Cllr Colin Noble is the Health and Social Care Spokesman for the County Councils Network, and the Leader of Suffolk County Council.
With temperatures noticeably dropping outside, we are on the cusp of the period that inspires the most anxiety from health and social care professionals.
As the Leader of a county council, my staff are bracing themselves for the unknown, but putting robust plans in place to ensure any ‘winter crisis’ is kept at bay – as I’m sure councils are doing across the country. However, planning for the forthcoming period and beyond has been made more difficult; with storm clouds gathering between Whitehall and councils because of fraught debates over delayed transfers from hospital.
The context behind this leads back to the government’s much-welcomed additional £2bn for social care last March. The government showed it was listening to our concerns over the fragility of the social care system.
Councils have invested this money in making the system work better for patients. Some of the examples of where this money has been spent includes investing in additional care packages, raising care home fees to help stabilise the market, step up/step down beds, recruiting extra dementia nurses, and expanding rapid response services. In short, it is designed to make the system work better: both to reduce delayed discharges, and to better support the care needs of residents.
Initially, completely unrealistic targets were imposed on counties, on average 43 per cent, rising to a high of 70 per cent. Subsequently, 32 local authorities received letters asserting that if they do not improve discharge targets by November part of this £2bn funding would be withheld, or equally concerning, diktats from Whitehall would be issued on how the funding should be spent locally.
The imposition of targets and the positioning of NHS England has led to delays in agreeing details of the Better Care Fund (BCF), which is a further pot of cash for local areas to better integrate health services. The concerns of Ministers are understandable. Rates of delayed transfers of care have continued to rise; a real issue for the health service but also a moral issue: no-one deserves to be stuck in hospital longer than they should do.
However, rising delayed discharges should be of little surprise when you consider the myriad of factors involved: the funding available for social care, rising demographics and demand, and, in particular whole system performance: two-thirds of delayed days are attributable to the NHS, not councils.
Just under half of the 32 councils written to are county authorities, who have faced a financial quandary unmatched in local government. Counties have 30 per cent less funding per head of over 65s than they did in 2010 and face a £1bn black-hole in social care funding by 2020/21. Recent research by LaingBuisson also showed that self-funders are propping up the care market to the tune of £670m.
However, we must consider ways to use money already in the system more effectively. This goes to the heart of why the current loggerheads between councils, NHS England, and the Department of Health is counterproductive and potentially highly damaging as we approach the winter period. Counties have worked tirelessly with local NHS partners to develop BCF plans that provide real impetus to reduce demand. The prospect of this funding being withheld or taking it out of local government control and placing it in a national body’s hands, could I fear, only worsen the situation. In this instance, centrally-led initiatives are no substitute for local knowledge and expertise. Worse still is the prospect of hospitals commissioning social care packages, something that Simon Stevens recently suggested. Local care markets in the counties are already in a fragile state; any such moves would only lead to increased competition for limited care placements, and ultimately drive up the cost to the public purse.
Rather than short-term, centralist thinking, I believe we should channel our efforts into prevention and early intervention. People are living longer, meaning that they are increasingly likely to have more complex conditions that require greater levels of care than in the past. It is logical to focus on managing these more complex needs in a community setting and stopping people from entering hospital in the first place.
Government may need to give health and social care another funding injection in the Budget for the winter, but Ministers must also give local areas the opportunity to implement their BCF plans in full and deliver a preventative, community-based, approach.
For those 32 councils living under the spectre of having funding withheld, they must be given time to see the fruits of their labour. If government persists with siding with the NHS, the aforementioned examples of how councils are investing resources could all go to waste and local partnerships with health will be permanently set back. Fixing health and social care is not going to happen overnight. They are two very different beasts, multi-layered and steeped in years of bureaucracy and regulations.
Look at the not-too distant past. 12 green and white papers have failed to deliver meaningful reform and haven’t touched the surface of what are two fundamentally different systems and management styles; that of the NHS and of local government. One contains a culture of top-down diktat and a problematic record on securing long-term efficiencies; the other a track record of managing reduced budgets and a culture of democratic accountability with a mandate to deliver change driven by communities.
That’s why whole-system reform is needed. We have failed to evolve the systems to match the demand, needs, expectations, and ultimately the money available to pay for them. It is this fundamental question that we need to focus on in the forthcoming social care green paper, rather than a running battle over who is to blame for delayed transfers.
Ultimately, it is revolution, rather than evolution, that is needed to unpick the systemic issues that drive the actions of both health and social care. But to make that happen, we need collaboration, not consternation.