Finding Savings in Adult Social Care – presentation for ADASS Seminar

1. John Bolton - Consultant JRFB Ltd Finding Savings in Adult Social Care – presentation for ADASS Seminar

2. Adult Social Care Efficiency Programme 2012-14 • Link to the report and annex: • http://www.local.gov.uk/web/guest/ • productivity/-/ journal_content/56/10180/3371097/ARTICLE(all one line) • http://www.local.gov.uk/web/guest/productivity/-/journal_content/56/10180/3371097/ARTICLE

3. Three Year Programme • 48 Councils in England (all volunteers to have external challenge and a review of their savings over a three year period). • The Adult Social Care Efficiency Programme –The Initial Position • The Adult Social Care Efficiency Programme – • Interim Report 2013 • LGA Adult Social Care Efficiency Programme – • The Final Report 2014

4. Savings from reducing costs • 1. Focusing on efficient business processes. • 2. Reviewing management and staffing levels. • 3. Negotiating the “right” price for the service to be delivered. • 4. Ceasing to be a provider of services and closing down services where there is supply from the independent sector. • 5. Procuring care in the most cost effective way. • 6. Reviewing the range and type of services that are offered and encouraging the take up of Direct Payments and ensuring that the resource allocation system is fair and does not overstate needs. • 7. Creating supported housing including Extra-Care Housing as an alternative to residential care. • 8. Undertaking a “base budget” exercise. • 9. Requiring all partners (including the third sector) to deliver value for money.

5. Savings from reducing costs/ increasing income • 10.Looking to reduce duplication costs through integrating with partners (health or housing). • 11. Looking to develop a single service for younger adults across transitions. • 12. Ending some subsidised services e.g. meals on wheels or transport. • 13. Rationalising staffing accommodation, introducing hot-desking and other accommodation moves. • Increasing Income • 21. Ensuring that government grants are funding mainstream services. • 22. Ensuring that the right agency is paying for the services required. • 23. Maximising the contribution that customers make to the cost of their care (within the government guidelines).

6. Savings from managing demand • 14. Changing their model of care from one of paternalism and protective interventions to one which promotes independence and manages risk with customers. • 15. Diverting people away from formal care packages through good information and advice services. • 16. Ensuring (sometimes in partnership with the NHS) that most people receive some form of “preventive” intervention before they are assessed for longer term help including effective reablement or recovery and good use of telecare and falls prevention programmes. • 17. Applying eligibility criteria for services in a consistent manner. • 18. Offering small grants to voluntary and community groups to encourage them to offer preventive services. • 19. Developing a risk tool to assess who is at risk of needing an admission to older person’s residential care in the future and how this might be avoided. • 20. Exploring a range of alternative options before making as assessment about residential care and moving people from residential care to community housing where appropriate.

7. Managing transformation • 24. Having a clear political vision for adult social care which has at its core a model of care which looks to “promote independence” for citizens and to find some of the care solutions from communities, families and individuals. • 25. Giving clear leadership from senior managers, which involves working with staff, stakeholders, providers and other partners to ensure they understand what is required from the new culture. • 26. Entering into full dialogue with their NHS partners around integration of services and the use of the Better Care Fund. • 27. Developing a new compact with the citizen and the local community about shared responsibility for meeting needs. • 28. Having effective performance management data and project management skills to assist them in meeting their savings targets.

8. Managing transformation • 29. Developing a partnership with the local business and others to secure the right employment opportunities. • 30. Developing a programmewith GPs to assist self-funders avoid costly mistakes. • 31. Using regeneration opportunities and capital monies to make longer term revenue savings. • 32. Deliberately increasing their costs by paying the “living wage” or the “London Living Wage” to secure the job market. • 33. Publishing their own guide on how to save money. • 34. Engaging with the public for their participation in the best way to achieve value for money.

9. Some interesting findings • Quite significant variations between councils on the level of savings to be found – most have to meet 3% per annum (some more) • Promoting independence is the new mantra • Several approaches to managing the “front door” from People2People (social enterprise) in Shropshire to Calderdale’s “Gateway to Care”. • Impact of reablement variable – can be much better targeted on those with more complex needs (not on people who will recover anyway) • Telecare can be targeted at existing customers to reduce their need for some

10. Ways of saving money • Manage costs • In-House v External (Close services) • Procurement of supply • Personal Assistants v Contracted Care • Price for service received – outcomes • Increase income • Manage demand • (Demographic Pressures) • Diversion - Prevention • Eligibility – incl CHC • Community/Family Responsibility • Promote Independence • Practice that focuses on outcomes – social workers drive costs

11. Features of high performing councils • Review outcomes delivered through audits • Strong clarity of measures that will support Performance Management – understand and uses the data • Clear vision and direction for social care – led by Politicians and Senior Managers • Strong focus on managing demand with competence around managing costs

12. Approaches to Social Care • Personalisation strong focus on Personal Budgets/ Personal Assistants • Get the RAS right • Efficiency Model • Assess against eligibility criteria with some Prevention (Reablement) • Procure cost effectively • Integration • Work with NHS to develop fully integrated services • Promoting Independence • The purpose of social care is to assist people to live as independent a life as is possible outside the formal care system

13. Some interesting findings • Quite significant variations between councils on the level of savings to be found – most have to meet 3% per annum (some more) • Promoting independence is the new mantra • Several approaches to managing the “front door” from People2People (social enterprise) in Shropshire to Calderdale’s “Gateway to Care”. • Impact of reablement variable – can be much better targeted on those with more complex needs (not on people who will recover anyway) • Telecare can be targeted at existing customers to reduce their need for some

14. Is better Commissioning the answer? • Those councils who have procured domiciliary care with fewer providers who have allocated areas in which to work have delivered savings (though some problems experienced in the transfer from previous providers) • Those councils that have used housing solutions – including extra care have had a mixed results in saving money – some have higher costs (in both older people and LD services)

15. Some new learning – assessments and carers? • Is the assessment about someone’s needs on a given day or for their potential for recovery? Massive variation in outcome of assessment between professionals –whatever the eligibility criteria of the council (or the panel system) • Are Carers being asked to make a contribution to the care of their loved ones or has the state taken over? – Compact between Carers and State. This is the biggest variable between Practioners.

16. Is integration with the NHS the solution? • Limited evidence of direct savings from integration with health – but can assist if both parties share objective of promoting independence. Many councils in tussles with NHS over CHC. • The Better Care Fund will deliver for some councils but not for others (but not the councils fault). • What are the outcomes of speedy hospital discharges – a correlation between speedy discharge and high admissions to residential care - Is residential intermediate care commissioned for that purpose? Do Councils and NHS understand the flows? • Is reablement targeted at those with more complex needs – can people re-able themselves with the right guidance? (from Physios) • Some evidence of rising demand for social care from integration

17. Can Personal Budgets help? • Personalisation can deliver savings when delivered at scale – particular with the development of a proper Personal Assistant (PA) service. (About £1 an hour lower cost than commissioned services – even when paying Living Wage) • Many service users receiving Direct Payments do not spend their full allocation – Councils are both collecting back this money and adjusting their RAS to take account of this.

18. Can prevention help? • Investing in communities (low level services) is hard to identify from where direct savings can come. Some good practice in relation to diverting people to community or family for solutions • Councils can so far manage to contain demographic pressures in all service areas – more challenging for younger adults with learning disabilities –all councils continue to work on the interventions that help with this. (Further LGA work on this) • Is a bit of care bad for you? Are people prescribed “dollops of care”- when there are more suitable alternative (e.g. tackling social isolation/ use of telecare etc)? Massive national variation. • Are permanent decisions being made when someone is in a crisis? Evidence suggests that this is where many “wrong” decisions are made for the longer term. Getting the right intervention at the right time (one that promotes independence).

19. However…… • Most Councils continue to manage reductions to residential care for all client groups through: (though significant variations between councils) • Better procurement of Intermediate Care • Better use of reablement/rehabilitation • Focus on recovery (mental health) and recuperation • Focus on outcomes • Focus on promoting independence • Some good use of housing solutions/adaptations and telecare (which promotes independence)

20. Where to next? • This is getting harder and harder for councils to sustain – 50% of the savings from Councils have come from Adult Social Care (according to National Audit Office). • Councils are having to get tougher and tougher –limiting “soft options” around choice or control – councils not funding “fun” • The NHS can offer much more to help manage demand for social care – but its hard to get that message across

21. Professor John Bolton Independent Consultant 07789748166 john.bolton@jrfb.co.uk JRFB Ltd can offer you a 2-3 day challenge/assessment of areas for potential savings for £1500 - £2000. For more help……….