The debate about the crisis facing elderly care tends to focus on either the broad implications for public finances or on emotive stories about the later lives of vulnerable individuals. Neither perspective is helpful for adult social care chiefs at the local level, and can just make the problem feel insoluble to those doing their best under difficult circumstances. But as Winston Churchill said: "It is not enough that we do our best; sometimes we have to do what's required". There are practical steps that local authorities and their partners can take that will make a real, sustainable difference to the people they serve.
Councils can be fitted into three broad categories depending on the way they respond: Transformers, Titanics, and the Inbetweeners.
Transformers recognise the scale of the task ahead and understand that conventional responses will be inadequate. They have begun to do different things in radical ways. In Greenwich, for example, staff from the council and the NHS will soon be based in the same building as a further step towards integration between health and social care.
Councils which can be considered Inbetweeners see that something significant is happening, have ideas about how things need to change, but lack the skills and experience to implement that change quickly or effectively.
The Titanics do not fully recognise the problem, or believe that adult social care in its current form is unsinkable. Change here is ineffectual or focused on the wrong things.
So what defines a Transformer authority? Transformers comprehend the scale of the challenge and use this as a lever for change. They recognise the figures in the Barnet "graph of doom". Their analysis showed demographic growth would result in 70% of the borough's total revenue being spent on adult social care within 20 years. That focuses minds and challenges the status quo.
Transformers prepare the ground to minimise opposition. First, they set out the principles that must underpin the changes. Hampshire's adult services directorate has a strategic aim "to maximise independence", which helps to ensure services focus on what its users can do, rather than what they can't.
These authorities then anticipate and plan for the response to change. Engagement is essential to encourage supporters – and to mollify the opposition. In Hampshire, elected members and staff spent months talking to carers and users of learning disability day centres to convince them of the need to move towards alternative opportunities, which would give service users more freedom to do what suits and fulfils them.
Transformer councils then actively manage demand, not confusing demographic growth with increased demand for council-funded services. Access to council services here is focused on those most in need, while the more able are signposted elsewhere. Dorset county council invests "seed corn" funding in local community groups, which provide excellent social care support at minimal cost to the council.
In contrast to Titanics, Transformers actively expand their suite of traditional social care tools. They make telecare or re-ablement the first option for new clients. They convert residential homes into extra-care apartments and they commission step-down beds to prevent hospital discharge direct into residential care.
Transformers look again at their contracting arrangements, challenging those contracts that perversely incentivise unnecessary growth in packages of care. Wiltshire council has introduced outcome-based contracts under which providers are expected to build service user independence. Early results show that a good proportion of users are emerging from their period of initial support with low or no future social care needs.
Transformers engage with local NHS colleagues at the most senior levels and set clear objectives for integration of health and social care, long before they worry about the detail of organisational arrangements. They design evidence-based care and local financial incentives to achieve the desired results. Finally, Transformers understand that culture change is critical. Staff will be wary that changes may harm service users and will try to hold on to the status quo. Social care professionals must be challenged, and supported to see their role differently.
Transformers see culture change as a project in itself that must be driven like any other. The Titanics, who cannot take on these challenges, risk sinking. Experience elsewhere – for example, when a school is placed in special measures – suggests that in the wake of catastrophic failure the old regime immediately loses its influence, if not their jobs. So if councils want to continue to set their own local adult social care priorities, staff need to take the tough decisions required to become sustainable now.
Steve Carefull is an expert in adult social care at PA Consulting Group.
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