by Michael Griffiths
We recently held a seminar by Professor John Bolton*, JRFB Ltd and visiting Professor at the Institute of Public Care at Oxford Brookes, as part of the LSE Health and Social Care Formal Seminar Series. Professor Bolton’s presentation on Policy, Practice and Austerity focused on two themes: why social care’s current policy isn’t affordable; and, the examination of an emerging care model in the UK that has its roots in practice rather than academia or policy.
According to Professor Bolton, the big challenge faced is this: can we manage demand in social care at a time of increasing demographic pressures and decreasing resources?
In England the solution to reducing austerity has been to create “The Better Care Fund”. The aim is to encourage an integrated approach from health and care that designs services in a way that enables the public to be less reliant on acute hospital services and using the money that is freed up to fund the gaps in social care. However, the health service has failed on its own to solve this particular problem historically and there is little evidence to suggest that integration with social care is the answer. Integration may have an intrinsic logic but it is unlikely to deliver the savings required?
Health care excels at interventions when the patient is ill, but fails to recognise long-term conditions — while in social care older people admitted to residential care suffer dementia or incontinence, or are recovering from, falls, strokes, etc. These are areas where health performance is patchy. This does not mean integration is intrinsically wrong, but the case for integration does need much more examination with a stronger focus on changed outcomes from the whole system.
To complicate matters, the funding formula for health now has a bias on population rather than deprivation: this means that the wealthier south will gain a greater share of available money. Furthermore, with councils suffering a 25% reduction in grants over the next 3 years, in addition to a 10% reduction in grants in the 3 years previous, councils currently spending 66% of their budget on care for adults and children will see a reduced care budget. These combined changes will disproportionately hit poorer parts of England.
There is preoccupation in social care of assessing care needs that is, unfortunately, replicated in the Care Act. Typically, someone reaches crisis point and then asks for help from the care system. At this point, a quick assessment is made of the person’s health or social care requirements. The pressure to quickly assess the person’s needs disregards the fact that if someone falls ill in the 21st century, it is likely that they will get better. The patient would benefit from a longer period of assessment – currently, too many people’s assessment in a crisis leads to an extensive care package and runs the risk that the patient becomes care-dependent.
With reduction in council budgets, some councils are beginning to consider various preventative interventions in the process of care. At the model’s heart is a method whereby the individual asking for assistance is offered a range of interventions that maximises their chances of independent living. Furthermore, shorter interventions can often result in long term benefits: for example, a shorter intervention in helping a homeless person back on their feet can allow them to function without any future support.
The advantage to approaches such as those above is that the client is assessed through a set off evidence-based interventions before the assessment of long-term care needs is decided. Professor Bolton argued that across social care there is evidence for restorative interventions – from the recovery model in mental health services to reablement interventions for older people. In addition to this evidence Professor Bolton also cited a Canadian study that showed that those older people who received small amounts of care had much greater needs for longer-term care and higher mortality rates than those who built personal resilience to manage their conditions.
There is also some good news on the horizon regarding dementia: evidence is emerging that the most likely causes of dementia have the same cardiac similarities that lead to stroke or other heart conditions – the implication being that a healthier, active lifestyle could reduce dementia in old age. Furthermore, there is evidence that these lifestyle changes may arrest the disease if dementia is detected in its early stages, and there are some promising new drugs in development that look as if they will arrest the disease also.
In summary, social care requires plotting interventions and not making hasty assessments; managing demand through a whole range of interventions; government and other stakeholder recognition of how these interventions work; and giving the social worker freedom to think creatively rather that offer a set of prescribed off-the-shelf traditional longer-term products.
About John Bolton
John Bolton was previously the director of strategic finance for social care at the Department of Health and recently set up his own consultancy (JRFB Ltd); he is also a visiting Professor at the Institute of Public Care at Oxford Brookes. Professor Bolton also chaired the Department of Health’s transforming adult social care programme board and led on the implementation of the “Putting People First” agenda to personalise care; he was also the author of the influential paper “Use of Resources in Adult Social Care” and has worked extensively on financing and efficient use of resources in adult social care.
About the author
Michael Griffiths is Support and Communications Assistant within the Personal Social Services Research Unit at LSE.