Delulu is the Solulu?!

So now we wait!

The word is that there’s a lot going on behind the scenes between the great and the good, about what options are practicable, as opposed to delusional, with regard to charging reform and the costs cap – all political parties having been allowed by the media and the sector as a whole, to avoid saying very much about social care, before the election.

Hints of a new Royal Commission are unlikely to be welcomed by any body of expert opinion, Andrew Cozens, one of those experts, himself, said last week.

His view is that it isn’t really very surprising that there has been no announcement that social care is broken, from Wes Streeting, although Labour has said publicly that the NHS IS broken.

Cozens suggested that this was because the system is not in fact broken; rather, it is working in exactly the way governments have always expected it to work, meeting tightly defined eligible needs, primarily for those with limited means, within a strict financial envelope. He acknowledged that what causes so much ‘distress’ for users and carers is councils’ inability to reduce, prevent or delay the need for care outside of this framework.

To my mind, that’s an incredible position to set up and defend, given that prevention and reduction duties are INSIDE the Care Act and when the real problem is that unmet ELIGIBLE need is not being met.

I do not know how Cozens can state that social care is not broken, even if he meant it tongue in cheek, when the evidence is clear that most directors already KNOW that

• they are not managing to create care plans to meet assessed need and have backlogs of overdue assessments to get through;
• the Transforming Care cohort are still stuck in psychiatric hospitals for want of commissioning of anything that could feasibly meet that cohort’s obviously eligible needs, even if the NHS shared the cost –
• the Ombudsman finds fresh examples every week of unmet planned for need, as well as needs that no proper process under the Care Act could have defensibly failed to identify.

Cozens has said that while former Labour health ministers Alan Milburn and Lord Darzi have been brought back to government, nobody has yet been back to Sir Andrew Dilnot, or to new intake MPs like Anna Dixon, who chaired the Archbishops’ Commission on Re-imagining Care. He mentioned hints of a new Royal Commission that might yet be announced but thought that expert advice would be that there is a better understanding of the issues and options now and that little would be gained by a two-year reconsideration of them.

He rightly guesses that the new government would be daunted by the costs involved, now that they have got to think about it, whilst everyone knows that social care is the main cause of the budget crises of top tier councils and pressuring the productivity of the NHS.

He suggested that the Care Act remains a sound legal framework “if reinforced by serious policy positions on key issues like wellbeing, co-production, rights, the workforce, market sustainability and charging.”

I am not sure what that means. Wellbeing and coproduction are surely already part and parcel of the sector’s values, in theory.

NHS leaders being allowed to wipe the sector out by requiring subservience to local ICB plans, would not be a mere policy decision, however. It would be a covert political decision, because it would continue the trend of removing people’s existing legal rights to enforceable social care services, below the radar.

Managing market sustainability and the preservation of the workforce are decisions which all involve MONEY; this is not merely a matter of policy. It is a matter of the political will for the long-term underpinning of the funding that matters.

Funding is the first and foremost problem and it is delusional to suggest anything else.

This last week saw Section 151 officers speaking up about the prospect of a return to multi-year settlements, pledged by Labour before the election – some fearing that they will only get 2 years’ worth indicated at this point, or maybe 4 years’ worth, but with even less money overall.

What they want is clarity from government earlier on, in any budget year, and transparency and hopefully reform, regarding the elements of the funding formula for councils. Major organisational changes such as redundancies require a long lead-time. Consultation of the public regarding the equalities impact also makes for pressure between December and March of any given year. Bidding for the funds does not seem to be regarded as helpful amongst s151 officers – eg for pots such as the Accelerated Reform Fund. 

A multi-year settlement for now, however, could possibly indicate the bare minimum of funding for say four years, and then provide for upward reallocations later on in the cycle.

Melanie Williams, the president of the Association of Directors of Adult Social Services, has been heard this week, describing funding and other measures to improve performance in the NHS – but not adult social care alongside, as equivalent to “pouring water down a sink with no plug in.”

She was leading on the ADASS annual survey, which revealed amongst other things –

• 90% directors are not fully confident their budgets will be sufficient to full meet their statutory duties this financial year, with 16% having no confidence at all.
• Some 37% of directors reported that they would be using one-off funding such as council reserves to balance their books
• Over 75% of councils reported that the size of care packages of those discharged from hospital has increased in the past year
• More than 400,000 people are still facing a wait to be assessed, for their care package to commence, or for a review of their care plan
• 91% of directors said that increased NHS pressures had or will lead to adult social care taking responsibility for services that previously would have been delivered by health providers (ie CHC clients or those who had previously had discretionary shared care contributions)
• a 7.5% increase in people needing ‘double handed care’, since last year, which increases costs to councils, but without any increase to income through the charging system, since most are currently already assessed to pay all that the system allows
• Increase in home care hours bought by councils has been identified from 697 hours per person in 2022 to 750 hours in 2024, contributing to a disproportionate rise in councils’ spending on home care by over a quarter during this period, because of the rising cost of care in any event.
• 35% of directors believe their council would receive a “requires improvement” label if their council was inspected by the Care Quality Commission right now. The government funds less than 10% of the average cost of preparing for these inspections, which underlines the irrationality and lack of length and breadth of strategic thinking in the DHSC
• The most concerning statutory duty for directors is around market stability with 60% ranking it as their greatest worry
• ADASS estimates that the amount allocated for adult social care in 24-25 will be 37.2% of a typical overall council budget

The LGA has separately estimated that adult social care services face a £3.5bn funding gap by 2025.

Ms Williams said that coping with the pressure, and positioning health and social care in competition, affected staff and public’s mental health and wellbeing.  She is not wrong.

Her view is that the NHS unfortunately targets reviewing packages of support for community services because they are “controllable”, while the “large contracts” for hospitals are set and cannot be adjusted.

People being discharged from hospital more quickly and then not being seen as eligible for NHS funding means a cost shunt to councils and to the people themselves.

The short-term fix of a s75 pooled budget funded spell in a free comfy care home which is above the councils’ carefully negotiated fee rates does nothing for councils when the person stabilises and then either wants to stay in that likely better-than-adequate setting, or go home to 4+ visits a day, we would suggest.

Directors report that this rise in complex care, in part, is the result of an ongoing push to discharge people from hospital more rapidly when they are barely ready to leave. 

• The average size of care packages for people being discharged from hospital has increased in 76% of council areas over the past 12 months.
• People needing low-level input at home are at risk of missing out, or their needs escalating. This means that people are more likely to need informal care, or to access emergency care and hospital treatment.
• When waiting for NHS treatment, people often face deteriorating and loss of independence, which requires more social care support.
• This emerging complexity of care tasks is not being reflected in social care budgets from central government.
• Councils have overspent £586mn nationally and are required to deliver £903m in savings to their current budgets and a further £905m of savings next year.

The King’s Fund also called on national bodies recently to do more to create an environment in which ICSs can succeed.

The 42 ICSs that cover England are responsible for spending over £100bn of NHS funding. Based on 24 in-depth interviews with local leaders in four case study sites plus a series of online workshops, the Kings Fund has published Realising the potential of integrated care systems, in which it argues that national leaders should avoid the temptation to undermine local partnership working through heavy-handed, top-down performance management and stick to recommendations in the independent review of ICSs led by the Rt Hon Patricia Hewitt. 

It identifies that the intense political focus on hitting key national targets such as driving down waiting lists, and extremely difficult economic circumstances  could derail improvements proposed by integrated care systems.

Sarah Walter, director of the NHS Confederation’s Integrated Care Systems network,said “The integrated working between the NHS, local authorities and beyond which ICS facilitate and drive is critical for meeting the health needs of the population. Using councils’ expertise is critical as the network will continue to “influence the new government to deliver the ambition they have set out for social care and beyond”.

As blogged about here, before now, we do not know why nobody in serious journalism has dared to explore, publicly, what all this means for women in the workforce, for the economy, and for people’s wellbeing.

Even though it is the law that these duties are met, and met defensibly adequately, it appears to be literally irrelevant in the society in which we live – and in part because journalists will not address it or look at the situation from a legal rights or access to justice perspective.

The position of ADASS’s president is that the new government must shift to investing in more social care, supporting unpaid carers, and providing healthcare in our local community to prevent people reaching crisis point and ending up in hospital in the first place.

The next government must have the courage to commit to a long-term, fully funded solution for social care and shift from short-term crisis management, especially during winter, to more care at home in the long term. Care at home is better for all involved, but also makes more financial sense.

It is not surprising, therefore, that social services council leaders begged last week for deferral to the planned social care charging reforms given their estimate that there is a £30bn “black hole” in funding over the next decade, having risen by a third since the reforms were last mooted.

An October 2025 start date would mean that local authorities would soon be paying for all eligible care costs when anyone had contributed £86,000 towards their care, through their objectively identified and metred care needs costs, or through their social care charges, if funded.

It is said that 86% of upper tier councils are not prepared for these charging reforms to be introduced, and that 90% support a delay of at least a year or more.

The £17bn previously allocated before the last deferral in 2022 was used to  offset inflation costs, sustain the market’s viability, ease the backlog in overdue packages or to recruit more social workers.

The government cannot just take money currently being spent on day-to-day adult social care services for these reforms without having a devastating consequences for councils and the thousands of people who rely on local authority care.

I presume that when Mr Cozens speaks of the better level of learning that the sector has now developed about charging reform, he is referencing National Audit Office’s report from last November, on the prospects for (any) government for reforming adult social care in England.

It found that some serious work has been done on the issues besetting both mainstream political parties’ loose plans to resurrect the Care Costs Cap. But it concluded that the significant risks DHSC must manage, if it is to succeed in delivering its vision for adult social care, are bound to be exacerbated by the following underlying problems:

• Restarting charging reform activity would add to resourcing pressures (unavoidably, as we can see winter looming again and as set out above in the ADASS survey)

• Uncertainty over how much it would actually cost local authorities to pay a fair cost for care to providers – the estimate had been £1.8 billion to fully pay providers a ‘fair cost of care’ in 2022-23, but there were concerns over the quality of data provided in the exercise, particularly the accuracy, robustness and consistency of the data. The DHSC has already acknowledged that it will need to revise its plans;

• Limited delivery experience in DHSC on adult social care – NAO identified that the DHSC has had a long history of implementing projects and programmes on the health side, and an established delivery body in the NHS, but that it does not have the equivalent for adult social care;

• The absence of a long-term plan for achieving its own vision – DHSC has no funding certainty beyond the current Spending Review period, with which to offer multi- year settlements;

• The absence of a ‘theory of change’ for how the proposed system reform measures would contribute to long-term reform outcomes. It said that whilst the DHSC may be committed to evaluating its reform activity and is putting plans in place for project level evaluation, it has not set out how its planned system reforms, as set out in Next Steps, will help it achieve the goals set out in its own White Paper.

Two years into its 10-year plan, NAO thus concluded that DHSC has a long way to go if it is to deliver its ambitions.

“To maximise its chances of succeeding, DHSC will need to make sure it understands how the different strands of its reforms relate to each other, and the cumulative impact on local authorities and other stakeholders. It must be clear what the critical steps are, manage delivery against those closely and put in place governance needed to manage delivery risks effectively.”

It recommended that DHSC should

• assess the impact of its current and planned reform interventions on local authorities, and other stakeholders, to ensure that the cumulative impact of its policies are manageable;
• set out a costed plan to the sector for implementing charging reform from October 2025, incorporating lessons learnt so far;
• review its portfolio reporting to ensure that it provides the management information needed to give assurance around overall progress and management of risks to delivery and that it has the resources it will require within the Department, in terms of both capacity and capability to deliver the next stage of reform;
• and finally, review its arrangements for delivering and overseeing its reform activity, incorporating external challenge, so it can come to an informed conclusion as to whether a different approach is required going forward.

The King’s Fund authors concluded that “the behaviours of national, regional and local leaders will make or break ICSs. There is an urgent need to ensure that accountability arrangements drive behaviours that reinforce system working rather than undermine it. Success depends on supporting people at all levels to think, plan and act in ‘system-focused’ ways.”

We would say that injecting more legal framework knowledge into the mix would mean that plans and actions would be developed in rights-based focused ways, too; and that without a focus on the impact on members of the public of doing nothing, and what a social care safety net needs to do, the project will be doomed to disappoint.  

So if those two wholly missing strands of THINKING were what a Royal Commission was tasked to look into, now, that would not be a waste of time. But its scope would need to be tightly constrained and start out with the assumption that charging reform along the lines of Dilnot, is the right way forward. The country cannot afford to go back to 2011 all over again.