Looking to 2015: The experience of quality will become paramount
Des Kelly OBE, Executive Director, National Care Forum
I predict that 2015 will be a landmark year for the care sector. Why? There are so many competing priorities to be addressed. They include, in no particular order, future funding; demographic pressures; public sector cuts and continuing austerity measures; dementia and other long-term conditions; quality concerns; reform of regulation; commissioning for outcomes; transformation; integrating health and care. Take your pick – they are all challenging.
2015 will bring the implementation of the Care Act and with it changes to fundamental standards, regulation and inspection, scrutiny and overview. There are three particular features to consider simultaneously. The first is that these radical reforms to social care are taking place following at least five years of austerity, resulting in substantial reductions in public sector funding. The context, therefore, is a sector suffering the pressures of underfunding. Secondly, future funding remains uncertain until the Department of Health consults on its proposals and plans (and the Governments interpretation of the Dilnot Commission recommendations are not due to commence until April 2016). The third, and most pressing factor, is the fact that in May 2015 there will be a General Election. There could be a change in policy direction.
That said, it seems there is already evidence to suggest that health and care will be a key election issue. We can, therefore, expect a lot of media coverage of pressures on the NHS. It is to be hoped that social care providers can use the opportunity to emphasise the importance of the relationship between health and social care. Integration of health and social care is starting to happen, but it still has so much more potential.
We are only just beginning to appreciate how social media will affect the provision of care services. It has already brought a new dimension to notions of openness, transparency and accountability. Information gets into the public domain so quickly and comprehensively; social media has the power to undermine reputations that have taken a long time to build. I believe that the provision of care and support services, and their quality, will increasingly be subject to such public scrutiny with opinions aired before there has been a chance to investigate and form a judgement. How providers react will be in the spotlight… And watched by the media. Add this to the mix of a duty of candour, fitness of purpose for management and corporate accountability: robust governance systems will be necessary.
Don’t get me wrong, I welcome these different ways to improve quality of care and support services and taken together they will strengthen inspection and regulation. Quality, however, cannot be inspected into a service. Quality cannot be commissioned into a service. Clearly they are both important, but it is the experience of quality that has primary significance – that is the outcome defined by the person receiving the service and the responsibility of the provider. Let’s hope that the New Year progresses our understanding of these vital elements.
2015 – A year of immense change? Undoubtedly ‘yes’
Roger Harcourt, Partner and Head of Healthcare, Shakespeares
The title poses a question to which the answer is undoubtedly ‘yes’ and the medium-term outlook suggests that the only constant is change. Some changes impacting in 2015 are generated by improvements that have inbuilt implications for the future.
The first stage of the Care Act 2014 comes into force, to be followed in 2016 by the second stage. The first part (effective April 2015) deals with care and support reform. It focuses, amongst many other things, on ‘wellbeing’ along with duties and powers to ‘meet needs’ which replace previous entitlements to services. There is a focus also on the prevention, reduction and delay of needs arising. What is less well appreciated is that the Care Quality Commission (CQC) will be bringing in its oversight regime of the financial health of ‘difficult to replace’ providers. This cannot just apply to large national operators, as it needs to look at the local landscape. Are you a medium-sized local provider, with high borrowing relative to the value and profitability of your homes? Will the CQC ‘control’ the lending and sales market by indicating what the sensible levels for bank leverage and debt service cover are?
The second stage of the Care Act comes into force in April 2016 and includes the cap on care costs. This will require education of the general public, the majority of who still think that this means all care costs and not just the care element. Once the care element cost has been quantified by local authorities, this will create transparency in the level of ‘hotel costs’ included within a fee and perhaps some interesting discussions between families and care home operators. Will this create a transfer to lower cost providers, or will the family take the view that they will still pay the fees because they want ‘the best’ for Mum and/or Dad?
The Better Care Fund moves into the mandatory phase for local authorities and Clinical Commissioning Groups to pool budgets from 2015. The driver is to deliver more integrated commissioning of health and social care and reduce pressure on NHS hospitals. The single pooled fund across the country for 2015/16 is set at £3.8 billion, with £3 billion of this coming from the NHS budget. Examples of targeted activity include reductions in avoidable emergency admissions, reductions in non-elective length of stay, and a reduction in the delayed transfer of care. These provide clear opportunities for the market to respond with provision of step up/step down care, reablement/rehabilitation services, together with respite and outreach provision.
There will undoubtedly be further pressures on local authority budgets in 2015 and beyond. These fee pressures have led to new-build care homes mainly being built in areas where there is a greater proportion of self-funders and top-ups available. There has been a North/South divide in new-build activity in the sector for a few years now and the difference in the trading performance of homes across the UK is clearly evident in the recently released Knight Frank 2014 Care Homes Trading Performance Review. With land prices south of the A14 corridor now heating up, providers are looking to the Midlands and North with greater focus, but generally only the affluent areas.
Quality ratings are being re-introduced by the CQC, at the same time as what appears to be much more rigorous testing of providers and less tolerance of poor provision across the various areas inspected. So long as we see consistency from the CQC, this will provide the public with an independent ratings system which they clearly value.
Oh and finally, there is a General Election in 2015 to boot, which if it results in the election of a Labour Government, brings with it the intention to repeal the Care Act 2014 – but how quickly will this happen and what will the intention to provide social care linked to the NHS bring with it in terms of large scale structural change and opportunities?
2015 – A year of immense change? I think so!
2015 – A wide range of issues and challenges to be addressed
David Pearson, President, Association of Directors of Adult Social Services
The view of what 2015 will bring was acutely highlighted at the recent National Adults and Children’s Services Conference. The hunger for local councillors, members, providers and advocacy groups working with government departments to seek solutions and innovation was evidenced by the fact that the delegate list had to be closed a week before the conference. The mood was positive about the opportunities and authentic about the challenges. Ministers and shadow ministers were all in attendance.
There was a wide range of issues covered. Announcements included the approval of the overwhelming majority of Better Care Fund Plans; new Standards for Commissioning by local authorities in adult social care; a joint paper on integration by the Royal College of GPs and the college of social workers, and a myriad other developments and contributions about the Care Act. These are all principled ways of saving money and how to progress the personalisation of services.
The recently-published Barker Commission report also produces a forward look at how a more joined-up health and care service may develop. However, it emphasises that integration is not going to be a silver bullet for the problem of how to sustain health and social care as needs rise.
A major challenge to continue into 2015 is the need to save 26 per cent of £3.5billion in social care over the last few years. This has prompted leaders, service users and colleagues up and down the country to dig deep to find creative solutions and mitigate, as far as possible, the impact. Reductions, savings and efficiencies of that magnitude can easily blunt enthusiasm, deaden creativity and frustrate the urge in social care to make a better world.
The conference also saw the publication of a joint document between the Association of Directors of Adult Social Services and the Local Government Association on adult social care funding. We have had a thorough exploration over recent weeks of the £30billion gap in the health service budget over the next few years, the paper highlights that by the end of the decade the equivalent gap is £4.3billion in adult social care. Directors fear that people who need services may not be able to access them; the quality of care may deteriorate and that it may not be possible to deal effectively with the pressures from the health service to ensure that people get the right care at the right time.
There is a culture of ‘can-do’ in social care. A future of person-centred, co-ordinated care, and personal budgets as part of a system of integrated care built on promoting wellbeing is being explored with enthusiasm. To realise the aspirations of the Care Act, we will need this determination and resolve in pushing forward with innovation. At the same time, we must ensure that there is no let-up in explaining the need for this resolve to be supported by sustainable funding for social care as well as health.