Category Archives: Social Care

As the NHS passes its 70th birthday the recent report from the Health and Social Care Committee on Integrated Care could find little wrong with the direction of travel within the health service. While critics might cavil about the threat of further privatization, the Committee argued instead that the service was entering a new phase of collaboration rather than competition. Notions about the Americanization of the NHS were misplaced, due in part to the terminology surrounding Accountable Care Organizations, while the somewhat less than transparent introduction to this new phase had added to the confusion. Such problems could however be remedied by a “clear and compelling narrative” developed by the Department of Health, NHS England and other associated bodies, which would reassure both patients and taxpayers that the path of transformation was sound, sustainable, and in their best interests.

The Committee also argued that clarity could be more readily achieved by developing this narrative from a patients perspective, rather than focusing on systemic transformation. Such a perspective would focus on “how patients experience the health and care services they use”, and that what matters is that providers, whether public or non-statutory, “create coherent and comprehensive services, share information, work together and put patients’ needs, priorities and goals at the centre”. Indeed one can anticipate the content to be apolitical, dull, and with cross-party consensus and a new ‘NHS Assembly’ lending extra layers of concerned neutrality towards the co-design of the forthcoming 10-year plan.

 

HOMOGENEITY

In order to contest this it’s essential to identify the real guiding narrative for transformation, one which, while not always transparent, is overtly politicized and global in reach. It’s arguable that such a narrative already exists, is securely in place and has been for some time, and seeks to reconstruct healthcare systems to benefit transnational capital. Led by a transnational capitalist class with few, if any, allegiances to domestic staples, particularly re-distributional welfare, the aim is to impose a kind of global homogeneity of healthcare organization. Such standardization will attempt to safeguard and simplify investment strategies, and to embed corporate control of both purchasing and service delivery within rapidly evolving ‘mixed economies’ of care.

Homogeneity also gives meaning to attempts at trade deregulation; the TTIP, for example, would be somewhat limited if domestic systems weren’t fully investor compatible. The use of capitated budgets for ACO providers, for example, is expressly geared towards private investor interests, as the upfront capital can be invested in the global markets, with returns on equity in excess of 16%.

The insistence on fiscal austerity has accelerated such changes, transcribing the demands of financial regimes onto healthcare systems via the concept of sustainability. This not only permits a reframing of what care is to be available, but also a radical reframing of the delivery system. It was no surprise, for example, that the World Economic Forum’s (WEF) year long deliberations on healthcare followed the announcement by Standard & Poors in January 2012 that national healthcare systems must demonstrate sustainability in order for their economies to maintain credit ratings.  Workshops held in New York, Berlin, Istanbul, Tianjin, Madrid, Basel, the Hague, and London that year, were, according to the WEF, “remarkable in their consistency of vision”, advocating, for example, delivery from “capital-light settings” using “leveraged talent models” and “low-cost channels, such as home-based models”. In other words, what’s happening to the NHS is being reproduced on a global scale.

It’s also important to identify chains of command within these processes, and, owing to its economic strength, a key role is played by the US. Not only will US corporations be privileged, but also the standard template mentioned above builds upon the country’s main organizational format: that of ‘managed care’. Private insurance-led and with minimal recourse to federal programmes, managed care also involves a range of hospital- or physician-based provider networks. And it’s no accident that prior to his appointment as Chief Executive of NHSE, Simon Stevens led the Global Health Division of the US’s largest insurer, UnitedHealth, and was also chair of the WEF’s Steering Group on system sustainability. The interoperability of transnational and US ambitions isn’t always so clearly expressed.

 

TRANSLATIONS

As mentioned, the WEF’s reports were released in early 2013, and Stevens’ first main task for NHSE was in producing the Five Year Forward View in late 2014. Conceived as an overall appraisal of the NHS, the centerpiece of the Forward View was the introduction of new care models, namely the Trust-led Primary and Acute Care Systems (PACS), the primary care-led Multispecialty Community Providers (MCPs), and the more radical variant, the system-wide Accountable Care Organization (ACO). Such formats would be test-bedded across England in a series of vanguard sites offering examples of how these models would shape up in practice.

One such example is the South Somerset Symphony Programme. Led by Yeovil District Hospital NHS Foundation Trust (FT), the project is an advanced PACS vanguard in all aspects of the FYFV’s vision, incorporating radical changes in workforce, infrastructure and partnership arrangements. Working relationships have been established with Somerset CCG and Somerset County Council, as well as partnerships with other providers, and commissioners are working on similar approaches for the rest of the county with the aim of establishing a countywide ACO by 2019.

In terms of finding private partners for the new model, the FT was guided by the US-based global consultancy, Oliver Wyman, a company that “serves clients in the pharmaceutical, biotechnology, medical devices, provider, and payer sectors with strategic, operational, and organizational advice”. Private partnerships with the Trust now include those for services in diagnostics, digital services, online booking and management, ophthalmology, and in elective care. The last named is provided by ASI, the international arm of Amsurg, the US’s largest operator of day case facilities. The FT also partners Interserve Prime in a ‘strategic estates partnership’, to develop a wide range of retail outlets as well as a nursing home, GP practice and pharmacy, all of which, according the Trust’s CEO, could be run by the private sector.

Also assisting in the transition to an ACO has been Optum, the UK arm of UnitedHealth. The Trust’s document, ‘Join the Revolution’ is worth quoting in full:

“As (we) move towards an outcomes based contract in April 2017, the creation of an ACO is core to its effective delivery. The ACO model born in the US market is new to the UK, and as such we have partnered with globally experienced Optum who are guiding our journey into this new world. The partnership initially for a 9-month period is helping to plan, design and communicate the way the ACO’s will work, and critically financially model the value of managing a budget for the whole population of Somerset over a 10 year contract period”.

As mentioned, commissioners aim to extend this approach to the whole county, with Optum supporting other peers in the locality. As a Kings Fund document points out, the CCG envisages restructuring its services so that it can play “a more strategic role in overseeing the system, and expects a ‘managed services organization’” – such as Optum – “will sit within the ACO and act as its ‘engine room’”.

 

TEXTBOOK

While at first sight the scale of change in Yeovil is surprising, a close reading indicates it’s more textbook than anomalous. According to the Kings Fund, Optum, currently “supports GPs and provider groups in delivering new care models, including through offering analytics, actuarial support, decision support for clinicians and support for contracting”. Which, it has to be said, sounds remarkably like a health insurer. One of Optum’s clients is the Modality Partnership, which while it began in Birmingham, now straddles several counties, and is perhaps the leading MCPs vanguard. Some of the new care models “saw strong benefits of partnerships with private providers such as Optum because they could offer capital investment to support transformation, particularly if the government is less able to provide this investment in future”.

Similarly for PACS vanguard sites in Birmingham, Airedale, Fylde and North Tyneside, the Oliver Wyman company helped introduce “proven care models from other countries, customizing them to local needs, and then implementing them”. One of Oliver Wyman’s senior partners, Crispin Ellison, served in the Prime Minister’s Office, where he “identified new care models for health and community care” that “drew on best practice innovation in public and private sectors globally, as well as lessons learned in implementing major change initiatives”.

At a conference held by Wymans in London several months before the publication of the FYFV, all the trusts and CCGs from the above mentioned sites were present, alongside representatives from NHSE, Monitor, 10 Downing Street, and several other authors of the forthcoming narrative on integrated care.

Interestingly Wymans has a regular advert in LaingBuisson’s ‘Healthcare Markets’, the UK’s leading journal for the private healthcare industry. Under the banner ‘Transform Care: Implementing New Models to Improve Care and Value’, the company offers “To build sustainable solutions that are patient/ customer focused, health and social care systems need to optimize outcomes and experience, while delivering on value. We help clients transform care through the development and implementation of innovative, proactive, patient-centred models that address gaps and inefficiencies in our current delivery system”. The narrative used for both private and public sectors is interchangeable.

The company may also invite local NHS ‘leaders’ to its annual conference in Chicago, which brings together CEOs from major corporations – over 50% C-Suite in the blurb – who are “committed to the market transformation that will migrate $1 trillion to new players, new industry segments, and traditional companies that are delivering better health value”. The companies involved in the 2015 event included the insurers Blue Cross, Humana, Anthem and UnitedHealth, as well as various big pharma companies and Walgreens and Wallmart. It also included the CEO of Yeovil Foundation Trust.

 

ENDPIECE

In a blog to accompany its submission to the Health Committee, the Kings Fund, which also acted as chief advisers to the report, said, “there is no evidence that private providers of clinical services are taking on a bigger role in areas that are furthest ahead in developing accountable care”. It also said that while the proposed ACO contract may in theory open the NHS to companies from the US to compete to deliver care to NHS patients, this was “highly unlikely in practice”. As the examples above attest this is simply not the case. The range of private healthcare provision in Somerset is remarkably extensive, so much so in fact that the vanguard can no longer be considered a public entity. US companies it would appear are not simply offering services, but providing capital investment, acting as brokers for other private providers, and also acting as de facto commissioners of care at a county-wide level. It would appear that the ‘engine room’ of change for the English NHS is firmly transatlantic.

In its conclusion the Health Committee thought that too much emphasis had been place on wider processes at work within the NHS, and had come at the expense of more accessible interpretations of the changes deemed necessary to keep the health service afloat. As such, the Committee argued that there “needs to be a clearer narrative to explain the direction of travel: what are these reforms trying to achieve; what does the end state look like; what are the risks and what the benefits for patients and taxpayers”. There isa clear narrative involved, developed in the meeting rooms and conference centres in Chicago, Davos, and other loci of power, which pursues a US-led transnational agenda. And it’s one that does not aim to benefit patients.

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The underfunding and commodification of support

Social policy has always distinguished between the ‘deserving’ and ‘undeserving’ in responses to need. When the post-war welfare settlement was decided, the battle lines against Beveridge’s 5 Evils of want, ignorance, squalor, disease and idleness were drawn with a vision of a ‘land fit for heroes’ to come home to. Injured servicemen and civilians were to have their sacrifice rewarded by the substantial provision of housing, work, education and health services, with a safety net of benefits for those unable to work. Disabled war heroes fell squarely on the ‘deserving’ side. Quotas were introduced to encourage larger workplaces to ensure that at least 3 per cent of their workforce were disabled, healthcare was made universal and accessible on the basis of need rather than the ability to pay, and charitable institutions providing long-term care for disabled people without family support were brought within statutory welfare.

However, as values and expectations changed and healthcare improved, more and more disabled people found themselves trapped at the mercy of the institutions designed to provide care. Along with the changes imposed by the 1970s oil crisis, the 1980s saw the rise of a disabled people’s social and political movement. Inspired by the Civil Rights movements against racism and sexism, disabled people began to agitate for the removal of segregation and oppression through special education, institutional care, sheltered employment and residual benefits.

Community care and independent living

Sometimes, policy cycles come together in fortuitous ways. Alongside the bottom-up rise of a politicised disabled people’s movement came a top-down concern with reducing the role of the state and capping the rise of expenditure on residential care. Additionally, evidence from social work pilots in Kent that provided care services in the community showed that it could be more cost-effective than residential and nursing care. The 1990 NHS and Community Care Act was heralded as an opportunity to allow disabled people to be empowered and live independently. Services were to be provided in the community using a range of providers: a mixed market of care.

Of course, community care was fraught with tensions. Feminist researchers pointed out that care in the community meant care by the community, and that this meant, overwhelmingly, that women would provide care. Social work researchers pointed out the balancing act of rationing access to resources whilst trying to support and empower people was impossible. Disability activists pointed out that the very idea of ‘care’ was disempowering for disabled people and the practice of social workers acting as gatekeepers made it impossible for disabled people to be full citizens. It became clear that commodifying care wasn’t working.

Commodifying independence: direct payments and self-directed support

As with the initial community care pilots, direct payments for disabled people started small. A number of English local authorities circumvented the rules preventing directly paying disabled people by setting up third-party trusts and enabling people to purchase their own care and support.

These were hugely successful. Initial evidence showed that the services met people’s needs better, were more responsive and flexible, and were more cost-effective than statutory social care. Disabled people welcomed the opportunity to be in control and local authorities welcomed the opportunity to save money. With increasing pressures on social care spending leading to the forced integration of health and social care and increased rationing of services, another seemingly fortuitous bringing together of top-down and bottom-up policy developments seemed about to take off.

However, the crisis in funding had a huge impact on what happened next. Social care budgets began to be effectively cut long before the 2008 economic and financial crisis led to austerity. The development of direct payments services were seen by many local authorities as an opportunity to further cut spending: rationing by need (by making payments only available to those with ‘critical’ or ‘high’ needs) and by design (by making the system of payments so difficult to use it effectively put people off).

Whilst the budget for self-directed support and direct payments continues to rise, the actual care and support disabled people receive — whether that is measured in time or tasks — is falling. Effectively, the state has outsourced the responsibility for rationing resources onto disabled people. Faced with reduced payments and rising service charges, increasingly, disabled people are finding it difficult to purchase the care and support they need.

A policy change that could have been marked by the significant empowerment of disabled people has instead turned into another way of reducing state support. The potential for direct payments as envisaged by disabled people themselves is huge. Our research uncovered ways in which creative and person-centred approaches were being used to enable disabled people to parent, to work, to take care of each other, to volunteer — to participate in society. But current ideologies and practices in welfare mitigate against this. Government can’t commodify independence unless it is willing to pay properly for it. All reduced budgets will achieve is placing disabled people in further precarious and vulnerable situations without empowering them at all.

First published on the Social Policy Association blog

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The National Assembly’s Finance Committee is undertaking an inquiry into the costs of care for older people. This is timely not least because the UK Government has promised us a green paper on social care finance by the summer 2018  thought there are media reports this could be postponed — it seems that the Brexit policy paralysis is contagious and spreading to other other areas.

No doubt in advance of the the anticipated green paper, there has been a flurry of papers and publications in recent weeks. They will add to the dozen or so commissions, green papers etc that have been published over the last three decades. With the exception of Scotland most have been filed under “too hard to do”.

Socialist Health Association Cymru Wales has made its submission to the National Assembly’s Finance Committee and it can be accessed here.

 

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This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

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Caring for others is a fundamental part of any society: by ensuring that everyone in need of care has access to assistance and support, we guarantee the wellbeing of every person and hence of society as a whole. Indeed, so central is the provision of care to the idea of societal health and progress that it was once considered an integral part of the post-war welfare state.

However, in Britain today, we are moving further and further away from the ideal. Decreasing quality in care for the elderly and disabled, on-going withdrawal of government support for the social care sector, and extortionate costs for care services are all evidence of a broader process of commodifying care. As the financialisation of everyday life has found its way into the care industry, caring for others has been turned into a commodity for profit-making that is only answerable to the demands of the market.

How did we end up in this situation? What are the consequences for both those dispensing and those in receipt of care? And how, if at all, can we get out? Some of these questions lie at the heart of Lydia Hayes’s book Stories of Care which takes as its point of departure the current state of the British paid care sector, in particular with respect to homecare provisions. The rising demand for elderly care has prompted the British state to shift financial resources away from institutional care and towards the provision of care in people’s own homes. Estimated to employ about one million care workers for the elderly and disabled, the homecare industry is almost entirely run by the labour of working class women who confront increasingly badly paid, precarious, and inhumane work conditions, with only very partial protection by labour law.

The Labour of Care

Hayes’s book traces the transformation of care from what was once a public good, however imperfectly conceived and implemented in practice, to an entrenched crisis of social care in Britain today. At the core of her book is an argument about foregrounding the role of policy and law: we cannot understand the most recent process of commodifying care but as part of a more encompassing and complicated history of how legislators, judges, and policymakers have systematically devalued and discriminated against the work of those employed in the care industry. What is more, they have done so by using labour law as a tool for cementing both classist and gendered forms of control. Whether with respect to questions of equal pay and sex discrimination law, the right to employment protection in the event of unfair dismissal or the national minimum wage scheme, women in general, and working class women in particular, have never had the same rights and legal protections as their male counterparts.

But if the devaluation of working class women’s paid care work runs deep, then privatisation has taken this to a new level. Privatisation has driven the reorganisation of carers’ status from public sector employees to agency workers self-employed personal assistants. Culminating in the Care Act 2014, market-driven reforms have refashioned caregiving as a fundamentally economic enterprise which supposedly liberates care recipients by enabling them to engage as economic actors in the market of social care. And while politicians have promoted ‘choice’ as an improvement on an older paternalistic system of care, this narrative ignores that choice remains a fiction for those with limited means. Self-employed carers today face ever harsher exclusion from the benefits of traditional employment rights, while their clients have to make do with increasingly badly run, patchy, and insufficient services.

From paid care to informal care

But market-driven reforms have not only deeply impacted upon the labour of care with respect the paid social care sector. As I show in my research with working class women (Personalising the State; forthcoming, OUP), when it comes to informal care, there too neo-liberal reforms have deeply impacted upon the most intimate forms of human care. By informal social care, I refer to the mostly unpaid and invisible labour that working class women – as the main bearers of social reproduction – engage in inside their own homes, with respect to their children, grandchildren, kin and others who they consider part of their households. In these settings, the practical value of social care is inseparable from its moral worth.

Yet, informal care also becomes the terrain for penalization and state control. Means-tested welfare policies that have largely replaced the post-war system of social insurance prioritise ‘single’ claimants over collaborate households. Neo-liberal shifts to ‘law and order’ governance turn working class women into the bearers of collateral consequences of harsh policing, as they find that they can be evicted from their social rented homes for the activities of other household members. And under austerity politics, policies like the bedroom tax have further reduced women’s autonomy over their own homes by defining what constitutes an adequately-sized home.

The effects of these policies are both classist and gendered: they are classist because they operate in areas of policies that disproportionately target working class citizens – welfare, social housing, and criminal justice. And they are gendered because they act on domains of social reproduction that remain the responsibility of women.

Where to go from here?

What does the future hold? At a time when the number of people in need of care is growing more than ever, it seems obvious that the case for political reform is pressing. Hayes’s book advances a range of recommendations with respect to the paid care sector that target the reversal of the state’s criminalization of care workers, a fundamental reform of equal pay law, a new suit of legal rights with universal protection, and the establishment of collective bargaining. But a broader lens on care pushes also the need for reform both within and beyond the case of labour law: if the value of care work is to be adequately recognised across the spectrum – both in its paid and in its unpaid, its formal and informal capacities – then the marginalisation of working class forms of care with respect to housing, welfare, and criminal justice policies, ought to be addressed.

More radically, there is a need to rethink the very basis of citizenship relations, and relations between citizens and the state. As the lived experiences and voices of carers shows, caring for others is not something that ought to be subject to the logic of profit making: it is a moral activity, one which is founded on a recognition of shared vulnerability. It is precisely by reconnecting the moral value of care with the political and economic conditions in which working class women perform their labour that we can begin to formulate an alternative political economy of care: one which pushes against the ever-increasing drive towards profit-making and commodification, which rejects the logic of penalization and state control, and which reinstitutes care as a fundamental public good.

First published on the British Politics and Policy blog.

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Almost a million adults have currently given up paid work to care for friends and relatives. Most of these unpaid carers are women and in large part they are exiting the labour market because social care provision is inadequate. Meanwhile, life for the women who are paid to provide social care has become much harder. As social care provision has been eroded, they have faced a regressive, sexist, and systematic subordination of their interests as women, and because they are women.

The inadequacy of equal pay law

In 1997, most care workers were employed by local authorities and received an employer-funded pension, pay when sick, and the security of 37 hours a week of regular work. However, female care workers were underpaid in relation to men in comparable work. State employers promised that within a decade they would eliminate sexist wages and provide the care workforce with equal pay. This simply didn’t happen. Instead, sexism in wage-setting was effectively put on steroids through privatisation: the care workforce of today is employed in jobs which carry less than half the financial value of the jobs that care workers occupied 20 years ago. A systematic degradation has also been made possible by the utter inadequacy of equal pay law. Evidently, the Equal Pay Act 1970, and provisions in the Equality Act 2010 which replaced it, are not fit for purpose.

Equal pay law was supposed to ensure that the blight of sexism in pay-setting was eradicated. Not so for care workers. Where women do not work in close proximity to men, equal pay law offers very little and prevents women from comparing their wages to those of men who do not work for the same employer. It is a widespread misunderstanding that equal pay law protects the wages of women: it does not. Rather, the right to equal pay prevents male wages from being undercut. Inadequacies in equal pay law perpetuate the historic subordination of women in low-waged work, prevent care workers from achieving economic independence, and exemplify the economic invisibility of skills and abilities which are thought to arise ‘naturally’ in women.

The inadequacy of minimum wage law

The financial crisis of 2007/2008 heralded UK labour market changes in which care work became the largest source of low-waged work for women. The real value of the national minimum wage fell each year until 2014. For more than a decade, politicians and policy-makers were aware of minimum wage law being flouted in the social care industry. Nothing was done despite voluminous evidence that huge numbers of care workers were paid unlawfully low wages.

In various forms, non-compliance with national minimum wage law has continued even though the state is the main customer as well as the regulatory overseer of the social care industry. When the social care minimum wage scandal of 2017 highlighted that thousands of care workers were paid nothing more than pocket-money to ensure the overnight well-being of vulnerable adults, employers were outraged that they should have to pay care workers what was legally owed. The government’s initial response was to suspend the full enforcement of minimum wage law in the social care sector; months later, it implemented an industry-specific exception scheme in which care workers will not receive all the wages to which they are entitled until March 2019 and employers will avoid penalty fines.

The inadequacy of statutory pay protection

Yet a lack of political interest in enforcement has not been the only minimum wage issue to blight care workers’ earnings. Care workers are failed by the current right to a minimum wage where their work is not recognised as ‘work’ for the purposes of statutory pay protection. Regulations exempt the work of co-habiting family members paid as care workers via direct payments from minimum wage protection. Regulations also exempt the work of care workers who live-in and are treated ‘like family’ by their employers from minimum wage protection. In case law, the work of carers who are contractually required to remain on-site during lengthy shifts is not automatically recognised as ‘work’. Judges have devised special tests to apply when care workers bring minimum wage claims. Unlike the situation facing other workgroups, it is not enough for care workers to simply be present because their contract requires it: they must additionally show they are busy, needed, working alone or carrying special responsibility for others.

The engrained culture of non-payment

The National Minimum Wage Act 1998 and its accompanying regulations were supposed to communicate the universal value of paid work but do not require employers to pay for all the hours they require a worker to work. The scheme merely calculates a minimum wage total to be met or exceeded when pay is averaged across all hours worked. Although the right to a minimum wage was supposed to prevent exploitation, it has become standard industry practice for care workers to work for free during increasingly large parts of each working day. For example, in 2014, homecare employers calculated that workers were unpaid for an average of 19% of their working time due to non-payment of travel time between clients. On top of this, they were routinely unpaid for time spent training, waiting for ambulances or other healthcare professionals, time spent waiting for co-workers to help them lift heavy clients, time spent in supervision meetings with management – and the list goes on. An engrained culture of non-payment in the care industry has been made possible by the inadequacy of UK minimum wage law.

Why all this matters

Hands-on care work is the UK’s most highly female-segregated occupation. Traditionally, women are expected to provide care for free within families and they continue to provide the vast majority of unpaid work at home. A sex-based ideology about women’s subservience to the needs of others still circulates in the contemporary labour market, and minimum wage law does not do enough to assert the value of care work.

There are two million workers in adult social care, the vast majority of them women. If we continue to tolerate care workers being employed to work without pay, the future of care work will be based on sexist expectations that care work should be done for free. Unless we stand up and demand that carers’ skills attract decent economic reward, the future of social care will be based on the idea that caring skills are ‘natural’ for women and don’t have to be paid for. Until the wages of care workers are free from sexist devaluation, and until the work of care workers is fully recognised, the labour of all women is devalued.

First published on the British Politics and Policy blog

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Deborah Harrington’s interesting posting on “The Myths and Legends of Hypothecated National Insurance” (March 29 2018) in particularly relevant in the light of media speculation about hypothecated taxes or National Insurance contributions to pay for health or social care.

In Wales there is a further variation on this general theme with Professor Gerry Holtham (Dept. of Regional Economics at Cardiff Metropolitan University ) proposing the establishment a social care levy for Wales. (See link below)

The levy, based on weekly payments between £1.75 and £7, would differ from a tax in that the receipts would not go into a general government budget but rather into a separate social care fund with its own independent trustees. “A portion of ..(the fund) receipts would go to local authorities to expand social care provision straight away. The greater part of the receipts would be held back for future needs and meanwhile invested to grow over time and enable even greater social provision to be made in the future as the population ages.”

And following the National Assembly for Wales having secured its own tax raising powers at the beginning of October 2017 the Welsh Government Finance Secretary, Mark Drakeford, signaled that a levy to support social care was one of the new tax ideas he was considering.

Solving Social Care. And more besides

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There is an unwritten – but golden – rule in political speech-making (as in story telling): pledges should come in neat numbered clusters, often in threes or fives, any fewer and it seems you have nothing to say, too many more and no one will remember them. So, the Health and Social Care Secretary Jeremy Hunt was taking a chance when on 20 March he made his first speech on social care to the British Association of Social Workers, setting out seven key principles to guide the forthcoming social care Green Paper. But the risk is not only that the commitments will prove less than memorable, but that they will fail to be sufficient to address the long-standing challenge of reforming long-term care.

The seven principles cover familiar ground and press the right buttons to connect with important values, but there is nothing here that suggests radical thinking or unexpected developments, or indeed that anything much has moved on since these issues were last on the table. The seven principles are the following:

  1. Quality.
  2. Whole-person integrated care.
  3. Control.
  4. Respect and nurture the workforce.
  5. Supporting families and carers.
  6. Sustainable funding.
  7. Security for all.

Another danger with a numbered list is that it implies a hierarchy – rightly or wrongly – and many of those listening to the speech will have been mentally rearranging their preferred order.  Be that as it may, the list is largely uncontentious; no one is going to argue against these principles, and they may well be the ‘right’ ones. Some others could have been added, perhaps principles reflecting universalism; building inter-generational solidarity and social inclusion, but this isn’t a bad starting point. The fact that a very similar list could have been proffered at any time in the last decade points to the reality that the problem with social care reform is not with the underpinning principles or objectives, but with how to create an affordable and acceptable funding model that enables these ambitions to be delivered.

Quality

It is self-evident that services need to be of good quality and that too often they are not, and that the way services are inspected should play an important part in driving up standards and rooting out poor performance, both in provision and in commissioning. But that improvement agenda will come with a price tag.

Whole-person integrated care

The focus on whole-person integrated care develops a familiar refrain; the fault line running between health and social care creates fragmentation and confusion. It makes it virtually impossible for the lay person to understand or navigate, particularly when they have complex needs and co-morbidities that require a coordinated approach. Joining up services has long formed the core mantra of successive Health Secretaries, and the ambitions for the delivery of the Five Year Forward View for the NHS revolve around the goal of  achieving integration through the vehicles of Sustainability and Transformation Partnerships and Integrated Care Systems.

Jeremy Hunt has announced yet more pilots around joint health and care assessment and plans as another step towards integration, adding to the multiple developments around the Better Care Fund and the Vanguards promoting new models of care. But such innovations have not been met with uncritical acclaim; there are flaws in models that chase funding, and analysis by the King’s Fund among others points to the limits of transformation in a ‘downward spiral’ when additional funding is being used primarily to reduce hospital deficits. The National Audit Office has similarly suggested that the ambitions of Sustainability and Transformation Partnerships are overly optimistic.

Announcing new pilot initiatives to address integration by changing systems and processes is insufficient, particularly without addressing the big question of funding, and indeed the impact of separately funded health and care systems on individual users.

Control

Control, the third principle, is about personalisation and people having scope to direct their own care and support, and access to the information and support they need to do so.  Again, these are familiar words that have been part of the lexicon of care for more than a decade, and still the reality for people is often very different. How we get to the destination remains unclear; merely repeating the familiar and warm words is not enough.

Respect and nurture the workforce

Respecting and nurturing the social care workforce is overdue; these are the underpaid and undervalued care workers who are too often the focus not of praise but of criticism. The announcement that there will be a joint NHS and Social Care 10 Year Workforce Strategy is welcome, and an opportunity to address critical issues of recruitment and retention, career pathways and promotion opportunities that will attract and support people into working in social care as a valued career choice.

But the strategy will need to address the reality that many people in social care are not going to want to move into nursing, or to follow a career path. The need to embrace the skills requirements and opportunities for people who will continue to provide vital day-to-day personal care for people in their own homes and in the residential sector must be part of the strategy, as must be the question of regulation and accountability for groups that are still outside the framework of professional regulation.

Support for families and carers made a welcome appearance as a principle identified by the Health and Social Care Secretary. Indeed, many will have wondered what had become of the National Carers Strategy that was consulted on almost two years ago, and then disappeared from view. Hunt confirmed that “ahead of the Green Paper we will publish an action plan” on how to support carers. What that might look like is not known but Jeremy Hunt confusingly spoke in the same breath about volunteers, and about tackling loneliness, which might suggest that clarity around an action plan for carers is still a little way off.

Sustainable funding and security for all

The last two principles – sustainable funding and security for all – finally get to the big issues that remain unresolved, but fail to indicate anything about how they might be addressed. The Green Paper is still primarily about funding long-term care for older people, and the decision to separate this from a wider consideration of care needs for younger disabled people was widely criticised when it was announced following the 2017 election. Some sign that this approach may be shifting was evident in Hunt’s acknowledgement that the answer will not “be necessarily the same for different age cohorts” and that “there may be changes that are equitable and achievable for younger people that would not be either of those for the generation approaching retirement.” Getting a sense of inter-generational solidarity and buy-in to a revised social contract will be critical to reform, and any approach that salami-slices the population risks instead becoming highly divisive.

Hunt underlined the principle of “shared responsibility” in achieving security for all, with a “partnership between the state and individuals.” But importantly, he accepted that the current system “is far from fair”, particularly in the lottery of health which means fully funded care for illnesses such as cancer, and largely unfunded support for people who develop dementia and degenerative conditions. The Green Paper will present ideas about risk-pooling and potential costs, and will need to do so in a way that avoids earlier criticisms of a death tax.

Breaking the silence on long-term care is an important step, but the debate has barely moved since it was last visited. The Care Act remains on the statute books, but the implementation of the capped cost model of funding has been cancelled, and we are back to a position many would think we were in following the Dilnot Commission’s report in 2011. The confusion which surrounded social care during the 2017 General Election campaign caused a rapid unravelling of the policy; whether the seven principles for the Green Paper will provide a sufficient foundation for development and for genuine fresh thinking remains to be seen. On the basis of what Jeremy Hunt has outlined so far there is perhaps some reassurance and hope that a principled way forward will be found, but certainly there are no grounds here for excitement or unbounded optimism.

First published on the British Politics and Policy blog

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Over the past decade there have been growing calls for reform of social care funding. Following numerous Commissions, Inquiries, and election promises, yet another Green Paper is promised for summer 2018. There are strong arguments in favour of a social insurance approach, and much to be learned from Germany’s experience about building a financially and politically sustainable funding model.

Mandatory long-term care insurance (LTCI) was introduced in Germany in 1994. Launched at a time of welfare state retrenchment, it was configured to deliver financial sustainability. After a decade of stable funding that built institutional and popular legitimacy, there have been modest increases in contribution rates and the value of benefits has increased. A series of reforms since 2008 has also extended the scheme to provide coverage for people with cognitive impairments such as dementia.

English social care funding today resembles the fragmented, residual, local government-based, means-tested situation in Germany before the introduction of LTCI. While acknowledging the different institutional frameworks of the two welfare states, there are nevertheless important lessons that England can learn about sustainable funding and achieving consensus on reform.

Universal social rights and cost-containment

A major driver of reform in Germany was the reliance on stigmatising means-tested social assistance by older people who had ‘spent down’ their assets. There was also disquiet amongst regional (Länder) governments about the pressures on their budgets, while policymakers wanted to insulate health insurance funds from long-term care costs, discourage unnecessary institutional provision, encourage new providers and support family care.

Major welfare state reforms in Germany require broad political support. This need to achieve consensus delivered an LTCI scheme featuring universal social rights within a strong cost-containment framework. The Federal government has substantial regulatory and cost-controlling powers with the overall budget, contribution rates, ceilings, benefit levels and eligibility criteria all fixed by Federal law.

Pay-as-you-go LTCI funds are managed by (legally distinct) health insurance schemes. The individual contribution rate is currently 2.5% of wages payable up to a contribution ceiling with childless adults paying a little more. For those in work, employers pay half the premium while the retired pay full contributions, thus helping to address inter-generational equity concerns. LTCI membership is compulsory and non-employed people are covered by employed householder insurance contributions.

Benefits can be claimed by people of all ages. Eligibility thresholds were developed to fit the funds available, but there is no means testing and no account is taken of individual circumstances. Until 2008, eligibility depended on the level of physical ‘care dependency’ but has now been extended to include care needs arising from cognitive impairments. Although all are eligible for LTCI, most beneficiaries are over 65.

There are two ways in which benefits are distributed: cash payments to the person needing care who then pays a family member, volunteer or paid carer; and in-kind professional services. Cash payments are more popular and significantly cheaper than services. Levels of benefit are based on dependency and range from £283 a month (the lowest cash benefit) to £1,784 a month (the highest in-kind payment). Most beneficiaries receive home-based care. Benefits don’t cover all costs, with shortfalls being made up by private funds or social assistance.

LTCI’s original design aimed to demonstrate that a defined contribution approach could work in social insurance. It was agreed through broad political consensus and delivered a decade of stable funding, albeit at the cost of consistently falling real-terms benefits (down by over 20% between 1994 and 2008). A series of recent reforms have expanded and strengthened LTCI, improving access, benefit levels, and care quality. The original eligibility criteria were criticised for their bias towards physical disability, so LTCI was extended to cover people with dementia and other cognitive impairments while core benefits were also enhanced.

What lessons can England learn?

German LTCI embodies a societal acknowledgement that long-term care needs are neither individual nor negligible residual risks. Long-term care is a social risk requiring social protection. This is not a partisan position; the need for reform, the introduction of LTCI and subsequent scheme expansion were all agreed by both main political parties.

The Federal government manages contribution levels, eligibility criteria, and benefits payable ensuring tight cost containment. Benefits were increased for the first time in 2008 and are now reviewed every three years. After 25 years of operation, despite population ageing, an extension of the scope of LTCI, and increases in benefit levels, contributions have only increased by 0.8% of salaries.

The society-level pooling of risk, the creation of a single fund and the key Federal government role have eased financial burdens on regional governments. Central government provides the legal framework, policy direction, and much of the funding for policy implementation, thereby giving political and public assurance of the long-term sustainability of LTCI.

LTCI is a universal scheme with employees, employers, and retired people all contributing. Eligibility rests on care needs alone and the previous dependence on stigmatised means-tested social assistance has been significantly reduced. Universality enhances the popularity of LTCI – disabled children, working age adults, and affluent older people are all potential beneficiaries. Over time, LTCI has become increasingly equitable.

LTCI was designed to support family care; recent reforms have increased social protection measures for family carers. The hypothecation of LTCI funding also makes an explicit link between contributions made and benefits receivable that English care does not. All of these arrangements help to enhance the popularity of LTCI.

Conclusions

While LTCI is congruent with the German social insurance model, it was still a radical departure from past policy. LTCI added the first new social insurance pillar in decades; moved the focus of public care funding from regional to Federal level; and expanded public welfare effort at a time of welfare state retrenchment. The need to achieve political consensus and the welfare austerity agenda of the 1990s shaped the predominantly public, defined contribution design of the programme. Using the established health insurance funds and associated infrastructure allowed rapid implementation and avoided the need for major institutional reforms.

LTCI benefits depend on current need rather than past income and LTCI shares the lower contribution ceiling of German health insurance. This reduces the redistributive impact of the scheme and means the main beneficiaries are those who don’t qualify for means-tested benefits. The probability of ‘catastrophic’ care costs for people with average and above average incomes is reduced significantly by risk pooling under LTCI, thus making it popular amongst this group.

At inception, the design of LTCI (fixed contribution rate, low contribution ceiling, and fixed price benefits) delivered multiple policymaker goals. These include medium-term contribution rate stability, universal benefits, support for family care, a lower funding burden on regional government and less reliance on stigmatising social assistance. After a decade of institutional existence, established policy networks and commentators became increasingly articulate about the short-comings of LTCI. The stability of the scheme provided a platform on which a second decade of funding growth, eligibility expansion and structural improvement has been built.

By Caroline Glendinning and Mathew Wills 

First published on the British Politics and Policy blog

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The outsourcing of public services to private companies is a model in disarray. The impetus for challenge has been the collapse of the outsourcing giant Carillion but concerns have also been raised across a number of other public services including probation, the prison service, forensic science service, and the NHS. Much less interest has been paid to the longer-standing privatisation of adult social care, where the debate tends to be focused on levels of funding and the respective obligations of the state and citizen to contribute to individual care costs. This relative absence of policy interest in examining the ownership structure of adult social care may be due to three related factors – market penetration, market fragmentation and market fragility.

Market Penetration: The longer the period over which outsourcing has taken place and the greater the penetration of the market, the more difficult it is likely to be to reverse the situation. This is the situation with adult social care, where the process has been in train for over 30 years and the current structure is deeply embedded. In 1979, 64% of residential and nursing home beds were still provided by local authorities or the NHS; by 2012 it was 6%. In the case of domiciliary care, 95% was directly provided by local authorities as late as 1993; by 2012 it was just 11%.

Market Fragmentation: There is no compact adult social care service that can be easily repatriated into public sector ownership. Rather the sector is characterised by a multiplicity of fragmented, competing providers. The care home sector supports around 410,000 residents across 11,300 homes from 5500 different providers. The situation in home care is even more diverse with almost 900,000 people receiving help from over 10,000 regulated providers. Nor is it any longer the case that the state is even the dominant commissioner of these services – the privatisation of care alongside tighter access to local-authority-funded care has resulted in a large growth of self-funding ‘customers’.

Market Fragility: The third complicating feature of the adult social care market is its fragility and the politically toxic consequences of market failure. The first major casualty was Southern Cross in 2011 – a large national care home provider which had 9% of the market nationally but a much greater share in certain regional areas. Much of the Southern Cross provision was eventually taken over by another major provider, Four Seasons, which is itself now at high risk of going under. Either through financial collapse or strategic withdrawal the market model is at tipping point.

There is a growing view that the problems associated with the outsourcing of adult social care need to be addressed, but if no ‘big bang’ change is feasible, what are the alternative options? Better and fairer funding is a prerequisite but the local state (as the biggest commissioner of services) and national government (as policy-maker) can also act in other ways that could create better care quality and reshape the provider mix. Four dimensions can be identified: commission local and small; commission holistically; commission individually; and commission ethically.

Commission Local and Small

The trend, especially in the residential sector, is for small operators to be replaced by large provider chains with more than fifty care homes which in turn house up to a hundred residents each. A focus on smaller and more local commissioning is needed to counteract this trend. Small organisations hold vast expertise about the issues affecting people locally and can serve very specific communities of interest. Moreover, much of what they do focuses on bringing people together which ties in closely with the policy focus on loneliness, ideas around Asset-Based Community Development, and on supporting communities to rebuild their own social infrastructure by harnessing community businesses.

Complementary to this is the concept of Local Wealth Building, a growing movement in Europe and the USA based on the principle that ‘places’ hold significant financial, physical, and social assets of local institutions and people. The key here is local ‘anchor’ institutions (public, social, academic, commercial) and their procurement role in supporting the local supply chain. This will include opening markets to local small and medium enterprises rather than looking to national and international chains. Central government also has a role to play here, for example by minimising corporation tax rates for small local businesses.

Commission Holistically

It no longer makes sense to think of social care commissioning in isolation. Rather the focus is upon ‘holistic’ or ‘place-based’ commissioning. Most social care is commissioned separately from other place-based interventions. However, market-shaping is a much broader strategic task spanning several council departments and other partners – social care, transport, housing, economic development, health, community safety, training providers and more. Coordination on this scale would require significant investment in capacity, skills, and structures – in effect, the reinvention of robust local governance.

Commission Individually

Policies on access to social care support have created two groups of ‘individual commissioners’: those who fund their own care and those whose care is funded via an individual budget. Both are in need of greater support. A market requires ‘customers’ who seek and digest information to inform their choice of product. From this perspective the care home market in particular has some characteristics of an inefficient market – entry is often unplanned, made in response to a personal crisis and with very low rates of switching to a different provider in the event of dissatisfaction. The Competition and Markets Authority  raises the prospect of enforcing consumer law, but others will take the view that it is simply not possible to replicate a market with informed ‘consumers’ in the social care sector. However one option that can work for some people is that of personal budgets and more recently personal health budgets, though here too there are issues to be resolved around matters like making choices and decisions; receiving information and advice; budget management, monitoring and review; and risk management and contingency planning.

Commission ethically

Ethical commissioning could include the following dimensions.

Commission from ethical employers: Commissioners need to be able to distinguish between the workforce practices of different providers and prioritise those acting as ‘good employers’. This might have several components such as prioritising providers that comply with minimum standards around workforce terms and conditions, have effective training, staff development and supervision, and encourage staff to participate in collective bargaining.

Commission from transparent providers: A ‘transparency test’ could stipulate that, where a public body has a legal contract with a private provider, that contract must ensure full openness and transparency with no ‘commercial confidentiality’ outside of the procurement process. All providers of public services should – at a minimum – publish details of the funding they receive, performance against contractual obligations, the suppliers to whom they subcontract services, the value of these contracts and their performance, and user satisfaction levels.

Commission from tax compliant providers: The ownership of all companies providing public services under contract to the public sector, including those with offshore or trust ownership, should be available on the public record. At the same time, a taxation test could require private companies in receipt of public services contracts to demonstrate that they are domiciled in the UK and subject to UK taxation law.

Commission from not-for-profit providers: A fresh approach to adult social care offers the opportunity to rethink the role of other sectors. Whilst wholesale renationalisation seems unlikely there is every reason to encourage local authorities to begin to build up their own in-house provision and to support all organisations with a social purpose, whether in the public, private or voluntary sector. This could include encouragement for user-led organisations, social enterprises, mutuals and others to recruit and train service users in innovative ways.

The privatisation of adult social care in the UK has an unusual policy trajectory compared with other sectors. Devoid of any real debate or stated purpose, a 30-year process of outsourcing has grown unabated and unchecked. The scale of penetration and the dismantling of alternative providers have resulted in a situation that fails to meet ordinary market standards around choice and control. And now, as a result of austerity politics, there is every chance that the private sector will lose interest and leave the market with serious consequences for those in need of services and support. Whilst it is not feasible to simply eliminate a model that has become so deeply embedded, a combination of better funding and smarter commissioning can, over time, reshape ownership structures, increase provider stability, focus on ethics rather than cost, and enhance the quality of care.

First published on the British Politics and Policy blog

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An update on the work relating to the joining-up of health and social care in Cheshire West and Chester and a view on the next steps. This is a fast moving agenda and often people get just one part of the story.

Jigsaw of services

A fragmented system 

First of all its worth recapping on the fact that health and social care have very similar challenges but remain fragmented. Health fall under the purview of the NHS covering things like GP services, community health services and hospitals. It is ultimately accountable to the Secretary of State and free at the point of delivery. In Cheshire West and Chester, health care is commissioned by two clinical commissioning groups. One for the Vale Royal area covering Northwich, Winsford and surrounding areas and another for West Cheshire covering Ellesmere Port, Chester and surrounding area. Ideally we would like one commissioning geography so we have a common approach across the Borough.

Social care covers support that maintains people’s independence covering issues such as mental health, physical disability, learning disabilities and support to older people. It provides or arranges services following an assessment and is means tested. Its accountability is to local elected Members.

Both health and social care are currently experiencing massive challenges in demand as people get older and conditions become more complex. Funding is not keeping up with this demand.

Something needs to change both in terms of investment and the way services work. I want to emphasise however that its been made clear to us by the Cabinet that the shared public service ethos of the NHS and social care need to be preserved. The answer can’t be to encourage the market to fill the space. Actually the direction we have been given is that collaboration rather than competition is the answer.

One of the major issues is that services can often be reactive and only kick in once somebody is unwell or in crisis. Some of this is because the range of services across health and social care are fragmented and don’t  join up to prevent people from needing intensive support.

Often GP services are not connected up with hospital services. Community services are not joined up with social care. We have separate processes, separate budgets and separate ways of working. This leads to missed opportunities to intervene early to support somebody to lead a healthier and more independent life.  This is not the best use of public resources but also isn’t fair on our residents who can see that the left hand isn’t talking to the right hand.

Local challenges

At the local level we have a number of challenges where we feel the further  joining up of health and social care would make a huge difference.  Obviously it’s great that people are living longer but often this means we will have people living with multiple conditions that require a joined up approach over health and social care.

We have issues with health inequalities and poor lifestyles particularly in our more challenging areas.

  • Our demand at A&E is at very high levels.
  • We have too many delays of residents from hospital to other settings, reducing capacity in our hospitals.
  • Our GPs are under pressure to support the most complex patients.
  • Wider staff are under pressure to deliver the best possible care.

Financially, in the West Cheshire area, it’s been estimated that unless the way we work changes, we face a financial gap, mostly in the NHS, of around £65 million by 2021. We’re fearful this could lead to some form of top down intervention in the NHS where we lose the ability to set our own destiny. This is already happening, to some extent, in the Vale Royal area.

What this means for vulnerable residents

Not joined up services

But these are all organisational challenges. Ultimately the biggest challenge faced is that our residents are not receiving the care and support they need. They can’t understand why things can be so fragmented particularly if they have complex needs.

What integrated care looks like? 

So what would more integrated look like and how could it help? Well this video provides some background. Its been produced by a national health charity known as the Kings Fund and I think is sums it up very well.

Emerging national policy 

This challenge has been recognised by national politicians and the needs for more integrated care was a key feature of the latest Labour Party manifesto.

Some guiding principles 

Labour will focus resources on services to provide care closer to home and deliver a truly 21st century health system. We will work towards a new model of community care that takes into account not only primary care but also social care and mental health…..

The National Care Service will be built alongside the NHS, with a shared requirement for single commissioning, partnership arrangements, pooled budgets and joint working arrangements. We will build capacity to move quickly towards a joined-up service that will signpost users to all the appropriate services at the gateway through which they arrive.

Our response

  • We will focus on change that benefits our residents rather than just structures
  • We will make this local and bottom up. This is not being driven by the STP and we will  take action to avoid this being ‘done to’ us through a top down reorganisation
  • We will ensure full public engagement throughout this process
  • We will not participate in any competitive procurement process or participate in any process that reduces the public service ethos and leads to fragmentation
  • We will make the case for additional funding to NHS England and central Government
  • We will push for one health and social geography that reflects the local authority boundary
  • We will fully engage and protect our staff through this process
  • We will only proceed if there is a sound business case and political support
  • We will ensure that the governance incorporates the local democratic mandate and fully link into the Health and Wellbeing Board

 Its hopefully helpful to set out what we’ve already done around integration and what the next steps may look like.

  • Back in 2013, nine integrated care teams were set up including GPs, community services staff like District Nurses, social workers and support staff. Their job is support people with complex conditions, particularly those at risk of needing hospital care and residential care.
  • We have also worked with NHS colleagues on a single care record to bring together vital health and social care information into one place. This enables to take a joint approach to planning care and avoiding people having to tell their stories many times.
  • We have recently joined up our reablement teams with a similar team in the Countess of Chester. This was designed to ensure people can be supported to get back home as soon as possible.
  • We have pooled around £100m of health and social care funding through something called the better care fund which enables us to make joint decisions on resources to support the public rather than just thinking about the separate resources for each organisation.
  • Our A and E in the Countess has enhanced its services and created a new facility in the hospital to support urgent treatment and avoid admissions where they are not necessary.

We think the next step however is to bring all this good practice together into a much more robust integration programme. This will ensure that the actions we take are better coordinated and implemented with real rigour.

The step after that, some years down the round, may be to develop something called an Integrated Care Partnership. This is where you take integration to its full extent and you would have one budget, one management team, one set of outcomes, one local governance approach, one public sector approach and one clearly defined way of working. In other countries this has been called an accountable care organisation but we don’t use that term as it’s often confused with the American model where the profit motive and the market drive health and care. Clearly that’s not the model we want to follow.

What this means for our residents

Already the joining up of care is benefiting local people. This case study outlines where an integrated approach has delivered a better service that has avoided wasted time for staff and most importantly our residents.

Mary, 85, has memory loss, is deemed “frail elderly” and has an allocated social worker named Ann. Ann receives information regarding a potential safeguarding concern relating to financial abuse by Mary’s family members.

At times, Mary can be reluctant to engage in support from social care, making co-ordinating support for Mary difficult. With integrated care, by carrying out joint visits with health staff, professionals are able to build a trusting working relationship with Mary. By working jointly with the community matron, Ann is able to complete a detailed assessment of Mary’s needs, including looking into the safeguarding concern, using information provided by health colleagues that would not have been available without an integrated approach.

On one occasion, Mary develops a Urinary Tract Infection and becomes extremely confused very quickly. Mary is deemed to be unsafe to remain at home and, working jointly with community matron colleagues, Ann is able to quickly access respite care for Mary to prevent a hospital admission. Mary is now back at home and tells staff she feels well supported.

Full integration programme

We think our immediate next step is to make the case for comprehensive integration programme that will make a real difference on the ground. This would precede any more radical change such an Integrated Care Partnership.

It would involve bringing the health commissioning team in the CCGs together with the local authority commissioning team so we take a common approach. This would perhaps be quicker to do for the West CCG area initially as the commissioning team in vale royal also links into East Cheshire council.

We will develop new care pathways for our residents, working  with clinicians and social workers, so there is real clarity on care can be joined up around individuals. We also want to improve the way our integrated teams operate. Having been in place for around 4 years we want to ensure they have the tools and resources to support people in the community.

A key priority for us to take further joint action to avoid residents being delayed in hospital and not getting home in a timely way. This involves joint ways of working between health and social care, more information sharing, better planning  and more capacity in the community to support local needs.

Our single care record could be enhanced further so that further information can be shared to inform joint working.

Our information, advice and guidance we will look to join this up with the NHS so that our residents know where to go for support. We’ll also be looking to join up our data and intelligence to better target our resources at people with complex needs.

What next? 

Following the implementation of this programme, one possible destination could be an integrated care partnership. This would take integration to its full extent. It would involve health and social care coming together into one unified arrangement.

Integrated care partnership

This would involve joint governance through the health and wellbeing board and a integrated care partnership board. It would be supported by one commissioning team, one management structure and one pooled budget that could be up to half a billion pounds.  The budget and responsibility to pull the system together would sit with one existing organisation. This would very likely be an NHS provider due to legislation and the fact they would be contributing the majority of the resource.

The service delivery would remain in the public sector and involve all local NHS services and some adult social care services. Until the concept has been proven and we have the same geography with health we cant put all services in this arrangement initially. We would also start with any staff being transferred  through secondment rather than TUPE

Where else is this happening?

This model has just been put in place in Salford, a Labour controlled Borough.

Salford Together logo

The area had delivered a very similar integration programme since 2014 and felt that the next step was to take integrated care to its full extent.

In July 2016, local leaders established a new joint commissioning board, comprising city councillors and GPs from the CCG’s governing body, to oversee a larger pooled budget of £236 million for all adult health and care services (excluding specialised services).

Under the new arrangements, the city council and CCG  direct Salford Royal Hospital Trust to deliver or manage a range of adult health and care services. In mid-2016, the council transferred its 450 social care staff to Salford Royal to undertake assessments and contract for the provision of adult social care support. This means that Salford Royal will deliver a large proportion of the services, including acute care, community health care and some social care services in-house.

Potential timescales 

So what does this journey look like in terms of timescales? If Members are supportive we will resource up for a full integration programme as soon as possible. This would be supported by a team with the best talent from across health and the local authority. Its initial focus would be for West Cheshire but we would also look to put in place arrangements with Vale Royal.

Also we will lobby heavily for a single health geography that aligns to the local authority’s boundaries

We can start further work thinking about the feasibility of an integrated care partnership but this will not be the priority. The key focus will be on changing services on the ground. Any business case for a more radical arrangement would need to follow and be a Member decision.

In 2018 we will start to see further changes on the ground, with the majority of the projects delivered by 2019. Only after that point would any integrated partnership go live by which stage we hope to have moved to a single health geography.

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Every winter, the crisis of care deepens. Here we are, in the eye of the storm, with the contradictions glaring out from the abyss. 10+ hour waits at A&E, causing countless unreported harms in delayed treatment. It’s upsetting to think soon, someone is likely to die in the corridor, just as last year (The Guardian, 2017)

The infamous Corridor is usually where patients are taken by Ambulance when they are unable or unsafe to walk (e.g. the bedbound, the nursing home resident) or when their condition requires continual assessment & management (e.g. amber-flag sepsis, breathing difficulties on oxygen etc.), but are not life-threatening (heart attacks, strokes, etc.). When the Ambulance Triage bay is full, patients queue on beds on Corridors, waiting to be moved into the bays and triaged. With hospital staff unable to safely care for the numbers on the Corridor, ambulance staff remain with the patients until able to handover. Ambulances parked at A&E cannot respond to life-threatening calls. Not only this, I have seen colleagues waiting 2 hours beyond the end of their already long 12 hour shift (and remember, we usually do 4 in a row, and many are now on 6+), unable to go home due to A&E delays. This has a massive impact on morale and fatigue, and subsequently, the care that clinician is able to give.

The question may be asked: If the corridors are full of patients brought in by Ambulance, why are Ambulances overloading A&E? This is the question I wish to address in this article.

On top of the everyday demand of people who are genuinely ill and require A&E admission, it is possible to point to categories of Ambulance/A&E patients that don’t require admission and therefore, are contributing to the crisis on the corridors. No, I’m not talking about drink or drugs.

The first one is the policy of Residential and Nursing Homes (I’ll refer to them collectively as ‘care homes’) to outsource medical care to the state, despite residents paying in the region of 4 figures per month for care. Rather than invest in falls prevention and staff trained in health assessment (such as Advanced Nurse Practitioners, Paramedics or Emergency/Urgent Care Practitioners), many homes state that carers must call 999 (some are generous and allow for 111 – which usually results in an ambulance in any case) for any medical condition – emergency or not. I have personally been to numerous 999 calls (and 111 referrals) for simple coughs, colds, chronic pains, or low energy falls or slips out of bed with no injury. Often, by the time we arrive, the resident is soundly asleep, and receive a surprise awakening at an uncivilised hour to have Ambulance crews poke and prod for a short time, hopefully without shipping them off to A&E.

In this way, care homes absolve themselves of any financial responsibility towards the medical side of a patients care (except in nursing, where medications and some care is given, but no health assessment, diagnosis or management which requires further training).

As a Paramedic, it is my opinion that the NHS is indirectly subsidising privatised social care, with the proceeds going into care home profits, with no incentive to reduce the bill to the state, and no incentive to invest in prevention.

Why would a capitalist invest £100k/year+ in a team of Paramedics to provide care within the home in order to prevent drawing on the state’s resources, or invest in falls prevention, with no financial incentive to do so? I stand wholly for the re-nationalisation of care homes into the NHS system. However, while we blindly hang on to a mixed system, it is important for the NHS to look at charging care homes for state resource use, thereby incentivising investment in preventative care. This will, of course, introduce its own corruptions and contradictions – an incentive to not call 999 may put genuine patients at risk, for example. This illustrates that incentives are merely a plaster, and nationalisation is the only cure.

Research has been undertaken to understand the medical picture in care homes (Smith et al., 2015), and they correctly point out that care home patients have more complex needs than the average elderly population, requiring more admissions than average. However, they miss the underlying profit motive for over-engagement with emergency services, and the reasons for high conveyance rate by Ambulances to A&E.

The Mirror (2018) recently reported that ambulance conveyances had risen 62% from Care Homes since 2010. This will be partly a function of the aforementioned increased engagement with emergency services. However, to understand why there is a high conveyance rate from Care Homes by Paramedics, many of which are for ultimately non-emergency conditions, one must understand that Paramedics are formally trained only in emergency conditions – those that go to the ‘Resuscitation’ area of A&E. We pick up the non-emergency conditions as we go along, but that doesn’t make for confidence in discharging on scene. Combine that with a culture of fear imposed by management in the Ambulance Service, especially the fear that a wrong decision could see you sacked, and you end up with conservative medicine, and a large number of nursing and residential home residents in the Corridor at A&E with non-emergency conditions.

A similar process plays out as a result of a computer triage system employed by 999 and 111 with inherent vulnerabilities that cause a large number of ambulances to be sent to the same non-emergency conditions in the community (More in depth analyses of this issue can be read here and here). Without training and confidence to discharge without further care, and when alternative pathways are closed or oversubscribed, they end up in the Corridor at A&E.

When the Ambulance Service is being flooded, the first place one must look is how we manage the floodgates. A computer has not made an adequate gatekeeper, and clinicians must return to the role in order to correctly manage demand.

Many alternative pathways being closed is another major factor in large numbers of conveyances, leaving paramedics isolated and without choices for safety netting. Paramedics, despite the lack of training and the fear, try incredibly hard to refer to other services if possible. A ‘Safety Net’ allows ambulance clinicians to feel more comfortable discharging on scene. Long established services have been closed due to CCG budget cuts. Also, many new trial alternative pathways are introduced during office hours, when most remaining services (such as patient’s own GP) are already open. Unsurprisingly, these are undersubscribed, and are often closed soon after. The problem doesn’t disappear during office hours – it is incredibly difficult to get a same-day GP appointment – but it is especially prominent out-of-hours. It is during the night and on the weekend when ambulance clinicians are left isolated, and it is easy to see why many take the safe option of conveying to A&E.

The Corridor is a result of a perfect storm: Emergency Ambulance Clinicians being sent to non-emergency calls without the correct level of equipment, training or support, left without a suitable alternative pathway, in the face of media attacks and fear of repercussions from management, are practicing conservatively and filling up A&E Corridors.

To stop the Corridor Catastrophe, the Socialist Health Association should stand for:

  • Renationalisation of Care Homes & the rolling out of Health Assessment staff and falls prevention schemes. In the interim, a charge to the Care Home should be placed on Emergency Service contact. Both should result in lower 999 engagement, and more preventative medicine investment, lowering the number of conveyances to A&E.
  • The reintroduction of ambulance clinicians with medical support as gatekeepers to the 999/111 system, abolishing the use of computer triage. A well trained Ambulance Clinician on the phone with adequate support will be able to assess and manage calls more efficiently than a clinician in an Ambulance. Correctly directing non-emergency demand away from emergency-trained clinicians will lead to less conveyances in the name of conservative medicine, and free up ambulances to deal with true emergencies.
  • The establishing of a separate urgent care service which can draw on the great work done by Ambulance Clinicians in the urgent care field, and the advantages of mobile assessment, and can progress in delivering the right care with improved training, equipment and GP support, without impacting the safe delivery of emergency care. This service can bridge the gap between emergency and primary care, taking the pressure off A&E.
  • The adequate funding of alternative, community pathways to take the pressure off A&E.
  • The introduction of a ‘Just Culture’ within the Ambulance Service to enable Ambulance Clinicians to feel able to give the correct care for the patient, not the correct care to keep their job safe.

James Angove is a pseudonym. The author is a socialist and a paramedic in the UK, whose identity must be hidden due to the treatment of health care professionals and other whistleblowers who talk about issues within the health service.

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