of wellbeing has 9 dimensions. They include dignity, respect and control over one’s life and services. You couldn’t put a cigarette paper between this and the UN definition of Independent Living. The Act also has provisions that enable councils to be honest about what they can and cannot afford. It also requires councils to  actively find out what resources are required to meet all needs in the communities they serve.

    Our fourth key conclusion is that none of these transformative provisions are being enacted by Barnet Council. Barnet like all Councils, maintain they deliver the national template. All the Care Act has done is provide new language for the same old practices that demean service users by telling them what their needs are, and then defining ‘need’ to suit their budgets.

    Our fifth conclusion is that the problem lies with the secondary legislation – the Statutory Guidance and Regulations. These are the responsibility of Government, not Parliament. They have been constructed in a way that allows councils to by-pass  key provisions of the Care Act   and focus on eligibility rather than wellbeing. These practices serve the political expedients of controlling spend to budget while delivering the political convenience of denying the existence of any unmet need.

    None of this is the fault of local authorities or their social care staff.  Social workers do their best to squeeze as much out of the system as they can for individuals, but it’s a zero-sum game and there are always winners and losers. This is the inbuilt inequity of the system.

    This is an issue that affects all councils, as all will be applying the Statutory Guidance and Regulations. If there is a party-political criticism of the Barnet administration, it is in the enthusiasm with which they embrace the status quo. They have used it to drive spending down in Barnet to the point where they boast about being one of the lowest spending councils in the country, and by a long way.

    The Guidance and Regulations must change. They must make Independent Living the standard of wellbeing for all, require councils to deliver the spirit and letter of the Care Act, to report on unmet needs and require central and local Government to do all in their power to secure the resources required to minimise, if not eliminate, unmet need.  Local authority social care practices will need to be re-purposed  top to bottom. I believe these changes would comprise the ‘concrete steps’ toward ‘progressive realisation’ the UN expects. The UN gave a damning verdict of the UK’s delivery of Independent Living in 2017.

    With real co-production at the heart of needs assessments, as proposed in this new model, we might achieve better health and wellbeing outcomes which will actually save money in the long-term.

    And in the process the narrative will cease to be the dead end of how much money ‘social care’ requires. It attracts little enduring public sympathy. We should promote equivalence in the public mind between best possible wellbeing, which social care delivers, and best possible health of mind and body, which the NHS delivers.

    So, given that ‘adopting into English Law Articles from the UN Convention’ potentially includes changes to the secondary legislation to bring the Care Act to life, I fervently hope the SHA/KONP campaign has the greatest possible impact.

     

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    by Esther Giles, Former Director of Finance (Specialised Services) South Region of England, SHA member”

    This article tracks the extent and nature of marketisation and privatisation in the NHS up to the current proposed move to Integrated care systems (ICSs) and argues that the current ICS proposals are the logical conclusion of the marketisation reforms implemented progressively from Thatcher onwards.

     

    Some of David Cameron’s many famous last words were his pre-election pledge in 2010 that there would be no more “top-down reorganisations” of the NHS[1]. He then presided, in 2012, over the most chaotic and unlegislated top-down upheaval of the NHS that can be imagined or remembered. The resulting fragmentation and damage were never resolved, and so the NHS goes limping in the logical conclusion of the relentless drive away from a universal national service, and towards the current proposals for Integrated Care Systems (ICSs) modelled on the US Kaiser Permanente system of Accountable Care Systems.

    The 2012 Health and Social Care Act and Marketisation

    The internal market was given a fundamental boost by the Health and Social Care Act 2012. Under this Act, all NHS services above a stated value had to be put out to competitive tender, turning the provision of healthcare into an economic activity and, as such, subject to EU competition Law.

    Thus, private providers such as Capita and Virgin have been seen bidding to provide NHS services, mainly in community services. Sometimes they win and sometimes they don’t. And if they don’t, they look for opportunity to sue. In the South West, we saw Virgin win contracts for Community Services in Devon[2] and Bath and North-East Somerset (BANES). Richard Branson’s Virgin HealthCare won £1bn worth of contracts in 2016/17. It won these services from the NHS and from non-profit making services such as community interest companies.

    NHS acute hospitals have all stayed within the NHS so far, except for a short flirtation between Hinchingbrooke Hospital and the Circle Group, which ended in disaster, with the provider being put into “special measures” in 2015. The picture is very different for mental health care, where the private sector has had continued domination of parts of the market, in 2012/13, 22% (£1.7bn) of NHS mental health spend was with the independent sector, compared with 4% (£1.8bn) of acute spend. Providers include St. Andrew’s Healthcare, Partnerships in Care, and the Priory Group. For secure MH services, they are all building ‘private’ because the NHS cannot afford the capital funding to do so, Typically, these independent sectors beds cost the NHS 20% more than NHS beds[3].

    There is no evidence that the Internal Market has been any sort of success. No evidence that competition has improved outcomes in any but a few limited examples where causality is neither clear nor proven. The costs of the internal market are huge. Administrative costs in the NHS were estimated at 14% in 2005 compared with 5% before the 1980s; costs of the internal market alone are estimated in the range of £5bn per annum.  To quote Professor Paton in his 2015 study:

    “The ‘market’ in the NHS is a major source of waste. Creating and maintaining markets has incurred huge direct costs and significant ‘opportunity costs’ – money which could have spent upon patient care and clinical redesign.”

    The Private Finance Initiative

    The Private Finance Initiative (PFI) was introduced by John Major’s Government from 1992 and was embraced by the subsequent Blair government as a means of removing spending from Government balance sheets and thus reducing public spending in the short term. Most authorities would accept that the PFI has failed, and at material cost to the taxpayer.

    The promulgation of the Neoliberal Ethos in the NHS

    Progressive neoliberal reforms have reinforced the ideology of the market. All have fragmented the provision of healthcare and siphoned public money off into private sector balance sheets, shareholder dividends and profit margins. At the same time, pressures on NHS budgets require NHS management to reduce costs. It seems that the NHS has been presented with an imperative to cut costs and handed privatisation as an alleged means to this end.

    The NHS is one of the most efficient and trusted healthcare systems in the World. One of the reasons for its efficacy and efficiency is that people are given care according to their needs and irrespective of their means. This ethos belongs to its workers as well as to the organisation; for many people who work for the NHS, it is a vocation, and they care deeply about what they do. They have the intrinsic motivation that drew me to a career in the NHS. But, over the past thirty-five years, this ethos has been progressively undermined by the neoliberal ideology that delivery and innovation must be driven by competition and the profit motive, and that input costs must be minimised. This ideology appears to have been accepted, without challenge, by every government since and by the top management of the NHS, despite many public campaigns against privatisation. The consequence of this, combined with a political austerity consensus – that the deficit must and will be reduced by cutting public spending and selling off public assets, means that cost-cutting is accepted as part of the “solution” for the NHS. In a ‘business’ where more than 70% of costs are staff related, the next leap of logic is that staff costs must be cut.[4] This is interpreted and delivered in a number of ways, all of which serve to undermine the quality and energy of the NHS workforce and which include pay freezes, dilution of skill mix, reducing “management costs “, and the outsourcing and privatisation of individual components of the NHS.

    Many people- and not just socialists- have been dismayed over the years at the continuing and relentless reorganisation, marketisation, privatisation and fragmentation of the NHS. The market, with its endless and costly hand-offs between one commercial entity and another, cripples the best efforts of professional staff and those that support them.  Not only are these hand-offs costly to procure, but they also require constant and detailed policing. Furthermore, continuous reorganisation and market testing destroy morale and organisational memory. All these results of the market take focus away from patient care. I believe that the NHS works best with a collaborative rather than a competitive ethos. Where decisions about care are driven by the needs of the patient, not by the scope for profit. Where quality is a prerogative always, not just when it helps to win a contract. Where the entire NHS budget is used to provide and support patient care.

    NHS workers bear the brunt of the rhetoric and dogma at the heart of current policy, being presented as a cost rather than a benefit, a “burden” on the state, the costs of whom must be minimised. They must” tighten their belts” like everyone else – apart from the wealthiest. Now, the biggest crisis in the NHS is the lack of qualified staff, exacerbated by the removal by the current government of bursaries for nurses and by its disastrous instrumentalisation of migrants’ rights in Brexit negotiations. ​ It is a crisis brought on by what appears to be deliberate incompetence by the Government, mitigated only by the continued introduction of qualified staff from third world countries.

    The Extent of Privatisation

    A simple measure is the proportion of NHS spend on private sector providers as reported in the Department of Health Accounts. In 2004, this was 2.8%. and in 2018/19, it was reported as 7.3%. with privatisation accelerating after the Health and Social Care Act 2012. However, these figures mask the extent of private provision within NHS providers, where many ancillary services- such as cleaning, catering, portering and pharmacy- have been outsourced since Thatcher’s 1983 initiative. There is also spending on private providers of primary care (including GPs) to take into account. After adding these into the figures, the total spend of NHS England in the private sector in 2018/19  is estimated by David Rowland, Director of the Centre for Public Health and Interest as £29bn, or 26% of NHS England spending. So, there’s little doubt that privatisation is increasing in the NHS, and that “market reforms”, compulsory tendering under EU Law (until now), and a lack of ready cash are important drivers of this. It is of huge credit to NHS workers that, despite these onslaughts and years of pay freezes and cuts to services, they soldier on.

    Consultation on Integrated Care Systems

    The fragmentation forced by the disastrous 2012 Health and Social Care Act exposed the gross dysfunction of the internal market. It set commissioners against providers in an endless spiral of tactics to gain at the expense of the other, at huge administrative and organisational cost. The concept of the ICS could, in theory, see a return to the local system approach adopted in District Health Authorities (DHAs) prior to NHS marketisation, with funding being based on populations adjusted for cross boundary flows, with no internal market, and with local systems agreeing plans and setting budgets and quality standards for local services. This would provide the opportunity to remove layers of bureaucracy and unnecessary accounting and contracting and enable savings to move out to fund the front line. But it is clear from the consultation document that this is not the intended approach. And neither was this ever intended.

     

    The very core purpose of ICSs is to drive down care based on demanding cost savings targets imposed by the Government, in a service that is already one of the most efficient in the world. The ethos, even the language[5]  is that of the American accountable care system, where being seen to be cutting costs (and creating an industry out of that) is a key organisational driver and measure of success. And it is crystal clear that the policy march started by Thatcher and continued through Major, Blair, Brown, Cameron and May was to implement the Kaiser Permanente model first introduced by Alain Enthoven, and whose thinking was adopted by the Central Policy Think Tank when the internal market was first introduced into the NHS

    Specific Areas to address in the consultation document (and for Labour to develop) are suggested as follows:

    • the document retains the language and structure of the internal market in that it refers to provider organisations and provider collaboratives, and commissioners. The inference is that fragmentation can be addressed by provider collaboration (and, presumably, ultimately merger). Thus, it intends to retain the most pernicious and inefficient components of the internal market. A socialist radical approach (and which is Labour Policy) would be to remove the internal market altogether, and focus on quality assured service provision, supported by rigorous benchmarking of quality and cost and an overarching strategic and operational planning function. Undoubtedly there are extraordinarily strong vested interests in retaining the status quo, with “providers” having developed as big businesses in their own right.
    • The consultation document refers to “digital and data” to drive system working, and yet there appears to be no single NHS solution for this. Instead, there is a “Framework” calling on a wide range of “providers”, and the suggestion that there should be “shared contracts and platforms to increase resiliency”. An alternative to this would be an NHS-wide and provided digital data and information service.
    • Each System/Geographic area will have its own pot of money covering the whole of local spending on healthcare. Transactional costs are intended to be reduced through the “blended payment” model. An alternative approach would be to remove tariffs and set budgets based on the costs of the services required by the system. These costs could be budgeted on a variable basis using agreed parameters (such as variable capacity requirements).
    • Specialised Services need to be planned on a larger geographical footprint than other general services. This will require collaboration and planning between ICSs so that the needs of each ICS population are met in an equitable and efficient way. The funding for the relevant services should sit with the local ICS (managed on the same principles as RAWP with DHAs) so that they have the funding required to budget for all their locally provided services. Whatever mechanism is put in place should minimise transaction costs.

    [1] In a speech at the Royal College of Pathologists on 2 November 2009, Cameron said: “With the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS.”

    [2] https://www.somersetlive.co.uk/news/health/virgin-care-set-lose-multi-2038196

    [3] Based on tariff data collected internally by NHS England in 2018/19

    [4] “‘Since it takes time to train skilled staff, (for example, up to 13 years to consult), the risk is that the NHS will lock itself into outdated models of delivery unless we radically alter the way in which we plan and train our workforce. HEE will therefore work with its statutory partners to commission and expand new health and care roles, ensuring we have a more flexible workforce […]” [5 Year Forward View, page 30.]

    [5] Along with the structures, the purpose, and the key role of US healthcare corporations in importing it to the UK, even phrases like “Right care, right time, right place” to advertise the NHS Long Term Plan’s service closures programmes, are lifted straight from the language of accountable care in the US. It is not a coincidence that the Healthcare Financial Management Association (the professional organisation representing finance professionals in the NHS) has, for many years, operated an exchange programme with the US, and with many conferences featuring US healthcare models. The HFMA offers courses based on the US model.

    6 Comments

    This is SHA’s response to NHSE’s consultation on putting ICSs on a statutory footing. It is a curation of the generous and thoughtful comments of many members. Please forward to as many of your groups and networks as possible.

     THE SOCIALIST HEALTH ASSOCIATION’S RESPONSE TO “INTEGRATING CARE –

    Next steps to building strong and effective integrated care systems across England”

    WHAT SHA WANTS TO SEE

    A cooperative and democratic health and care system, fully funded through general taxation, free at the point of use, that eliminates the privatisation of clinical services.

     SHA cannot support these proposals.

    RESPONSES TO QUESTIONS

    Q. Do you agree that giving ICSs a statutory footing from 2022, alongside other legislative proposals, provides the right foundation for the NHS over the next decade?
    SHA does not agree. Our many reasons are explained below.

    Q. Do you agree that option 2 offers a model that provides greater incentive for collaboration alongside clarity of accountability across systems, to Parliament and most importantly, to patients?
    SHA does not have a view on this.

    Q. Do you agree that, other than mandatory participation of NHS bodies and Local Authorities, membership should be sufficiently permissive to allow systems to shape their own governance arrangements to best suit their populations needs?
    There need to be national standards, locally delivered, matched to the needs of an area. Please see SHA’s thinking on NHS democracy.

    Q.Do you agree, subject to appropriate safeguards and where appropriate, that services currently commissioned by NHSE should be either transferred or delegated to ICS bodies?

    NHSE, if it continues to exist, should plan for those requirements that are best planned at national level. These could include rare diseases and specialist services.

     SHA’s REASONS FOR REJECTING THE PROPOSALS.

    Based around place

    SHA supports the idea of services based on an area, reflecting the needs of that place. However, this document leaves place ill-defined.

    Relationships with Local Authorities

    There is poor legislative alignment of responsibilities of Local Authorities (LAs) and ICSs.  This is an issue particularly with reference to Public Contract Regulations 2015, which will still apply to Local Authorities and could increase the regulatory burden on local government, create barriers to joint planning arrangements, or result in inappropriate planning via an NHS channel as discussed elsewhere.[i]

    Interactions with local government are alluded to but only vaguely described.  For example, the document states ‘[the proposals] will in many areas provide an opportunity to align decision-making with local government’ [our emphasis]. This is very weak. How will ICS’s that do not align geographically with local authorities function in this respect?  There is a clear risk that such multi-authority ICSs will drive a ‘one-size-fits-all’ approach across diverse communities and geographies in direct opposition to the stated aims of ‘decisions taken closer to the communities’ [para 1.9].

    Overall, it looks as though this is not a collaboration of equals. An ICS as described would be led by the NHS and the LA would be very much a secondary partner. The SHA would like to see a bigger and more equitable role for LAs.

    Devolution

    The statements on devolution such as at 1.11 can be applauded but the reality we know is that since 2011 the NHS has become more centralised. There needs to be more concrete proposals on how this devolution will occur. The mandatory nature of the proposals is a concern and there should be more local discretion within National Care Frameworks and oversight.

    Governance

    Clauses 1.12 and 1.15 are good clear summaries of what the ICS should do and provide. However, 1.16 on page 7 states that primary care, community health and mental health services, social care and support, community diagnostics, urgent and emergency care will be working together with other public or voluntary services Including those providing skills training, assistance into employment, and housing. But no consistent mechanism, structure, governance, regulatory, or accountability framework is defined for this.

    Strategic commissioning/planning (P2, third bullet point) requires the resources of a CCG and of a CSU, but the proposal appears to leave the CSU as a separate organisation (see P24, 2.68) outside of the ICS. No explanation is given for why this is better. Our view is that the CSUs were created outside of the NHS to provide a first landing place in the UK for US insurers who failed to take up the challenge. The most cost-effective route to back office services and business intelligence would be to bring them back into the NHS as shared services operations.

    These clauses do nothing to strengthen the requirement for probity in contracting and appointment procedures made scandalously apparent through court actions presently being pursued in the wake of inappropriate commissioning during Covid.

    There are poorly delineated internal and external accountability processes. As others have noted[ii], [iii] this is a consequence of a lack of precision regarding the function, roles and relationships of ICS. These issues should be clarified.

    There is insufficient detail regarding the openness and transparency of appointments, decision-making and data sharing by ICS and the role of independent sector (IS) organisations in ICSs. While we note that the Government considered ‘it likely that statutory organisations will hold the ICP Contracts’. [iv] Our understanding is that ‘accredited’ companies can be brought in to draw up policies and make service decisions within ICSs. These services could include:

      • Enterprise-wide Electronic Patient Records Systems – for Acute & Community and for Mental Health Hospitals
      • Local health and care record strategy and implementation support and infrastructure
      • ICT infrastructure support and strategic ICT services
      • Informatics, analytics, digital tools to support system planning, assurance and evaluation
      • Informatics, analytics, digital tools to support care coordination, risk stratification and decision support
      • Transformation and change support
      • Patient empowerment and activation
      • Demand management and capacity planning support
      • System assurance support
      • Medicines optimisation

    The role of independent sector organizations in this context must be more clearly defined and regulated, and subject to governance appropriate to a public body. Where possible the NHS should provide such services and/or be empowered to provide any such expertise. We do not agree with private companies being brought in as decision makers. They are bound by law to maximise shareholder profit, not to provide a public service.

    In addition, the document does not address the potential difficulties arising from the requirement on ICS organisations to comply with various competition rules, such as not sharing commercial sensitive information or fixing prices.  For multi-site ICS providers, this presents a system risk in terms of having to share patient and staff data or information with other organisations.  In general, insufficient attention is given to issues around sharing personal health information by ICSs.

    Guidance should be also clearer on the overriding importance of transparency in ICSs decision making. Efforts should be made to limit the use of ‘commercially sensitivity’ as a spurious justification for subverting transparency.

    There is insufficient consideration of potential conflicts of interest within the proposed ICS (e.g. between providers and commissioners, or between public, voluntary, and commercial partners) and how these can be prevented or mitigated. Notably it has been suggested that providers will be able to influence allocations via the ICS partnership board, and there is a credible concern that ‘bigger players’ will skew funding decisions.[v]

    Governance and PCNs

    1.17 mentions PCNs but the regulatory framework through OfSted for children’s services, CQC, NHSE/I, is currently not fit for purpose because it is overlapping and contradictory. There is no governance framework at the moment for PCN collaborations with community and mental health Trusts, and accountability is difficult to pin down.

    Data

    The paper promises to invest in the infrastructure needed to deliver on the transformation plan. This will include shared contracts and platforms to increase resiliency, digitise operational services and create efficiencies, from shared data centres to common EPRs.

    Digital is essential to the current and future NHS. SHA warns against the vaunted flexibility of the transformation plan allowing personal data to be misused by commercial interests even more than it is now. SHA also warns against services rushing into digital solutions without adequate evaluation and without enabling non-digital solutions for those who still require them.

    Health Creation is not mentioned in this paper.

    SHA supports the concept of Health Creation. That is the process of bringing people in contact with each other, building confidence and thereby enabling communities to take more control of their area and their health and care.

    An option we would like to see would be mandating 1% of a PCN’s budget to community strengthening – population Health Creation

    Population health, but almost no mention of Health Inequalities

    There needs to be a clear vision of the metrics of “population health” especially if this it to be the main outcome or “productivity” upon which the NHS and its partners is being judged. The consultation  paper seems silent both  on what these metrics are and on what role the NHS is to play in delivering that outcome. For example, is the metric of population health a pre-determined blend of longevity and the quality of life delivered?  To what extent is managing the ” social determinants of health” to be allied with the NHS as opposed to being the task of wider government and indeed others?

    “Integrating Care” does not really explain “population health”, but the HSSF is more explicit:

    “Population Health Management is an approach aimed at improving the health of an

    entire population and improves population health by data driven planning and delivery

    of care to achieve maximum impact for the population.”

    Any concept of patients and staff planning and evaluating the service, which will involve decisions on what to prioritise, is absent. Instead, the HSSF accredits corporations to support an ICS in taking such decisions. We should propose a 5th principle on the necessary need to involve patients in these arrangements. There is good evidence that such effective engagements lead to better services.

    In practice the emphasis on the role of Foundation Trusts and clinician-leadership is likely to prioritise clinical service provision, whether primary or secondary care, with limited focus on prevention and population health. This is an inherent structural weakness of the ICS model as currently specified.

    SHA cannot support ICSs without a far clearer commitment to tackling health inequalities through tackling the wider determinants of health and working closely with LAs, housing and other key partners. The document states that greater co-ordination between providers at scale can support… ‘reduction of health inequalities, with fair and equal access across sites;’. It is not clear how this follows as no mechanism linking these two is articulated. Vague commitments as outlined in the document are inadequate to address this persistent and worsening problem. Specific goals and mechanisms for reducing health inequalities should be explicit in the proposals.

    Single pot for finance and the legislative proposals
    On the face of it, a single pot (2.40), linked with reducing the importance of competition seems like a significant step forward and a more equitable and efficient approach to funding. SHA is supportive to the extent that these proposals reduce the contract negotiation and monitoring which is so wasteful of time and effort in the NHS, with savings in overhead costs and improvement in services designed by providers aiming at better outcomes, not by commissioners principally aiming to reduce expenditure. There must be appropriate risk sharing because of the danger that an individual ICS could be destabilised by unforeseen and one off events.

    It is not clear how this single pot will be spent, assuring fairness, value for money, quality.

    At 2.47 there is a limited mention of capital. There is no mention in the document of NHS Property Services or Community Health Partnerships or the NHS Estate. This is a major weaknesses in the proposals.

    Taken together with “Integrating Care”, this makes clear that fixed payment to secondary care providers must conform to the ICS system plan. Initially , the fixed payment would be based on the current block payments under the heading of COVID-19, which make up the majority of current CCG budgets. Fixed payments will be determined locally. While national tariffs will no longer apply in general, they may be retained for diagnostic imaging, a highly privatised sector. Some elective activity, again involving the private sector, will also be exempt from blended payment. In other words, private sector suppliers of clinical services will be protected from any local cost reductions.

    However, we also see impossible control totals which will make investing and innovation extremely difficult and constrain ICSs for the future. In effect, this continues austerity. We want to see comprehensive funding for an expanding, publicly funded NHS.

    Allusion is frequently made to anticipated cost savings and efficiency improvements [paras 1.8, 1.9, 2.22, 2.46, 2.51] but it is unlikely that these will be realised in the short-term and short-term costs may even increase.[vi] Evidence from similar interventions in the UK and other countries provides at best equivocal evidence for longer-term improvements in efficiency.[vii], [viii], [ix] Quality rather than cost-savings should be the primary driver of any reorganisation.

    There are other concerns SHA has in respect of the apparent relaxation of privatisation.

    All clinical services should be retained in house and fall under a re-instated duty of the Secretary of State for Health to PROVIDE such services.

    Providers will still be able to use the private sector. There are contracts now through NHS Shared Business Services which appear to require no formal tendering.

    Beware of cementing existing privatisation. This can happen through sub-contracting as above and by current private sector providers expanding through what ever contracting process there may be. The most likely beneficiary is likely to be the privatisation of mental health services through the Priory and similar organisations.

    Backroom functions will continue to be privatised.

    “Integrating Care” never mentions “private”, “independent sector” or “third sector”. The document

    uses a new codeword, namely ‘others’. This suggests that NHSE fully expects the private sector to play a most important part in the future, including for clinical services. (NHSE/I “Integrating Care” KONP)

    Covid has shown us, if we needed showing, that a truly nationalised health and social care service is needed and vital, with the advantages of national estate agility, workforce planning, driven by a national public health strategy to invest in the social care infrastructure of the national economy, whilst local partnerships freed of wasteful market practices are responsible for local delivery and can be locally accountable.

    Staff

    Whilst the fixed payment would be determined locally, neither “Integrating Care” nor

    “Developing the payment system” refer to national agreements on wages, terms and conditions.

    The SHA is very concerned that, despite papers on responding to the staffing problems, we have not seen any recommendations for comprehensive staffing programmes that support pay justice and adequately protect workers.

    Despite discussion emphasizing the key role of the workforce in effecting these changes, mechanisms to allow direct representation of workers or their trade union spokespersons on ICS are entirely lacking in the proposals.

    Any proposal for ICSs should make explicit commitments to ensuring that all workers receive the National Living Wage (and preferably the real Living Wage) whether they are employed by the NHS or by subcontractors to ICSs. ICSs should commit to abolition of zero hours contracts in all its activities.

    Democracy

    Despite frequent criticism of ICSs as being distant from communities and undemocratic (as indeed is the NHS as a whole), this paper gives little confidence for any significant democratic change. Healthwatch is not sufficient, too health focused and with too few teeth.

    SHA would like to see financial transparency, accountable to communities. SHA would like to see ICSs exploring the opportunities for participatory democracy – such as community development, citizens forums, coproduction networks.

    “Current ICS arrangements are outrageously disconnected not only from real democratic structures but also from real centres of identity and community. They are administratively defined and they are under the control of officers who are not accountable to local people.

    What I would like to see is NHS Sheffield accountable to the local people of Sheffield (and likewise for other communities). It is totally inappropriate to leave accountability and governance of supposedly statutory bodies open to development and interpretation by officers of the ICS. All the assets of the ICS should be treated as public assets, especially all the capital assets and these must all be put under local (not national) control.” Duffy, SHA member

    With many thanks to all those SHA members who generously contributed to this response.

    We have also drawn on documents from Keep Our NHS Public and the Local Government Association.

    [i] Integrating care: Next steps to building strong and effective integrated care systems. Local Government Association (https://www.local.gov.uk/parliament/briefings-and-responses/integrating-care-next-steps-building-strong-and-effective accessed 23/12/20)

    [ii] Delivering together: Developing effective accountability in integrated care systems. NHS Confederation/Solace (https://www.nhsconfed.org/-/media/Confederation/Files/Publications/Delivering-together-FNL.pdf accessed 22/12/20)

    [iii] Integrated care systems (ICSs) (https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/integration/integrated-care-systems-icss accessed 24/23/20)

    [iv] Government response to the recommendations of the Health and Social Care Committee’s inquiry into ‘Integrated care: organisations, partnerships and systems’ Cm 9695 (https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiJw-_Dt-ztAhWkoVwKHXuRAkIQFjAAegQIARAC&url=https%3A%2F%2Fwww.gov.uk%2Fgovernment%2Fpublications%2Fgovernment-response-to-the-health-and-social-care-committees-report-on-integrated-care&usg=AOvVaw2k1pzGscqk30BYEL_QbNJt accessed 26/12/20)

    [v] On the day briefing: Integrating care, NHS England and NHS Improvement. NHSProviders 26 November 2020 (https://nhsproviders.org/media/690689/201126-nhs-providers-on-the-day-briefing-integrating-care.pdf accessed 26/12/20)

    [vi] House of Commons Health and Social Care Committee Integrated care: organisations, partnerships and systems Seventh Report of Session 2017–19 (https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjb-oSstuztAhUNYsAKHabDDoYQFjAAegQIBBAC&url=https%3A%2F%2Fpublications.parliament.uk%2Fpa%2Fcm201719%2Fcmselect%2Fcmhealth%2F650%2F650.pdf%3Futm_source%3DThe%2520King%2527s%2520Fund%2520newsletters%2520%2528main%2520account%2529%26utm_medium%3Demail%26utm_campaign%3D9379676_NEWSL_ICB%25202018-06-13%26dm_i%3D21A8%2C5L1EK%2COYZ6AS%2CM5X8X%2C1&usg=AOvVaw0-ZVcp3j_Sh049yv9kdNTA accessed 26/12/20)

    [vii] John Lister, How Keep Our NHS Public should be campaigning on Integrated Care Systems. November 24 2020. (https://keepournhspublic.com/resources/how-keep-our-nhs-public-should-be-campaigning-on-integrated-care-systems/ accessed 26/12 20)

    [viii] Government response to the recommendations of the Health and Social Care Committee’s inquiry into ‘Integrated care: organisations, partnerships and systems’ Cm 9695 (https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiJw-_Dt-ztAhWkoVwKHXuRAkIQFjAAegQIARAC&url=https%3A%2F%2Fwww.gov.uk%2Fgovernment%2Fpublications%2Fgovernment-response-to-the-health-and-social-care-committees-report-on-integrated-care&usg=AOvVaw2k1pzGscqk30BYEL_QbNJt accessed 26/12/20)

    [ix] Scobie S (2019) ‘Are patients benefitting from better integrated care?’, QualityWatch blog. Nuffield Trust and Health Foundation. (www.nuffieldtrust.org.uk/news-item/are-patients-benefiting-from-better-integrated-care accessed 26/12/20)

    SOCIALIST HEALTH ASSOCIATION RESPONSE TO ICS CONSULTATION 7 1 21

    2 Comments

    Joint authors:

    Colin Slasberg Consultant in Social Care

    Peter Beresford visiting Professor University of East Anglia

    In September, while the Health and Care Select Committee Inquiry into funding for social care was still sitting, we wrote an article highlighting the case of Anna Severight. The Committee played a clip of Anna’s testimony to Matt Hancock, Secretary of State. Anna is a 34 year old disabled woman who receives enough support to be ‘fed and watered’, but not enough to have a life ‘worth living’. Hancock noted this was a sad example of people not getting ‘all they would like’.  He thus failed to recognise that having a life worth living is something very much more than what people ‘would like’, a mere wish or want. Characterised by dignity, control over life and services and being able to engage in society a life worth living is a need recognised in the law by the Care Act.

    We had prepared a submission to the Inquiry to give them advanced notice of the issues and how councils, encouraged by central government, are ignoring what the Care Act requires. We wondered in September whether the Committee when it finally reported would correct Hancock and identify what needs to happen to address Anna’s plight.

    What the Select Committee says

    We now know. The Committee’s final report, encouragingly, opened with Anna’s story as powerful testimony of the system’s failings. It then proceeded to do nothing about it. The Committee concluded the system needed £7BN more to meet demand from demography and to pay care workers what they should; £5BN more to make personal care free; £3.1BN to introduce a care cap.

    Although not much more than government has recently found to fund its failing track and trace system, such increases would represent more than doubling of current spending on social care. Even so, the Committee’s proposals would not give a single penny toward giving Anna the support she needs. Indeed, if a care cap and free personal care are introduced and not fully funded – which on past precedent is a high risk – Anna’s chances of a normal life would reduce even further. The increased gap in funding would be made up through yet further restriction of eligibility.

    Here is the nub of the issue. The eligibility regime has long allowed councils to adjust ‘need’ to their budget. When NHS clinicians make their diagnoses, the essential ingredients are the patient and the clinician’s knowledge and judgement. If not always working perfectly, the founding NHS principle that need must precede resources provides the policy context. As need outstrips resources, so waiting times go up. Not so in social care, where the equivalent of the clinical diagnosis is assessment of need. Whilst social workers gather information about the person, it is managers with responsibility for budgets, often working through ‘panels’, who make the decision as to whether a need is ‘eligible’ and therefore will be met. This enables councils to control the flow of demand to ensure spend matches budget. Councils, unlike the NHS, are permitted neither overspends nor to leave any need unmet.

    In an almost absurd denial of the empirical evidence of this reality councils hotly deny it. They claim the eligibility decisions are the social worker’s, are entirely based on need and resources never come into it. That they are able to get away with this is due in no small part to political leaders having no interest in challenging them. It is a system that keeps the lid very firmly on demand, whilst silencing the voices of the older and disabled people within. It’s a system that suits those political leaders indifferent or even hostile to the needs of older and disabled people who want to keep the pot as small as they possibly can get away with. It also suits more liberal or more generous leaders who want to make the pot a little larger, but who don’t want the true limitations of their generosity exposed. They are able to secure virtue from comparison against the worst of their kind, not comparison with the best of what older and disabled people hope for.

    Can there be a different future?

    One view that is strongly pressed is for Independent Living to become a legal right. Independent Living as defined by the United Nations is indistinguishable from the Care Act’s vision of control, dignity and participation. At the moment, making independent living a legal right can seem a utopian ideal that no-one with the interests of older and disabled people at heart will disagree with. However, under our present politics, its prospects of happening in any foreseeable future are remote. The huge variability in individual costs will mean the service would have to be delivered on an ‘open cheque’ basis if councils will be under a legal obligation to meet every need for independent living. Given that service users’ quality of life doesn’t even make it into the top political priorities if the cross Party Select Committee report is anything to go by, the prospect of Parliament giving councils blank cheques to make independent living happen is very distant.

    We will continue to make the case for an end to the eligibility regime as the source of much that is rotten in the social care system. But we do so having accepted that spending will still have to be controlled given it must take place within budgets which have been democratically determined.

    Spending should be controlled in a very different way. Councils should assess and cost all needs as the Care Act requires – in effect all needs for independent living. Councils must be honest about which needs they can and which needs they cannot afford to meet. Political leaders should know how much funding they need to make available so that Anna and the many thousands like her have the life right for them. Political leaders should no longer be allowed hide behind their officers disappearing needs that the budget they have given officers is insufficient to meet. Political leaders must be held publicly and transparently accountable for the quality of the lives of their older and disabled citizens.

    2 Comments

    This is a very good leader in the Guardian on the need for change in social care and some of the issues that need to be addressed.


    https://www.theguardian.com/commentisfree/2020/oct/25/the-guardian-view-on-the-social-care-crisis-fix-a-broken-system

    4 Comments

    A GREAT LAUNCH OF THE SHA/KONP CAMPAIGN TO END THE CRISIS IN SOCIAL CARE

    On 10th October, SHA joined forces with Keep Our NHS Public, with the support of WeOwnIt,

    to launch our campaign to transform social care.

    Watch it here

    https://www.youtube.com/watch?v=wsDY7q-rVYM&feature=youtu.be

    With over 280 people registering, it was clearly a popular and vital issue.

    The day before, a poll conducted by Survation and commissioned by WeOwnIt showed that 64% of respondents said they wanted to see care homes run by public bodies. 61% believe that private care providers prioritise profit over delivering a high quality service.

    Participants heard excellent and meaty contributions from Unison and GMB, outlining their policies on social care and the currents fights for pay justice.. Two disabled speakers offered an insightful summary of independent living and democratic co-design of services with users. The National Pensioners Convention summarised their recent publication “Goodbye Cinderella” focusing in the benefits for older people of a coordinated National Care Service. The leader of Hammersmith and Fulham Council described how they have provided free homecare and Barnet Council Labour Group showed how they have been challenging their Tory council to deliver the real spirit of the Care Act, not merely it shadowy form.

    The Women’s Budget Group offered a powerful justification for a new economic settlement based around a caring society and showed how investing in social care reaps huge economic, health and care dividends.

    Finally John McDonnell spoke clearly and passionately about the need for a National Care Service, based on the campaigns key demands. He also warned that the Tories may offer up an insurance-based service as a route to shoring up the shaky private sector market in social care.

    Speakers endorsed the 7 demands of our campaign:

    1. National Care Support and Independent Living Service (NaCSILS)
      The Government shall have responsibility for and duty to provide a National Care and Supported Living Service to provide care, independent and supported living, adopting into English Law Articles from the UN Convention on rights of disabled people that establish choice and control, dignity and respect, at the heart of person-centred planning.
    2. Fully funded through government investment and progressive taxation, free at the point of need and fully available to everyone living in this country.
    3. Publicly provided and publicly accountable:
      The NaCSILS will have overall responsibility for publicly provided residential homes and service providers and, where appropriate, for the supervision of not-for-profit organisations and user-led cooperatives funded through grants allocated by the NaCSILS. A long-term strategy would place an emphasis on de-institutionalisation and community-based independent and supported living. All provision will deliver to NaCSILS national standards. There will be no place for profiteering and the market in social care will be brought to an end.
    4. Mandated nationally, locally delivered:
      The Government will be responsible for developing within the principles of co-production, a nationally mandated set of services that will be democratically run, designed, and delivered locally. Local partnerships would be led by stakeholders who are delivering, monitoring, referring to or receiving supported services or budgets, e.g. organisations representing disabled people (DPOs), older people, and people who use mental health and other services, in partnership with local authorities and the NHS.
    5. Identify and address needs of informal carers, family and friends providing personal support:
      The NaCSILS will ensure a comprehensive level of support freeing up family members from personal and/or social support tasks so that the needs of those offering informal support, e.g. family and friends, are acknowledged in ways which values each person’s lifestyles, interests, and contributions.
    6. National NaCSILS employee strategy fit for purpose:
      The NCSLS standards for independent and supported living will be underpinned by care and support staff or personal assistants who have appropriate training, qualifications, career structure, pay and conditions to reflect the skills required to provide support services worthy of a decent society.
    7. Support the formation of a taskforce on independent and supported living with a meaningful influence, led by those who require independent living support, from all demographic backgrounds and regions. This would also make recommendations to address wider changes in public policy.

    Many people were unable to get into the meeting because it was oversubscribed. It is clear that this is a vital issue that resonates strongly with the public and that this is the most propitious time for such a campaign.

    If you were unable to attend , watch the event here

    https://www.youtube.com/watch?v=wsDY7q-rVYM&feature=youtu.be

    We shall now consider actions over the next few months that could include petitions, motions to the Labour Party, work with Parliament, continued discussion with the Shadow Health and Social Care Team.

    JOIN US!

    WE CALL ON SHA BRANCHES FOR SUPPORT

    THERE WILL BE A FOLLOW-UP MEETING ON 2ND NOVEMBER TO PLAN OUR NEXT STEPS

    Details will follow

     

     

     

    Comments Off on A great launch of the joint SHA/KONP social care campaign

    Former Health Secretary, Jeremy Hunt, probably Britain’s worst leader since General Percival surrendered an army of over 80,000 soldiers to 36,000 Japanese soldiers at Singapore in 1942. It was the worst ever British defeat and led directly to the dreadful Japanese concentration camps. Hunt was in charge of over a million highly committed NHS professionals with oversight of Social Care, looking after nearly a million people. He surrendered these to a succession of debilitating neo-liberal reorganisations, privatisations and defunding regimes. Like Percival he could have fought for his people, but chose not to, and England is paying a high price.

    Percival’s reward was the pension of a Major General. Some think Hunt’s reward may be selected as the next Prime Minister. Think again.

    Apart from his duplicity with data, his bullying of Junior Doctors, and his hypocrisy in praising the NHS and shrinking nurse’s pay, there is the question of his ability to manage. Managerial incompetence is a common trait in this Conservative government, as exemplified by Grayling, Hancock, the Prime Minister, Priti Patel and others in the Cabinet.

    Hunt the manager.

    In every good organisation there are key performance indicators whose sole function is to help the executive steer the organisation most effectively. In British Rail one was trains on time. The purpose was to keep the passengers safe and satisfied, as the most important need was reliability, not speed, as the politicians keep getting wrong.

    A key indicator in Social Care was the performance of transferring patients from the hospitals back into their homes and care homes. The indicator was called Delayed Transfer of Care (DToC), which meant that something was preventing the patient from being discharged when they were better. It was measured by the month. It was a very important indicator, for two main reasons:

    • Cost: Each time the transfer from the hospital failed on average it causes up to 31 bed delays, i.e. unavailability. The cost of this is about £400/day, compared with £90/day in a home. So each DToC generates a net loss to the NHS of at least £300×31, i.e. about £9,000. At the time of Hunt’s appointment these Social Care DToCs were averaging 1050/month – a net loss of £9.5 million per month and steady.
    • Care: Patients who are well enough to go back get more ill if they stay in hospital, especially if they are elderly, thus occupying beds for much longer. They also require extra attention from busy nursing staff who are not always used to dealing with the elderly. There is also an increased risk of readmissions.

    The Department of Health details reasons for these delays, 40% of which are generated within Social Care. These are the major reasons, respectively: Awaiting Care Package at Home, Awaiting residential home placement or availability, and Awaiting nursing home placement or availability. As all these delays generate extra bed demands in Acute Care as well as, so to address these immediately would be a win/win, an act of intelligent leadership, especially for an opportunist like Hunt.

    Now, the bad news for Hunt: He has no organisational leadership qualities at all, especially when it comes to doing what is best for the organisation, i.e. the good of the users, the employees and the community. If he had he would have predicted a serious problem emerging in social care, and consequently a rise in the transfer of social care patients into acute care.

    Hunt became Secretary of State for Health in 2012. At that point Care DToCs were running at 1050/month, but trouble was on the horizon. Back in 2011 Nicholson, the CEO, set the NHS and Social Care the challenge of taking out £18 – £20 billion by 2014. Why? It was a classic act of hubris which of, course, the health system paid for. It was to be efficiency savings; but how? The care system was short-staffed, underfunded and, because of the privatisation, in negative productivity. Overworked and underpaid staff, the main source of innovation, were in no position to study ways of improvement. Morale was falling and the staff turnover was 27%.

     

    Hunt should have stopped it, but did not care, or have the nous – or else was confusing fewer staff per user as a sign of efficiency. Either way he should have kept his eye on the statistics. Social Care is a major driver of demand in the NHS. The better the care, the lower the rate of admissions into Acute Care: a very simple equation.

    By 2015 there were ominous signs. The rate of DToCs was beginning to rise in a statistically significant way. The trend was clear. The average was rising to 1250, a 19% increase. Any executive worth their salt would have instituted an instant investigation. Hunt did not. His NHS 10 Point Efficiency Plan mandated the “freeing up about 2000 to 3000 beds by ceasing DTOC delays in social care.” Just like that, like Napoleon instructing his troops to conquer Moscow – winter. There was no strategy, no plan that mapped out the route. Just an edict, and like Napoleon, thing got a lot worse.

    The average for the years 2016 to 2018 rose to 1900 DToCs, 80% greater than in 2012 – so much for “ceasing” DToC delays. It was not a plan but a target, and a silly one. This is worth unpacking. In five years Hunt oversaw an increase of about 900 DToCs from the Care sector alone. This is an increased loss of £8.1 million per month, or close to £100 million a year.

    Just how many staff in Social Care would that have paid for at £25,000 a year? The turnover would have stopped, the facilities enhanced (including private care) and morale and user satisfaction improved.

    These cold statistics disguise the misery of the people involved, nurses, carers, families and, most of all, the users, mainly the elderly. As Neil Kinnock said prophetically of the Tories if they got in:          I warn you not to fall ill, and I warn you not to grow old.”

    In summary, in the first three years of his appointment the total loss due to DToCs was £114 million a year. In 2015 Hunt sat on his hands, no doubt transfixed by Stevens’ unnecessary reorganisation along USA private care lines. Over the next three years the total loss would be £205 million per annum. The damage to the NHS and Social Care is incalculable. And remember we are only looking at 40% of all the DToCs, i.e. half a billion pounds a year. Much of that could have gone into PPE stock replenishment.

    A final irony: In Hunt’s 2016/17 NHS 10 Point Efficiency Plan the target mandated was to “reduce Delayed Days to 4000/day, which translates into 124,000 per month by September 2018”. This equates to 4000 Delayed Transfers of Care per month across the NHS and Social Care – a figure that is actually higher (worse) than they had been achieving regularly in 2010 – 2013! But what makes it even more damning is that it was, statistically, an unachievable demand. The average for 2016/17 was 4560 DToCs and the lower control limit was 4995, which meant that statistically there was less than a 1/1000 chance that it could be achieved. Setting unachievable targets is feature of Hunt’s tenure. Caroline Molloy details these in her withering assessment of Hunt in her article What did Hunt do to the NHS – and how has he got away with it? (Open Democracy, July 13, 2019).

    Matt Hancock now grasps the poisoned chalice Hunt has handed him. Luckily he is an optimist and probably sees it as a great opportunity. One day he may also be rewarded with the Chair of the Health and Social Care Select Committee like Hunt, for the utter failures, especially the disaster of his outsourcing of test and trace to private companies (0ver £10 billion), greatly exacerbating effects of the terrible Covid-19 pandemic in 2020.

    Dr John Carlisle

    Chair, Yorkshire SHA

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    The Welsh Government is proposing to use its legislative powers to require local authorities and Local Health Boards to  produce a market stability assessment report on the social care sector  in their Regional Partnership Board (RPB) area.

    The legislation will be supplemented by a code of practice on the exercise of relevant functions in relation to market stability reports and statutory guidance on taking a partnership approach to preparing and publishing market stability reports.

    This innovative piece of legislation is welcomed by the Social Health Association Cymru – Wales which has responded to the Welsh Government consultation document.

    ================================================================

    Response to Welsh Government Consultation by Socialist Health Association – Cymru / Wales


    What do we want to know? Welsh Government would welcome comments on the draft regulations, code of practice and statutory guidance from local authorities, local health boards, and other organisations or sectors which are represented on RPBs or have an interest in the provision of care and support to the local population.
    It would also welcome comments from members of the public, including especially individuals who need care and support, and carers who need support. In particular, we would welcome responses to the following questions:


    Question 1 Do you agree that market stability reports should be prepared on a regional basis, by local authorities and local health boards through the regional partnership boards? If not, please give your reasons.

    A.    The Socialist Health Association Cymru believes that the business model underpinning our social care service in Wales is no longer sustainable and we need to be planning for a National Care Service.

    The independent sector continues to express concern about its marginal viability with residential care providers requiring levels of bed occupancy that go against the Welsh Government’s policy of more care in a domestic and homely community environment.

    There is a recruitment and retention crisis which is worse in the independent sector due to poorer pay and conditions, less training and fewer opportunities for career progression.

    Within this context we believe there is an urgent need to undertake regular assessments of the continuing viability of the current model of provision.

    While the consultation document proposes reports on a regional basis, it important that the geographical spread of provision in mapped at a more local level.


    Question 2 Do you agree that market stability reports should be produced on a five yearly cycle alongside the population needs assessments? If not, what alternative arrangements would you propose, and why?

    We note that the proposals recommend that a five year assessment cycle with at least a mid-cycle interim review.

    A.   We believe that the overall fragility of the sector requires a three yearly overall assessment with a yearly review.


    Question 3 Have we specified all the key matters that need to be included in market stability reports? If there are other matters you think should be included, please specify.


    A.   While we are fully aware of the sector’s legacy of being heavily dependent on for-profit providers, we are surprised at the failure of the consultation document to consider what role public bodies might play in service provision. This is only briefly mentioned in the context of a sudden closure of an established private sector provider.

    The omission is all the more surprising as it recommended that the assessments should be linked the to Regional Partnership Board needs assessment.

    The implicit assumption is that local authorities will have no role in the management or shaping of the market beyond its present contract compliance assessments. This means that it will be for others to address gaps in service provision.

    The variation in local authority fees across is Wales in considerable. It is far from clear why this is the case though these fees are at the heart of any assessment of the viability of the sector.

    Question 4 Do you agree that market stability reports should be kept under regular review and revised as necessary, but at least at the mid-way point of the five year cycle? If not, what other monitoring and review arrangements would you propose, and why?

    A.  See reply to Q2


    Question 5 In your opinion, does the draft code of practice strike the right balance between what is required of local authorities and what is left to their discretion? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    A.    The document urges “reasonable” efforts for community engagement. This is a rather elastic requirement which could result in a minimum level of engagement. It would be useful to be more specific that efforts should be made to engage with organisations such as the CarersUK, Stroke Association, Alzheimer’s Society, Mind as well as any successor organisation to Community Health Councils.

    There should be a specific reference made to any community councils in the Regional Partnership Board area.

    There only the most fleeting reference to engagement with care staff and other support / partnership professional groups. There should be a clear requirement to engage with local trade unions involved in the Education, Health & Care Sectors e.g. Unison, GMB Unite the Union, RCN, NEU and Local Medical Committee. In some areas, where there may be low levels of trade union membership, the local trades union council ( if it exists) should be consulted.

    Local groups of faith should also be specifically included in any engagement. They provide comfort and support to many of our citizens in times of difficulty and they can have important insights into the needs for particular communities.

    Question 6 In your opinion, does the draft statutory guidance set out clearly the partnership approach that local authorities and local health boards should take in preparing their market stability reports? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    A.  See replies already given.
    The document mentions the need to anticipate trends but is rather limited in the scope of the horizon scanning it envisages. This is a vulnerable sector underpinned by a fragile business model. It follows that more vision is required in looking at delivery models of care e.g. more in-house provision by public bodies, the NHS or the Third Sector.

    Question 7 What impacts do you think our proposals will have on the duties of public bodies under the Equality Act 2010, or upon a local authority’s duty under the 2014 Act to have due regard to the United Nations Convention on the Rights of the Child, the United Nations Convention on the Rights of People with Disabilities, or the United Nations Principles for Older People?

    A.   This is a timely document and Welsh Government is to be commended in initiating this legislation. Not withstanding the attitude of the Westminster Government to international agreements the Welsh Government has always used best international standards to drive policy.

    A citizen focused, responsive, stable and caring service needs to be in place to meet international standards. This must include provision that is based on the needs and wishes of its users. The workforce must be well trained and valued.

    None of this will be possible if overall business model of care is not longer fit for purpose for the challenges of the 21 Century.

    Question 8 We would like to know your views on the effects that our proposals with regard to market stability reports would have on the Welsh language, specifically on opportunities for people to use Welsh and on treating the Welsh language no less favourably than English. What effects do you think there would be? How could positive effects be increased, or negative effects be mitigated?

    A.   This is particularly important. Bigger, footloose corporate bodies have a smaller footprint in Wales which is generally a good thing. Smaller, local providers with a local workforce are more likely to be culturally sensitive to their needs of citizens.

    In many parts of Wales the local population will include people who have spent most of their lives in an area and others who have moved in at various stages of their life cycle. Our providers must respond to this diversity.

    Many vulnerable users would wish to engage with services in their first language. The planning and service delivery process must be responsive to this need.

    The Welsh language is an important part of Welsh life. As well, individual communities have other cultural attributes which can provide support and comfort to local service users which should also be factored into a citizen centred service.

    Question 9 Please also explain how you believe the proposed policy around market stability reports could be formulated or changed so as to have positive effects or increased positive effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language, and no adverse effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language.

    A.   See Q8.

    Market stability reports should include a specific section demonstrating how the needs of Welsh speakers and other sensitive cultural dimensions are taken into account.


    Question 10 Under the Well-being of Future Generations (Wales) Act 2015, public bodies have a duty to consider the long-term impact of their decisions. We would like to know to what extent you think our proposals will support the principle of sustainable development set out in that Act. Further information on the Well-being of Future Generations (Wales) Act 2015 may be found here: https://www.futuregenerations.wales/about-us/futuregenerations-act/

    A.   Our health and care service is still too illness and crisis orientated. It needs to be more pro-active and enabling for all our citizens.

    Beyond the immediate pressures of Covid-19 and the longer term legacy we have inherited, the Welsh Government needs actively to promote a policy of prevention and early intervention to create a more equal and socially just society that is at ease with itself.

    This includes providing our young people with the best start in life, providing all citizens with the opportunity to live full and enjoyable lives and providing a healthy ageing strategy including tacking loneliness and social isolation for citizens as they progress through life.

    Question 11 We have asked a number of specific questions. If you have any related issues which we have not specifically addressed, please use this space to report them. Please enter here.

    A.   SHA Cymru welcomes this proposal to assess the inputs into service provision other than in crude quantitative ways. This approach could be extended to other field of policy e.g. to assess the scope and scale of service provision in different communities and localities.

    Our Chief Medical Officer has often pointed out that “one size does not fit all”. Different communities have different needs. If we are to address these varying needs at a community level we need to develop processes which could be informed by the lessons learned from implementing this legislation.

    Comments Off on ASSESSING THE VIABILITY OF THE SOCIAL CARE SECTOR — Response to Welsh Government Proposals

    I am pleased to circulate the details of the launch of the joint SHA/KONP campaign to reshape social care in England. The launch will be at 1100 – 1300 on 10th October

    Register for the event here

    This is a major national campaign with a wide ranging support. Your support and involvement will be vital.

    More details are attached, including a MOTION that we would like you to discuss at wards and CLPs.

    We look forward to seeing you there.

    Yours,

    Brian and Jean

    A SUMMARY OF THE SOCIAL CARE CAMPAIGN

    Comments Off on Launch of the joint SHA/KONP campaign to reshape social care in England


    The current business model for social care in Wales, like the rest of the UK, is under extreme pressure. This vulnerability has predated the present Covid-19 pandemic. Care Forum Wales, the main representative body for the private care sector, has claimed that Wales could lose half its care homes within a year unless urgent action is taken. A Care Forum Wales survey also reported that 84% of respondents said low pay made it difficult for the recruitment of staff. Responding to these long standing concerns the Welsh Government commissioned the Welsh Institute for Health and Social Care to study the variation in terms of employment in the social care sector in Wales.

    The study looked at the comparative experience of various social care sectors in Wales including local authorities, independent sector and the NHS. There were (2017) approximately 1350 providers in the independent sector with a workforce of 52,500 and 130 local authority services with a workforce of 11,000. While the study showed variation within sectors there were also important overall differences between the sectors which could account the differing sectoral work experiences.

    The median minimum basic pay for front line independent sector care workers was 18% less that for local authorities (£9.74/hr) and 9% for NHS. The differences for maximum basic pay were 32% less for independent sector workers compared to local authority staff (£11.88) and 18% less for NHS health care support workers. Independent sector care supervisors received 32% less in their median minimum basic pay compared to local authority supervisors (£13.37/hr) and 78% in their median maximum basic pay ( LA supervisors £18.03/hr) . In addition the public sector workers were much more likely to receive pay enhancements for pensions and activities such as weekend shifts, holiday cover and over-time.

    Compared to 55% of independent sector front-line workers about 25% of local authority staff were in permanent full-time employment while 23% in independent sector were permanent part-time posts compared to 51% in public sector. However there were less differences in more senior posts across the sectors. About 20% of front-line care workers across the independent, local authority and NHS had the equivalent of zero hours contracts. There was some evidence that not all staff were unhappy with the relative flexibility these contracts provided.

    The report confirmed that recruitment, retention and staff turnover is a problem for the sector as a whole. While all had concerns about the recruitment and retention of staff this was greatest in the independent sector. These problems were less in more senior staff positions and overall there was a greater problem in recruiting staff compared to retention. While the independent sector felt it was in competition with local authorities for staff, both felt under pressure from the NHS and outside sectors such as retail. As well there were geographical variations with rural areas having less problems that more urban ones.

    While pay was an important factor other issues such as the status of social care, work pressures and responsibilities were felt to barriers to recruitment and retention. On the other hand the caring and pastoral aspects of the work were valued by the staff and contributed to them staying in post in despite the poor levels of pay.

    The Welsh Government has responded to some of the problems in the sector with others more difficult to address due to ongoing austerity policies and the continuing failure of the Westminster Government to live up to its promised on producing a comprehensive set of proposals to deliver a quality, affordable social care service.
    In order to improve the skills and status all all staff care staff will be expected to be registered with Social Care Wales by 2022. Once they have been in employment for more than three months care staff will have the right to choose between a defined hours or “zero hours” contact. And last year (2019) the Welsh Government supported “We Care” a campaign and on-line portal to support social care recruitment.

    In the Covid-19 pandemic care staff were provided with a £500 grant in recognition of their work by the Welsh Government. However despite declaring its commitment to the workers in the sector, the Westminster Government refused to exempt the bonus from stoppages such as taxation and NI contributions.

    It is clear that most of those who work in the sector are committed to their job and value its humanitarian values even above pay. An unemployment fall-out from Covid-19 might provide some easing of recruitment and retention difficulties but this cannot be seen as a sustainable solution. More comprehensive measures are needed.

    For decades social care has been provided on the cheap with the cost, in the first instance, being borne by staff in terms of their pay, work conditions and their opportunities for career progression. This downward pressure was driven by the policies of out-sourcing and tendering and an under-valuing of the public sector. But this policy has more or less come to the end of the road.

    The Welsh Government realises this and has commenced a consultation process on legislation that will require local authorities and health boards to regularly assess the financial sustainability of the care sector in their catchment areas. This should provide important information to inform the future shaping of local social care services.

    But we need to do more. We must start looking for more radical solutions within the overall context of a National Care Service. As a first step domiciliary care services should be brought back into the public service as their contracts lapse. And we then need to see how this option can be extended to all other workers in the sector.

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