The CCN’s Future of Adult Social Care report is another addition to the discussion on how social care is delivered and how it fits into the wider healthcare system. It highlights the critical need for reform and proposes a system of ‘optimised local delivery’ with local government at its heart.
Briefing in full
Adult social care occupies something of an odd position in England. Despite being essential for its recipients, necessary for the NHS to keep functioning, and a sector that represents a significant part of the national economy, it is often not just the poor relation when compared to the NHS, it’s also the overlooked relation. Although social care has started to appear in the foreground more often as a result of the Covid-19 pandemic, it has been as an afterthought as often as not. The original Thursday night clap started, for example, as a clap for the NHS, and while social care workers were included in the second week, that inclusion was alongside a range of other people who continued to work during lockdown from shop workers to vets.
The calls for parity between health and social care have long existed. Yet, as highlighted in the Health and Social Care Committee’s report on the English social care system, despite the production of 17 White Papers, Green Papers, consultations, reviews and commissions in the past 20 years the fundamental issues facing social care have never really been addressed.
The development of social care has, instead, been a succession of ad hoc compromises and improvisation. While the NHS has, for good or bad, been the subject of longer-term strategic thought, social care has developed largely through a mix of local authority provision and commissioning with a market developing in the private and voluntary sector as a response rather than as part of a strategic plan.
However, if the Secretary of State’s lapel badge is an indicator of his thinking, then the change from an ‘NHS’ to a ‘Care’ badge might — despite the criticism — suggest that social care is moving up the agenda and the CCN report helps add to the moment by illustrating how a properly funded system can be locally led by councils that understand their population’s wants and needs with the government playing a role with an outcomes-based performance framework. The report looks at what it calls the foundations, values and themes that would be present in an optimised local delivery model.
Values and beliefs
The report starts by detailing the foundations behind its model, before covering the values and beliefs in a very short section. The values and beliefs are, however, likely to be those shared by almost every one working in social care and actually sit at the core of the proposed, so are worth considering first.
In essence, the report notes that for most social care users their preferred outcome is the one that promotes the most independence. However, although practitioners commonly share this view, they tend to underestimate the level of independence the service-user wants and can manage.
The report also highlights that social care should be a final option. Those in need of care should receive it only when it is not possible for their needs to be met by the individual; whether that by themselves, with their family or within their community network.
The report identifies four foundations on which social care should be built. For most people these are likely to be uncontentious.
First, is that adult social care should have a positive profile among decision makers and the public. While there was a moment during the Covid-19 pandemic when social care looked like achieving parity with the NHS the report notes that “there remains a general lack of understanding of what adult social care is and how it is delivered.”
The report also notes that this can have negative impacts, with decisions being made that result in unintended consequences, while a generally negative public perception of social care can mean some people avoid engaging with social care.
The report highlights the need for social care to have a national brand, not to compete with the NHS, but to raise awareness of the whole sector.
Second, social care needs to be delivered locally, although there should remain national oversight. Although comparisons are made with the NHS’s profile, the report is clear that the nature of social care, which is focused on interventions that enhance and prolong individual wellbeing, is not suited to a national delivery model in the way that healthcare is.
It notes that even though there are some types of social care that might lend themselves to a national model, especially the formal healthcare that is provided outside healthcare settings, this is a small part of social care. Instead, most social care is delivered by families, informal care within the community and local voluntary sector groups. These are best engaged and utilised through local, rather than national, structures.
The report does, however, recognise that national government has a role in creating the legislative framework and funding, as well as having a general oversight. National government would take on a more strategic role, providing guidance and assurance and using agreed outcome measures to allow it to intervene when necessary.
Third, social care needs a sustainable funding model. The funding difficulties the social care sector experiences are well-rehearsed, and this report adds another voice highlighting the lack of sustainability of the current model.
The report particularly highlights that the nature of funding, essentially reliant on an annual grant from central government, and the wider context of local government finance, creates a budget environment that discourages long-term investment and strategic development. The impact of this extends beyond local government, since it means that providers are unable to plan strategically or enter into long-term partnerships.
However, the report remains agnostic on how the finance issue is addressed. While it highlights what a proper funding model would do, creating a sustainable and accountable model, it is silent on what the funding model might look like.
Fourth, a whole system approach that places social care as an equal partner in the relevant structures. While this might be seen as an extension of parity with healthcare and other partners, this foundation goes further.
The report effectively highlights the need for a seat at a table, so social care is part any new structures the government creates, such as Integrated Care Systems, and is part of the leadership of these structures to ensure that social care’s strategic needs form part of the decision-making process.
This whole system approach, however, applies equally within existing structures. Social care should form part of a whole council approach, so that decisions made in other departments are made having given the social care implications consideration.
The report then considers how the optimised local delivery model would look. It uses an onion model with the values and beliefs at the heart, surrounded by the layers of service delivery, the wider organisational form and finally the wider structural form. Themes within each layer highlight how they will work.
The concept is simple and powerful, but as most people will recognise, fiendishly difficult in practice, especially in the outer layers where social care will be just one of many priorities calling for attention.
Service Delivery Enablers
The first four themes look at the operational level, considering what and how services can be delivered to individuals.
The first theme focuses the right service provision, using a mix of voluntary, community and formal services to maximise independence and meet specific needs. A key principle behind these is that they should follow an asset-based strategy, using services that have an understanding of the local population and is, therefore, best-placed to understand how their needs can be met by offering a mix of short- and long-term interventions.
These should be backed up by pathways, the second theme, which are designed around the individual to ensure they are at the heart of social care. These pathways should, therefore, easily cross boundaries whether internal, between council departments, for example, or organisational between the council and other bodies. Importantly, the pathways should be designed not just with the individual in mind, but so the individual can find their way in to and through the care pathway easily.
The third theme considers the buy-in from partnership and providers. Within the model the local authority will be a key coordinator, forging relationships between providers who are united by an agreed common goal. This should be backed by organisational connections, sharing budgets and risk as well as data. And should go beyond the traditional social care actors to include those that may not be directly involved in the provision of social care, but still have a key role to play, for example housing providers.
Finally, the fourth theme in the service delivery domain considers professional practice. This covers both the individual practitioners, considering their development, ways of working and the supervision and support put in around them. But it also considers how practitioners work collectively and collaboratively to achieve outcomes, crossing organisational boundaries to contribute towards shared decisions and outcomes.
The next set of themes consider the organisational wider social care environment. The key driver behind these is that for individuals and teams to accomplish all they need to achieve the broader social care outcomes, they can do this best, and perhaps only do it, within an organisational context that equips, enables and supports them.
Theme five looks at, perhaps, one of the most important: the organisational leadership and culture. As management guru Peter Drucker (sadly, probably never) commented: “culture eats strategy for breakfast” and it is incumbent on the leadership to be clear about its belief system — essentially its commitment to social care — and empower its staff to deliver on this commitment while mobilising the rest of the organisation to act in support of this or, at least, not in a way that undermines the social care goals.
Theme six embraces digital. Digital often feels included in reports just because it’s on a checklist somewhere — digital sounds like the future and serves as a good hook for bids and grants. Social care, however, has frequently been overlooked when it comes to IT improvements. Many places, for example, still have folders left in the homes of service users to record information and share between practitioners. While an eminently practical way to both share data and ensure the relevant information is always to hand, it usually leads to duplication when the information also has to be entered on organisation systems, is far from the levels of security usually associated with personal information and, most importantly, means social care is unable to effectively use the data collected by many partners to inform service delivery and development.
Workforce issues are highlighted in the seventh theme. Noting the high turnover of staff in the private sector, the report highlights the need to address some of the imbalances that mean that social care is not widely perceived to be a desirable career option. Part of this is the lack of parity between social care and other caring professions. The report identifies, for example, that councils often compete with the NHS for some roles and, in these situations, practitioners will usually opt for the better terms and conditions offered by the NHS. More generally, social care tends to have poorer remuneration, poorer career opportunities and fewer perks than alternatives in the job market.
Finally, for the organisational enablers domain, is the eighth theme of strategic commissioning. In the main this is the responsibility of the local authority, but the strategic aspect is not limited purely to the council. While they will be best placed to understand both the needs and strengths of their communities they can also work with other actors in the social care environment, such as NHS bodies and providers. By working together each can match their commissioning and provision to a place, rather than an organisational, setting, benefiting both the recipients of care but also the providers.
Organisational and structural form
Finally, and with just a single theme, the report considers the place of social care in the wider system. This means that everyone, even those that aren’t directly involved in social care, recognises they have a role. Whether these are the council’s corporate functions, helping to support effective social care or the council’s delivery functions, ensuring that the services they provide complement the aims of social care.
Creating an optimised social care model
The report’s conclusion and recommendations are simple and straightforward. Working from the premise that social care should, as far as possible, promote independence the whole system should have a shared and explicit set of values that underpin the sector.
On the practical side, the optimised delivery model should put local government at its heart, and while delivery should be consistent across the country, local authorities will be able to organise delivery to meet the specific needs of its area.
This will be underpinned by investment in local and national social care leadership, ensuring it is both visible and capable, and by achieving parity of esteem with healthcare.
Finally, at a national level government will have two parts to play. First is developing a new funding settlement, ensuring that social care is adequately and securely funded. Second is a performance framework, developed with local authorities, focused on outcomes that help maintain standards and allowing national government to intervene when needed.
The report suggests that, if implemented, the proposed model would increase independence and reduce costs. For example, though improvements in practice, better pathways and strategic commissioning, 18 per cent of older adults could be supported in a more independent setting than care, saving around £178 million per year and a £95 million per year saving by reducing home care hours by supporting strong community-based services.
In total, the report suggests the model could save over £1.5 billion in social care costs while improving the care provided to hundreds of thousands of individuals.
It is easy to be cynical about reports of this nature, especially one on a topic that generates lots of proposals but relatively little action. However, the CCN’s report offers a lot more than most.
A key difference between this report and many that have come before is that it is authored by councils and Newton, both of whom are experienced in the care sector. And this comes out from the report, which weighs in at over 100+ pages but is peppered with practical case studies and examples. While the ‘optimised social model’ might be an idealised outcome, it is anchored in practical experience and reality.
Perhaps the biggest omission is any discussion of finance. Whether this is a strength or a weakness is a matter for debate. Previous reports have highlighted the huge costs of social care and the size of the shortfall, which is only expected to increase. While the CCN report recommends a new funding settlement, it offers no suggestion on the size of this settlement, nor how it will be funded. And while it highlights the savings, it remains quiet on some of the implied costs, such as remuneration. When previous studies have suggested that many social care workers find retail a much more desirable employment option, it’s hard to see how parity will be achieved without more funding.
Addressing this omission at the report’s launch, however, it was commented that because it didn’t lead on funding, the CCN had found it much easier to open doors in government to talk about social care. There is a strong argument that when the government’s default answer to spending questions is ‘no’, opening the discussion with an invitation to consider what might be possible is a tactically savvy approach.
More generally, the report paints a picture of how a thoughtfully reformed, locally-led social care system might look. And it’s an attractive picture. Few would argue with a model that focuses on individual needs, promoting independence and a community-first approach to support that will not just benefit individuals receiving the care, but help to strengthen the communities they are in.
Indeed, like the question about finance, it feels churlish to suggest weaknesses in the face of such an optimistic model. Could a locally-led model, with hundreds of commissioners, providers and communities, ever achieve parity with a mighty national brand like the NHS? Or could social care ever manage to get its voice heard on a whole-system level when it’s competing with all the other voices?
And, most importantly, how will it fit in with the government’s white paper? Published the day after the CCN report, the government white paper, Integration and Innovation: working together to improve health and social care for all, was welcomed by Cllr David Fothergill, the CCN’s lead on care services, who welcomed elements of the white paper, while sounding a note of caution that local government must be involved in developing the proposals that follow.
Included in the white paper were elements from the CCN’s report, including involvement in Integrated Care Systems and the development of social care assurance frameworks. It also commends the casting aside of traditional boundaries between health and social care during the pandemic.
The white paper proposes social care reforms to be developed at a later stage, but it enumerates some principles that, again, are in line with the CCN report, increasing integration of care and the primacy of place when doing this, so providers are serving the priorities of a meaningful geography.
However, as is the way with white papers, much of the focus is on the reform of the tools already in the government’s hands; for this one, it’s the NHS and the formalisation of Integrated Care Systems.
The Future of Adult Social Care presents a possibility, and a compelling one at that, for how those reforms may work. While not easy to realise, one of the report’s strongest assets is that it comes from the local authorities delivering social care. It is authored with the implicit premise that there is no easy solution and, some of the suggestions will take hard work and commitment. But, as such, it is not an intellectual exercise of an idealised delivery model, but instead a potential structure based on today’s reality. Perhaps the biggest challenge in creating an optimised delivery model will be persuading the government of the model’s merits and then acting on them.
For more information about this, or any other LGiU member briefing, please contact Janet Sillett, Head of Briefings, on firstname.lastname@example.org