Speech: 21 October 2011, Andrew Lansley, NCAS 2011: Tough Times, Good Decisions
Andrew Lansley speaks at NCAS 2011.
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Thanks Peter [Hay] for that kind introduction.
I’d also like to say thank you for the leadership you’ve brought to our work on integration - both on the NHS Future Forum, and now, with Dr Robert Varnam, on our engagement on social care reform: “Caring for our future.”
I’ll begin with one key fact. Since I addressed this conference nearly a year ago, 200,000 older people will have been admitted to hospital with a fractured hip.
For half of them, it will be the second bone they’ve broken - in all likelihood, in quick succession.
For too many of them, it will mark the beginning of a rapid decline. A lengthy stay in hospital that leads to loss of independence. To isolation from family and friends. To depression and further physical decline.
Why this fact and not others?
The fact that the number of over 85 year olds will double within 20 years?
That most people in their mid sixties now will live to well into their eighties?
That we have over 15 million people living with long term conditions - and that the NHS spends three quarters of its budget treating them?
First, you’ll have heard all these before. Probably more than once this week
Second, there’s no clearer illustration of the need for the reform of both the health and social care system.
Every year, 100,000 older people will needlessly end up in hospital. Some of them will be lucky.
The preventative care that wasn’t in place the first time they broke a bone might be there second time round.
They might live in an area where there are intermediate care teams, staffed by both health and care professionals, with the sole purpose of helping them regain their independence.
But many of them won’t. Their relatives - if they live nearby and are able to help - might spend days making multiple phone calls to different agencies, rarely speaking to the same person twice as they barter for referrals and assessments.
And perhaps, on some level, horribly aware of the irony - that their loved one’s loss of independence won’t only be worse for them, it will likely cost both the NHS and local care services more.
Things are gradually improving. The use in the NHS of the best practice tariff for dealing hip fractures, which covers factors like rehabilitation, as well as falls and bone health assessment is steadily rising - from 24 per cent in April 2010, to 40 per cent in April this year.
And more local councils and primary care trusts are working together to provide the kind of preventative care that can prevent falls.
NHS and local government
But the point still stands.
The truth about the health and care reforms can be summed up very simply.
Too many people suffer from health problems that are preventable and end up in a state of dependence that for some, who’ve lived active and fiercely independent lives, will be their worst nightmare. Not only that, it’s no longer affordable.
The solution isn’t simple, but it’s possible.
In the Health and Social Care Bill, and in the journey we’ll undertake to reform social care, we do have an opportunity to change this.
And the strength of the partnership between the local council and the NHS will be absolutely critical.
The debate in the media about modernisation may focus on the role of GPs, or on choice and competition,
But one of the most fundamental aspects of these reforms is the role of local government. In both the commissioning and design of local services and as a powerful advocate on behalf of local people.
For the first time, we’re affirming in law, the importance of integration of health and social care services. It’s explicit in the duties of the regulators, and the responsibilities of the NHS Commissioning Board, health and wellbeing boards and clinical commissioning groups.
And the changes made in response to the Future Forum’s report granted even stronger powers to local authorities.
Putting beyond any doubt two things:
- the responsibility of local government in promoting health and wellbeing;
- and, even more critically, its role - in partnership with the NHS and local people - in developing and designing health and care services to meet the needs of local communities.
It’s by no means a new concept.
When Joint Strategic Needs Assessments were introduced four years ago, it was assumed that they would encourage local authorities and primary care trusts to work together not only to assess local needs, but to integrate the services they provided.
In some areas, where the council and the primary care trust has developed a good working relationship, they’ve led to better services for local people - even helped address longstanding inequalities in health and wellbeing.
But you’ll know of other areas where they simply gathered dust in the office of the local council or primary care trust.
For while it may have been statutory to have one, it was never statutory for anyone to take any notice of it.
Now, they will take on much greater prominence. They will inform the joint health and wellbeing strategy of the health and wellbeing board. And clinical commissioning groups will be required by law to take that strategy seriously.
I want to be clear. The role of local government is not simply one of scrutiny and oversight. It’s about bringing both strategy and leadership to this agenda, as well as greater accountability.
It’s local authorities who are best placed to represent the views of local people. And it’s local authorities who can bring leadership to public health.
The latest report on Local Involvement Networks (or LINks) shows that the public’s appetite to have a say in local health and care services is growing at a pace. The number of active participants in LINks has increased by a third. There’s more evidence of LINks engaging hard to reach groups. And social care is playing a much bigger part of LINks’s work.
The role of LINks will be strengthened through the development of local HealthWatch, who will champion the views of patients and the public, and drive improvements in the quality of health and social care services. They will be essential in helping health and wellbeing boards to lead on local public involvement in health and care services.
Local authorities are also best positioned to bring both leadership and better co-ordination to health improvement.
Because improving health outcomes means tackling the causes of poor health - whether that’s smoking, obesity. Or heavy drinking, which takes its toll not only on people’s health, but on our communities too.
So yes, Change 4 Life is a flagship, national campaign. But what makes that campaign real is what people find in their local areas to promote good health. Whether that’s access to green spaces and leisure centres, what happens in schools and children’s centres, or how local transport is organised.
This is why there will be ring-fenced budgets for local councils to spend on public health. And a new health premium which will reward local authorities who improve health and reduce health inequalities. With greater rewards for the areas who make progress against the toughest health challenges.
We now have 138 early implementer health and wellbeing boards, and from the boroughs I’ve visited and the people I’ve spoken to, the energy and appetite of local government to lead this agenda, and to work with local people and their local NHS colleagues, is palpable.
**Social care reform **
And now, we’re asking again for you leadership in the reform of social care.
In the work of the Commission on Funding of Care and Support, led by Andrew Dilnot, Jo Williams and Norman Warner, we are beginning to see some of the ways in which we could build a new partnership between the state and the individual to fund social care.
But while the question of funding is critical, it is but one aspect of social care reform.
In our engagement on social care reform: “Caring for our Future,” we’ve identified six areas where we think there is the biggest room for improvement.
Quality, workforce and regulation
So we know we need to do more on quality, and to support the care workforce to deliver better quality care.
In any discussion on quality, we cannot be oblivious to catastrophes like Winterbourne View, however rare they may be. The staff who worked there were guilty of the most abhorrent and shocking failings in their duty to the people who were in their care.
And everyone - care providers, care workers and regulators, national and local government - has a responsibility to make sure such terrible events are never allowed to happen again.
But improving the quality of care isn’t just about safeguarding. Or simply preventing the worst abuses.
Most poor quality care is, on the face of it, more mundane and more endemic in its occurrence - the daily indignities that some care home residents have to endure, not being listened to or treated with respect by the care worker who provides support in your home.
In the discussion we need to have on quality, our focus must be on improving everyone’s experience of care - making sure that whatever someone’s needs are, they are treated with humanity.
The last government saw extending compulsory regulation as the answer to improving the quality of the workforce.
But I don’t believe that bringing in more top-down regulation that imposes registration fees on the lowest paid care and healthcare workers is the answer.
There is very little evidence that suggests that further, nationally imposed regulation will do anything to improve either the quality or the safety.
Worst of all, there was the danger that it would weaken the responsibility and the accountability of the very people who should be dealing with these problems locally.
Under proposals in the Health and Social Care Bill, registration will be voluntary for social care workers.
Not regulation for regulation’s sake, but a system that focuses on driving an improvement in standards.
Not more nationally imposed bureaucracy, but giving commissioners, providers of care and care service users a way to ensure that professional standards are being met by the workforce.
Regulation is but one small aspect of improving the quality of the care and support workforce.
The Social Work Reform Board - which is made up of experts from the profession - believes that social workers are not getting the support they need to maintain the high standards that the public expect. And that we need greater professional leadership in social work.
The newly-established College of Social Work is already doing excellent work improving education and training, and better equipping professionals for the challenges faced in adult social care.
The College will put social workers at the heart of decisions about the future of their profession, helping to give social work the professional leadership and public voice it deserves.
Personalisation
The second area the engagement will cover is personalisation - how can we give people more choice and control over the care and support they use?
Local authorities - long before the NHS got in on the act - have been pioneers of personalisation.
We’ve seen the incredible difference that personal budgets can make, and their uptake is increasing. According to ADASS’s survey, a third of all people eligible for social care support are now receiving a personal budget.
But we have further to go still. Not only in increasing uptake, but making sure they genuinely empower service users and the professionals that work with them.
There have been concerns that social workers are still doing all the planning for people with care needs, rather than helping them identify their needs themselves.
Or that they get weighed down by more bureaucracy as their judgement on budgets is questioned and their support plans endlessly queried by funding panels.
I was interested to hear about the work of the disability consultancy, Paradigm. In partnership with the think tank, the Centre for Welfare Reform, they have been trialling a new scheme to empower both social workers and care users.
People with care needs are told what their personal budget is likely to be after an assessment. Social workers can sign off budgets up to a certain amount.
But critically, it’s the person who needs support who develops the support plan. No panels or bureaucracy to jump through. And more time for the social worker to spend planning support for those with very high level needs.
Shaping Local Care Services
Third, shaping local care services: how do we ensure that there is a wide range of organisations that provide care services that support people’s choices?
We know we need a broad, vibrant market of care providers to deliver the choice that people rightly want.
But events at Southern Cross show all too clearly the risks involved if a large provider fails.
I’d like to thank ADASS - and in particular, the incredible leadership of Peter Hay - in the work it’s led in response to the failure of Southern Cross.
We have begun the process of transferring Southern Cross homes to other operators, and we expect that process to finish in the next few weeks.
And through the engagement on social care, we need to think about how we can prevent provider failure, and how best we manage it if the worst happens.
Prevention
Fourth, prevention - how do we keep people independent and in good health for as long as possible?
We can all do the maths. Keep people from getting ill. Keep people independent - it’s better for them and it costs less.
We will shortly be publishing a report on the world’s largest pilot of telehealth and telecare - the Whole System Demonstrator.
For those in the pilot, it has already changed their lives. One of the three main sites is in Cornwall, where one participant, Eddie, from Looe, has had a lung problem that not only meant he was housebound, he was also a regular visitor to A&E - attending 5 times in the 6 months before he joined the pilot.
But by having telehealth equipment installed in his cottage, he can now monitor his own oxygen levels and blood pressure and take appropriate action when needed. The confidence this has given him means he is now venturing beyond his front door for the first time in 5 years.
Simple changes, and an extraordinary difference.
Integration
Fifth, in partnership with the NHS Future Forum, integration: how do we make sure that we build better connections locally between the NHS and other care services?
Some local authorities have recognised for many years that integrating health and care not only means a better service for local people. It also often means doing more with less - for both local care services and the NHS.
So Milton Keynes’s Rapid Assessment and Intervention Team, which provides support to help people recovering from an operation or fall and is jointly funded by the local council and the primary care trust.
Not only has it avoided 100 admissions to residential or nursing home care, it’s led to joint savings of £3 million.
Or Croydon Council and Primary Care Trust’s virtual ward, which identifies those at risk of emergency admission and puts in place care and support that can help them. The outcome? Fewer A&E admissions and fewer admissions to residential care.
We’re well beyond the stage where integrating services was a choice - something that was nice to do, but came at the bottom of a long list of other priorities that were deemed to be more important.
The spending review settlement of last year did enough to protect social care services, and to maintain quality for those who depended on it - particularly, taking into account the money allocate in the NHS budget for social care.
An additional £7.2 billion to support social care between now and 2014/15. Half of this through local government, on top of the existing department of health grant funding that we have maintained within the local government formula grant.
And the remainder through the NHS. £800 million this year - rising to £922 million the following year, and over £1 billion the year after that.
At the time, there was some scepticism that this money wouldn’t find its way to its target - that the NHS would spend it on other priorities.
But the evidence we have gathered so far about how this year’s allocation is being spent shows that this was far from the case.
The £150 million allocated to primary care trusts for reablement services has been spent on reablement.
Of the money to be transferred to local government the latest projections show that £128 million will be transferred to councils to spend on early intervention and prevention.
A further £117 million on reablement.
£50 million on crisis and rapid reactive care.
And £115m to help prevent councils from tightening their eligibility criteria.
So the bulk of that money is being invested into services that help keep people independent for longer.
Reducing their dependence on the NHS and other care services and improving their quality of life.
But it doesn’t mean councils have had it easy. There is no council represented here today that hasn’t had to make some tough decisions. And I can’t promise it’s going to get any easier in the very near future.
What I can say is that the focus on improving services becomes more, not less important, in a tough financial climate.
The rationale is simple - provide people with better care, you can also reduce costs.
Finally, the role of financial services: what role could they play in supporting care users, carers and their families? For people who want to take steps now to insure against care costs in the future, there are few products available that could meet their needs. So we need to explore this more fully.
In the current economic climate, it goes without saying that we’re not going to be able to do absolutely everything we’d want to do to improve social care,
The engagement is about what the priorities for social care reform should be in a difficult climate. And it’s these short, medium term and long term priorities that we’d like your help to identify.
I have heard concerns from some of you that this is simply another delaying tactic to kick the question of funding into the long grass.
But this is not the case. We also want to hear what people think of the recommendations made by the Commission on Funding of Care and Support.
When we publish the white paper in April on social care reform, we will also publish a progress report that will set out our response to the Commission’s recommendations on funding.
Conclusion
The issue of health and social care reform is not one we have any intention of hiding from - the harsh reality is that we simply can’t afford it.
And in some ways - in the local authorities that are pioneering greater integration and investing in prevention and early intervention - some of it is already happening.
And some of the answers - some, but not all - are already there.
Let’s go back to that fact I began with. Those 100,000 older people who end up in hospital unnecessarily, and in all probability, in long term care.
We already know how to prevent that happening - there’s no miracle of medical science we need to wait for.
But it does require new ways of working. Where closer working between the NHS and local government are the rule, not the exception. Where local government and the NHS, in partnership with local people, design local health and care services.
Where we have quality and excellence across the health and care workforce.
No one underestimates the size of the challenge - you’d be forgiven for thinking that this was a lifetime’s work.
And as we are addressing some of the biggest challenges of our generation, you might be right.
But I have confidence in the exceptional local leadership I know is here in this room today to drive and shape this agenda, and improve the health and wellbeing of the people in your communities.