Darzi Review of Healthcare for London – Implications for Social Care

Presented by Hannah MillerDirector of Adult Social Services

Friday 18 January 2007

INTRODUCTION 1.

• Thank you for inviting me to give evidence to the Joint Overview and Scrutiny Committee on the Implications for Social Care of the Darzi Review for Health Care for London and giving me an indication of some of the areas you are particularly interested in.

• I will touch on:– Prevention and care at home

– Polyclinics

– Funding including transitional arrangements

– Managing Long Term Conditions

– Recent developments in Social Care

• My views are my own but I am grateful for the input I have received both from Council and PCT colleagues in Croydon and Directors from other London boroughs.

INTRODUCTION (Continued) 2.

• Given the fundamental importance of social care being able to respond to the challenges of Darzi adequately in order to assure successful outcomes for the proposals, I am disappointed at the lack of serious engagement with Social Care professionals as evidenced by how few were actively engaged with the clinical working groups.

• 5 of the Pathway Groups had only 1 senior social care professional, 2 (maternity and newborn care and mental health) had none.

• In my view one cannot see healthcare as a stand-alone concept without coupling it with social care. If we were planning transformational workstreams locally in Croydon we would be planning and implementing change jointly across the health and social care economy. Why is it different when we are considering transformational change of health and social care across London?

INTRODUCTION (Continued) 3.

• Given the importance of the social care response to the successful implementation of the Darzi proposals, a key weakness of the report is the lack of any predictive modelling or triangulation of the proposals in order to gauge potential additonal burdens on social care.

• It is essential that joint research is commissioned to scope the effect and demand for social care and associated costings. We in social care need more certainty about impact before we can confidentially sign up to the changes.

• A PCT colleague reminded me that research had evidenced that the change from in-patient care to increased day surgery had not added additional burden to either the district nursing service or social care. The current problem with the Healthcare Review is the lack of certainty about effect.

INTRODUCTION (Continued) 4.

• Research may confirm the views of the more pessimistic among my social care colleagues or on the other hand could potentially affirm that the new models of healthcare could help reduce dependency on residential and nursing care with consequential financial savings to social care to offset increased expenditure on care in the home.

5.

Home care - potential impact on social care?

• The Darzi review envisages more prevention, diagnostics, treatment and rehabilitation in peoples own homes. There is still more to do in making the case with the public as it requires that people change their expectations about how they get quality care.

• Many people ring for an ambulance if they have a crisis. It is easier for the public to understand care in an institution.

• Even where the patient may be convinced about healthcare at home this may be less popular with family and informal carers who may feel that the burden of care will fall on them and will need reassurance about levels of support available to them.

• In Croydon we are introducing health care coaching to help people help themselves and to reduce stress for both the patient and the carer.

6.

Home care - potential impact on social care? (Continued)

• We need to exercise caution about the potential savings linked to healthcare in the home as there will be ‘downtime’ between calls and the learning in Croydon from the Virtual Wards pilots has demonstrated the need for a properly resourced virtual team to provide support and ensure best practice.

• A key question from Darzi is how can we avoid unnecessary admissions and assist in reducing delayed discharges. This involves all the things we know about best practice in intermediate care and joint working with health.

• More home care may place a burden on social care but may place an even greater burden on the NHS if investment doesn’t happen where it is needed. No one so far seems to have cracked it when it comes to significant disinvestment in hospital care.

7.

Home care - potential impact on social care? (Continued)

• This need for disinvestment was a major plank of the ‘Our Health, Our Care, Our Say’ White Paper which championed the expansion of Community health services and personalised social care.

• Darzi’s model mirrors what the Croydon Virtual Ward is trying to do. By identifying and intensively managing people with long term conditions before they reach crisis, we have shown in Croydon that admissions can be prevented. Telemedicine and telecare offer further possibilities for supporting people at home without necessarily increasing care cost still further.

8.

Polyclinic model

• Co-location of health and local authority services in the one site or hub and spoke polyclinic model is very attractive, not only for financial reasons. Co-location of polyclinics and children’s centres also makes sense. Building Schools for the Future offers the vision of combining a school, a children’s centre, a one-stop for local authority and a polyclinic all on the same site or as part of a networked model.

• There is a real opportunity to develop true healthy living centres (perhaps along the lines of Bromley-by-Bow) which can major on prevention and early intervention, e.g. as well as health and social care offering access to Adult Education, Welfare Benefits, Housing Advice and Job Brokerage.

9.

Polyclinic model (Continued)

• We should not forget the possibility of colocating hub&spoke/federated polyclinic surgeries alongside services for older people operating from extra care housing or resource bases.

• There are also opportunities to co-locate services for groups who traditionally have found it difficult to access to primary care – people with mental health problems, people with learning disabilities. This could be extended to other disadvantaged groups such as homeless people and asylum seekers.

• There is a risk however that just because polyclinics are attractive to service providers that they will not be equally attractive to service users. Consultation on this approach in Croydon met some stiff opposition from people who want personalised and very local services, not necessarily in their homes but certainly no more than a walk or short bus ride away. People like the one stop shop approach for services but with easy local access. This does not fit with a population of 50,000 for a polyclinic but could fit with a federated polyclinic model linking several local GP surgeries and offering a range of specialist services.

10.

Polyclinic model (Continued)

• One thing that may increase the attractiveness of polyclinics to the public is if they not only provide a wide range of services but also offer those services at the times people want them.

• The Healthy Croydon Partnership discussions in Croydon including health and social care professionals, executive and non-executive members, voluntary sector, service user and carer representatives were clear in their demand for such clinics not only to be open flexibly outside of normal working hours but to target services for all parts of the community including excluded groups to include advice, information, testing with particular reference to smoking, obesity, diabetes etc.

• There are opportunities for independent sector providers to provide some of the range of services available within polyclinics.

11.

Long term conditions - is NHS committed to ‘invest to save’?• There may be a conflict between the most cost effective

approaches to managing long term conditions and what the patient wants. Some professionals may ask: ‘Have we simply redefined the process of aging as a series of long term conditions?’ Is this another form of medicalisation of old age? To what extent can you ‘invest to save’ in the context of an increase in the number of older, frailer, adults? Alternatively, can we afford not to ‘invest to save’ given the ever increasing costs of caring for an ageing population?

• Darzi illustrates world class practice for strokes but acute respiratory problems, arthritis, diabetes and dementia, all need similar approaches. Pathways need to capture what can be done in the community to prevent or delay the onset of these conditions in the same way that heart disease has been tackled.

12.

Long term conditions - is NHS committed to ‘invest to save’? (Continued)

• World class care pathways for people with long term conditions needs to include what is world class in terms of discharge planning and support, rehabilitation and reablement and home support which is jointly commissioned and co-ordinated to delivery quality outcomes for individuals.

• There is an expectation that people are capable of independence but many need help to achieve this. The navigation model being explored in social care as part of the personalisation agenda can also be applied to health care.

• We also need to remember that for many people ‘home care’ means care in residential and nursing care homes and increasingly within special sheltered or extra-care housing.

13.

Funding of issues

• Lack of capital costings in the Darzi report is a flaw. Intuitively many of the Darzi proposals are attractive and make sense but if the sums don’t add up then it won’t work.

• Despite the various dilemmas I have identified I am not convinced at present that new definitions of personal and health care are needed.

• We need to assess people’s health and social care needs holistically and provide the combined care package to meet them as cost effectively as possible.

• Given the recent King’s Fund report highlighting a variation in eligibility criteria for social care as currently defined there may be a need for improved statutory guidance and a resolution of postcode lottery approaches as to who gets what level of social care service.

14.

Funding of issues (Continued)

Free NHS v means tested social care– contradictions in Darzi approach?

• The increasing interdependency of health and social care as envisaged by Darzi again throws into focus the differential approach to charging between health and social care. The forthcoming green paper is unlikely to finally bring resolution to this vexed question and we are likely to continue with the public totally perplexed in a post-Darzi world as to why they pay for certain elements of care at home and not others.

• We all need to cut our cloth according to the resources available. Someone needs to pay for care services, whether that is the NHS, local authority or individual. If the exercise is purely about saving the NHS in London money then it’s not going to work. Local authorities could struggle to pick up the tab. Many people may be unable or unwilling to pay for things that they have previously received for free. Asking local authorities to give the unwelcome news isn’t fair.

15.

Transition to new models of provision

• Any transitional or pump priming funding for new models of health and social care needs to flow through the system to where it is needed otherwise there is a risk that it is used to prop up hospital services that are no longer required.

• There shouldn’t be a need in the longer term for a specific fund for social care if the funding released from acute hospital care flows through to social care and community health care via normal spending allocation channels and that these funds are jointly used to commission the required continum of health and social care based on joint strategic needs analysis together with listening to patients/service users so we deliver the required outcomes for individuals and achieve VFM.

• In Croydon the Council and PCT have committed to predictive modelling to help us understand the impact of our commissioning patterns so we can continue to avoid any potential cost shunting.

16.

Transition to new models of provision (continued)

• However, in the short term government specific grant funding to local authorities will be essential to ensure they have the confidence to accept the challenges and develop the necessary amount and type of service required to support the Darzi models of healthcare. This links back to my introductory point that we are operating in the dark without a body of evidence of the effect of the Darzi proposals on social care costs.

17.

Role of pooled budgets?

• Darzi report suggests commissioning and funding of social care by NHS but why not commissioning of health services by local authorities?

• Ideally we should work in partnership to get the best out of service providers and not replicate systems either locally, regionally or on a pan-London basis, eg. use the same brokerage system for purchasing services.

• Where does Practice Based Commissioning fit with Darzi – or have the NHS already quietly moved away from putting too much purchasing power in the hands of GPs?

• Existing mechanisms of pooling budgets have led to tinkering at the margins but few authorities and their NHS partners have taken pooled budgets into the mainstream. Pooling may lead to loss of flexibility in an environment where a flexible response is exactly what is required.

18.

Emphasis on prevention – impact on social care• Shifting care out of hospitals through the prevention of

admissions and/or early discharge may well increase demand for social care. If the individual does not meet eligibility criteria or needs to pay for some of that care there may well be a demand from patients and their families to stay in hospital.

• One solution may be to extend the tariff approach, with a clear understanding from the beginning of the costs of the hip replacement operation, the transport home, the home rehab, any home care required etc. We’ll also need a clear understanding of who will pay for each element of the full care package.

• Proposals for high throughput, early discharge elective centres may place additional demand on social care but continues a trend that has been happening for some time.

19.

Emphasis on prevention – impact on social care (Continued)

• We must not forget the impact on carers of having patients at home – physical and emotional impact as well as effect on their work pattern.

• There is also the financial and physical problems of ensuring the old, the poor and the disabled can visit specialist hospitals and centres not in their own locality.

20.

Can local authorities help the NHS move from being a ‘sickness service’?

• One can argue that we still need a ‘sickness service’. There is nothing wrong with treating people when they’re sick. We’re not likely to see a drop in the numbers of sick people, although the nature of their sickness may continue to change, unless we successfully tackle the health and well being agenda around smoking, obesity, sexual health and increased physical exercise.

• What is challenging us is changing demographics, changing medicine, and changing expectations of our care providers.

• A more productive approach, which is hinted at in Darzi, but not fully exploited is our joint role in helping individuals and their families take care of themselves. Whether we call this Choice and Control or Personalisation - this is everything from support for direct payments, through to respite care, to benefits advice, to support back into work, to developing the range of options in the care market.

21.

Can local authorities help the NHS move from being a ‘sickness service’? (Continued)

• A concern of some of my social care colleagues is that without proper resourcing for this agenda which includes self-directed support, individualised budgets and so on that we will mask where costs are coming from and end up with budget deficits. Social care is a year or two ahead of Health in the thinking and implementation of this change agenda . There is still an element of unproven territory and high risk about the personalisation agenda and people who are sick and vulnerable are not necessarily up to making these kinds of decisions about meeting their future support needs. The notion of health coaching (and social care coaching) together with navigational help through the system are ways of helping minimise both the risks to the individual as well as the organisation.

22.

Can local authorities help the NHS move from being a ‘sickness service’? (Continued)

• Working on the Staying Healthy pathway group in the development of the Darzi proposals did show me that there are a huge range of opportunities for local government to work with the NHS, the third sector and business to reduce smoking rates, promote access to leisure and physical activity, reach children and young people on a wide range of health issues such as sexual health and drugs, and also to provide information and routes to services through non-traditional routes. Libraries for example are widely accessed and trusted settings for the provision of information.

• The opportunity for us to use the 2012 Olympics as a focus for stimulating innovative work around improving health and well being will be a sad, lost opportunity if we do not gather a pan-London momentum.

23.

Summing up of key points

• There is much to admire in the Darzi proposals.

• The direction of travel around prevention, early intervention, rehabilitation etc. is already the journey that successful health and social care partnerships are following.

• Some exciting challenges around joining up of services on single or federated sites and persuading the public this is what they want and that it will deliver good outcomes.

• On the downside is the lack of an evidence-based approach to the implications of the Darzi proposals on demand and costs of social care.

• Lack of clarity on capital and any necessary transitional revenue funding.

• ADASS in London looks forward to a real engagement of social care as an equal partner in the new set of workstreams which are reviewing models/care pathways for a future round of consultation later this year.