Emily's Health Survey

This survey details Local Authorities’ approaches the challenges they currently face in delivering social care. This is a very worrying time – a huge top-down reorganisation of the health service, which will involve local authorities having to take on additional responsibilities, is taking place at a time of unprecedented cuts in local authority spending power. 

 

The UK has an ageing population, and people are living longer with chronic health problems. Mental health problems, drug and alcohol problems, children’s health problems are all exacerbated by rising unemployment, falling living standards and poor housing conditions. Welfare benefits are once again a big target for cuts, and this will affect many users of social care – this is a particular concern in inner London, where capping Housing Benefit and moving to a Universal Credit is likely to cause the greatest hardship.

Local Authorities have been doing the best they can to improve and adapt services over the past decade, and that has meant changing the way services are delivered, and working more closely with the voluntary sector, the health service and private care homes.

And, of course, Councils have been expected to make efficiency savings year on year. They have, in general, responded well to this challenge, but concerns exist that the improvements in working practices and service delivery over the past few years will be put in jeopardy by the combination of funding cuts and health service reorganisation.

For this survey, 154 Local Authorities across England which provide social care were contacted. In each case, the Director of Adult Services was asked how their Councils were coping with change, and about their plans for the future. There were 61 replies (40% response rate) from Councils across the country – Labour, Tory, NOC, even Liberal Democrat councils responded.

I was impressed by the time and effort Directors and their staff had taken to respond to my enquiries – although not all those responding answered every single question, there were at least 45 replies to each question, apart from the questions about confidence in meeting future responsibilities from 2012 onwards, which 20 Directors felt unable to answer.  Many Councils asked for their responses to be anonymised, and I have respected this.

Emily Thornberry MP
24 April 2011

 
RATIONING RESOURCES

Many of those responding to the survey mentioned the demographic changes which were increasing the pressure on services – one commented that they had a predicted increase of 70% in residents aged 75+, whilst another told me that they had a predicted increase of 44% in residents aged over 90.

However, increased demand cannot be met by expanding services when budgets are being cut. There are three main ways in which a Council can maximise the services provided through the social care budget:

• Raising Charges
• Tightening Eligibility
• Reconfiguring provision

Most of the local authorities who responded had considered all three options

88% were increasing charges. Of the authorities who answered this question, 88% said that they were intending to increase charges. A quarter of these were pegging increases to inflation, but the others were introducing new and additional charges, raising or abolishing the maximum contribution from service users, or making other increases in charges. Several Councils said that they had no alternative but to increase charges.

The move to personalised budgets was generally seen as positive, but 51% said that this and other factors caused assessment times to increase recently. The majority (64%) considered that this was a temporary problem, and assessment times should reduce once personalisation was fully implemented.

16% were increasing eligibility criteria in 2010/11 or 2011/12. In addition 7% were considering changing in the longer term. However, it was interesting to see that 77% of those responding to this question were intending keeping their eligibility criteria unchanged, and this seemed mainly to be because they had no room to manoeuvre – they are already only meeting substantial and critical need.

It appears that Councils are reviewing the varying approaches to eligibility, and some of those retaining their current criteria indicated that they would be applying these criteria more strictly in future. Most Councils considered that it was counter-productive to meet critical need only, as this made it more likely that substantial needs would become critical in future.

Councils are being forced to look at the longer term, and there was emphasis on the importance of reablement and short-term interventions aimed at restoring independence.

63% were closing care homes and/or day centres. Many of those responding to this question simply confirmed that they would be closing homes in the next couple of years. However, some indicated that these closures were part of a planned reconfiguration of services, with reprovision being offered in a more cost-effective way, or with more emphasis on services in residents’ homes.

One Council commented that its care homes were going to be rebuilt, modernised, and run by independent providers, whilst another said that they were having to defer plans to develop more cost effective community based alternatives to residential care because of short-term budgetary problems.

54% were cutting the voluntary sector – with a further 24% considering this in future. It is clear that the voluntary sector is being expected to take on additional roles in some areas, but capacity may be lost if other funding is cut. Some Councils raised concerns about charitable and voluntary groups being destabilised and losing viability when contracts cannot be renewed. There was some discussion of John Lewis–style social enterprises, and it will be interesting to see whether any progress is made on this.


 
LOOKING TO THE FUTURE

It is clear that all the Councils responding to the survey had been looking very closely at their budgets, and the main concerns for the future are:

• Lack of certainty over future demand
• Reduced capacity to invest in prevention and new services
• Large front-loaded cuts make it difficult to achieve efficiency savings on top
• Impact on safeguarding of the CQC changes
• Additional responsibilities following SHA/PCT abolition
• Difficulties in integrating health and social care following NHS changes
• Mental health services, including dementia services and children’s health
• Conflicts of interest over commissioning
• Reducing confidence in meeting need in future years

49% expected numbers of service users to increase, but 27% expected a reduction. It was interesting to see the differing views on this point – those keenest to emphasise the importance of reablement and tightening eligibility were confident that they could reduce dependence on care services, whilst others were convinced that demographic changes would make an increase inevitable.

The other unknown is self-funders – at the moment, few Councils seem to know how many of their residents are wholly funding their own social care. There is, presumably, a risk that some self-funders may not be able to continue to paying for their own care indefinitely.

 52% felt that cuts adversely affected the development of new preventive services. Real independence for older and disabled people should be a key aspiration, and although some will always need residential care or help in the home these services should promote, rather than undermine, independence. So it is worrying to see that Councils feel that innovation is being stifled, and that new services which could prevent the need for long-term care cannot now be developed.

It was encouraging to see that 89% of Councils had reached agreement with their PCT over how current funds for reablement should be spent, although several said that reaching agreement had been difficult, and there was some resentment expressed on the way this money had been channelled through the health service.

Some concerns were also raised about the possible diversion of funds intended for disablement into other areas – particularly where PCTs are running large deficits. 38% said that their local NHS community services had been cut.

45% had serious concerns about efficiency savings. There were some sarcastic responses to my question over whether 2% efficiency savings were achievable – one council pointed out that efficiency savings could not be achievable on top of 27% cuts, and another just said 2% - if only….

However, the majority of Councils accept that they have no choice but to make these additional cuts – several made specific mention of the large hit to their Supporting People budget.

32% expressed concerns over safeguarding and the CQC regulatory role. Of those answering this question, most Councils were very clear about the need to prioritise safeguarding. However, some Councils have already raised concerns about CQC’s current performance, and there will be additional responsibilities falling on Councils as its role is diluted. One Council specifically mentioned concerns over risk management in the external care market.

38% mentioned cuts in NHS community services. Councils are already struggling with cuts in community health services and cuts in PCT staff which are affecting their ability to redesign services. They will be taking on additional responsibilities once the PCTs and SHAs are abolished – of those answering this question, most appeared to feel quite confident about this, although several mentioned a lack of clarity over new arrangements, concern that commissioning would become more fragmented, and concern over the role of acute Foundation Trusts in community services. There was also a mention of potential conflict of interest when Councils are involved in commissioning and providing services.

Specific concerns were raised over mental health and dementia services, and one Council pointed out that their local mental health trust was having to make savings of £15 million in 2011/12, at a time when other cuts would also be biting.

24% raised concerns over the integration of health and social care. In general, Councils answering this question felt that integration would improve over the next three years – although several mentioned that the improvement was driven by necessity in a time of such huge budget problems.

There were, however, a number of concerns raised about how Acute Trusts might function in future, and one Council pointed out that existing integrated children’s services would not have to be de-integrated to fit in with the new structures.

Councils were in general anxious to be seen to be willing to work with GP consortia and Foundation Trusts – although they pointed out that both partners need to be willing to make this a success.

72% are confident of meeting their social care responsibilities in 2011/12. 
However, this drops to 59% in 2012/13, and only 44% in 2013/14. It is difficult to be sure how accurate these figures are, as several Councils declined to answer or gave non-committal replies. Of those who gave clear data for each year there was a consistent fall in levels of confidence over the three year period. It is worrying to see that Councils feel so uncertain about the future – they have moved fast to put plans in place for now, but they will need some reassurance about meeting contingencies to restore confidence for the future.

 
CONCLUSION

It is encouraging to see that Local Authorities are taking so much care to configure their services to provide the best possible care for vulnerable residents, both now and for the future. However, the cuts are just too deep for them to develop new services and retain their partnership with the voluntary sector, and the Health Service changes are too sudden and too uncertain to foster confidence in the long term.

Local Authorities in the most deprived areas, with the worst mortality figures and the highest incidence of long-term ill health are suffering the deepest cuts in spending power. Front-loading the cuts means that huge changes have to be brought in very quickly, giving little time for consultation with staff and service users over the best way to minimise the impact on front-line services.

The most deprived areas are therefore least well placed to deal with NHS changes, and to take on additional responsibilities. There is a clear risk that services will not be effectively commissioned, and that decisions on cutting services, tightening eligibility and increasing charges will lead to some vulnerable people being left without the services they need.


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