This morning I read ‘How we can start a social care revolution in seven easy steps’ by Katie Johnson, KPMG, in the Guardian Social Care Network. I agree with her ideas, but not that it is easy. If it was easy, it would have been done by now. I am one of the many, many people who want to see this change, and be part of this change. Here I want to share what I am see my colleagues doing to actually move towards the steps she describes. I want to call out the people who are making it happen, and what else we need – some of the detail to deliver the big ideas.
- Champion independent living
Though care is needed when using the term “Independent Living” – a term that disabled people have fought hard to define, Katie is right, we absolutely need a ‘dramatic shift away from residential care towards the kind of support elderly people actually want and need’. This is of course not just important to older people and has to be rooted in co-production. People should be able to design their support around what matters to them, reflecting their outcomes, their priorities, within their personal budget or own funding. Individual Service Funds are key to this for people who choose not to take their personal budget as a direct payment. The Cinderella of personal budgets, ISFs have to have their place at the ball now. They are a way for people to have their personal budget without the administrative burden. To have power and control, through a provider of their choice.
Few councils have a flexible framework in place for this, co-developed with providers. Martin Walker is leading this work through Think Local Act Personal. Last week we visited Sheffield council together, to talk to the head of commissioning about what an ISF framework could look like there, building on a report by Disability Sheffield. We are also working with commissioners in London who are investing in Wellbeing Teams, and know that an ISF framework is a critical condition for these to flourish. I am confident that in the next six months, through Martin and TLAP’s work, there will be more examples of ISF frameworks to share.
Five of ‘the six innovations’ have a specific contribution in supporting the shift from institutional forms of provision, each starting with co-production.
Community Circles harness the informal supports that could enable people to live well at home.
Community Catalysts have demonstrated their contribution in Somerset. Over the last two years they have supported the development of a range of community enterprises that now provide 2,200 hours of care and support a week.
Shared Lives and Homeshare are different ways to support people to live at home or with another family.
Wellbeing Teams offer people support at home, through small, neighbourhood teams inspired by Buurtzorg where people choose when, where and how they are supported as well as choosing their team.
- Support families and carers
Katie calls for greater ‘provision of advice and assistance for families and other carers, and more effective liaison with voluntary and community organisations that are skilled in providing support to older people. This means creating partnerships that can empower volunteers and deliver more professionalised community care.’
I think Local Area Co-ordination (LAC) goes further than this, and the evidence suggests this too. Another of the 6 innovations, this creates a completely different front end to services, ensuring people are linked in to what is in their community, and has an asset-based, strengths based ethos. The partnerships that Katie calls for have to happen around individuals, and LAC makes this work.
Community Circles are another way to support families and carers, bringing people together to support each other and find local, personal solutions. A small study by PSSRU found that Community Circles can lead to reductions in carer stress and increased community connections. A Community Circle has supported the carer of someone who is living with a dementia, to ensure that they stay at home for as long as possible.
I can see how carers, family and circles will be able to benefit from a new initative being developed by In Control. They are creating a national network aimed at helping local people and organisations to support each other better to help people take charge of their lives in their communities.
- Shift the funding focus to community-based care
No one could argue with Katie’s next point, of creating a funding system that supports and incentivises “moving away from expensive residential provision …to create a fundamentally new system that offers holistic care in the home and keeps older people, wherever possible, out of hospital and residential care.’
The most powerful and inspirational example that I have seen in this area is the work of Sara McKee and Evermore. I am excited that we will be able to see this happening in the North West soon. I wonder what the combination of Evermore community housing, and self-managed teams like Wellbeing Teams could achieve.
- Incentivise local authorities
Katis says that ‘Local authorities should be incentivised to purchase individually tailored packages of care.’ Surely that is what The Care Act demands?
– If you are eligible for long term care and support, you have a legal right to a personal budget even if you are in residential care. Your support should be arranged through a personal budget as a matter of course.
(Relevant care act requirements: 11.2, 11.7, 11.16, 10.7)
– You should be told before you develop a plan how much money it should take to meet your needs, and how much money the local authority will put into your personal budget.
(Relevant care act requirements: 11.3, 11.7, 11.24, 11.10, 10.3)
– It is you and your family who decide how the personal budget is used, regardless of where it is held.
(Relevant care act requirements: 11.7, 11.29, 11.3)
Do Local authorities need to be incentivised to deliver this legislation? The Care Act requires a shift from prescribing services – for example, 30 minutes of home care five days a week, to outcomes. This shift is still to happen in most places.
I have been talking to commissioners about this.
One said: ‘no one is pushing us to deliver this anymore, there was a flurry when it first came out.’
Another said, ‘We are a couple of years behind on delivering the Care Act.’
I wonder whether this would be different if the legislation had been about health and safety, or equalities?
Katie argues that “Many councils want to do this, but their options are limited by what the market can provide or by a lack of imagination.” Introducing Individual Service Funds and supporting providers to move from block contracts are within the power of commissioners and would not require additional funding. Doing this in home care would create the conditions to move from task and time to co-producing services.
- Prevention rather than cure
“..prioritise prevention, rather than waiting for problems to arise and then attempting an inadequate cure.’ is Katie’s message here. Person- and community-centred approaches for health and wellbeing have significant potential to improve outcomes for individuals, support the development of strong and resilient communities and, over time, help reduce demand on formal health and social care services. Colleagues at Nesta and C4CC are working on developing and sharing these ideas and approaches.
When we think about prevention, we don’t always think about loneliness. Loneliness is the equivalent of smoking 15 cigarettes a day, and connections and community have to be part of the prevention agenda.
Again, I think some of the potential solutions are found in the 6 innovations.
Community Circles for example, bring people together, and help connect people who have no one in their lives. They have an impact on loneliness and health.
The Wellbeing Team operated by Love2Care in Devon is already demonstrating keeping people out of residential care. They have supported someone to leave a care home, and be supported at home. They are also supporting someone who wants to die at home.
Local Area Co-ordination is not usually cited as a prevention strategy, but it is. It enables people to pursue their vision for a good life and to stay safe, strong, connected, healthy, and in control.
- A better alternative to ‘integration’
Katie calls for “NHS providers and local government need to co-operate better to find the right kind of care for elderly people.’.
I am hopeful that the Integrated Personal Commissioning programme (IPC) can help us learn more about this in practice and with a focus on system and practice changes which support outcomes at the individual level.
We are exploring what integration can look like at the individual level for elderly people in Brighton and London. Two GP’s surgeries, one in London and one in Brighton will be introducing Wellbeing Teams, into the heart of how they support people at home.
Each Wellbeing Team includes a Community Circle Connector, and therefore basing Wellbeing Teams with GPs offer a genuine integration of social care and health, with the voluntary sector. Lets see what they learn and what they can achieve.
- Pool resources
Katie is again correct that “Just as the NHS and local authorities should look to share resources, there is a key role to be played by combined authorities and other city and county partnerships. They should be encouraged to pool their money to fund the transformation of social care.”
I live in Greater Manchester and am encouraged at the platform and infrastructure that the Greater Manchester Health and Social Care Partnership can offer. Combined resources are being used to attack collective challenges and serious efforts are being made to draw the Voluntary and Community Sector into this partnership
How can this happen at an individual level too? How can we support people to pool individual budgets when this makes sense?
The seven steps are sensible, but not easy, however as I hope I have shown, there are great people and organisations working to make this happen. I have shared the few, I know there are many more.