The golden threads of prevention

The public sector will have little alternative other than to adapt to continuing pressure on spending until the budget deficit is under control, or the end of the decade, whichever comes sooner.

However, as most commentators with an interest in a viable adult social care sector have pointed out: the status quo looks unsustainable. The UK already dedicates a lower proportion of GDP to caring for its older population than Canada, New Zealand and half of Europe. There will be 2.5 times as many people over 85 in the UK in 20 years as there were in 2010. In the next 12 years we face a 40% increase in the number of people with dementia.

In an ideal world, we would see a steady growth in adult social care funding to at least bridge the predicted £4.3bn gap by 2020. Realistically, aside from any financial support for new Care Act responsibilities, there seems no prospect of an increase in funds for adult social care.

How should local authorities respond? Many have done a great deal already, but there are two golden threads that must be woven through the fabric of adult social care provision. The first is a focus on prevention and independence-building; the second is commissioning for outcomes.

Many local authorities have taken tough decisions to protect adult social care budgets, meaning other service areas have suffered disproportionate cuts.

Whilst this may be defensible where the adult social care spending is statutory, it is much harder to take this approach when the spending is discretionary, such as for measures to reduce isolation or the risk of harm from falls. That means authorities may end up cutting relatively small investments in preventive schemes that keep people living independently for longer but end up with increased demand and much higher service costs downstream.

Robust evidence of effectiveness is the best hedge against future cuts. Hence the key to protecting and justifying spending on preventive services is to ensure outcome tracking is built in from the start. It is not enough to launch a preventive service because it ‘feels like the right thing to do’.

Commissioners need to describe exactly what benefits a service should deliver and then put in place measures to confirm that the results are achieved. Whilst this is not easy when the objective is a ‘soft’ one, like community development or building social capital, it is possible. For example, by tracking a control group to see if needs grow at the same pace, combined with systematically collecting detailed user and carer feedback. If the expected benefits do not materialise, the service should be ended on an agreed timetable.

Even where new care services are designed with clear outcomes in mind, these can be lost during the commissioning process. Local authorities too readily rely on input prices when letting contracts because they provide certainty and are easier to compare like-for-like across bidders. Instead, commissioners should try to get users and providers around the table in advance, to co-design a service specification that delivers the best outcome for the available resources.

Some councils have started down this road. Wiltshire, for example, let its domiciliary care contracts on an outcome basis. Their providers receive 20% of their fee upfront, with the balance payable only if an agreed outcome is achieved. These outcomes are set, with the involvement of the service user, to maximise independence and reduce reliance on other costly services. In order to achieve this, the council has had to re-train its social workers so rather than stipulating tasks by input time, they specify outcomes and assess whether they have been delivered.

Another example of an outcomes-based approach can be seen in Hampshire CC’s Argenti Telehealthcare Partnership with PA Consulting Group, which includes a significant payment by results component. This forces the partnership to focus on the outcome of increasing independence, rather than distributing telecare equipment indiscriminately because it’s ‘a good thing’. The latest analysis shows that service users with telecare avoid additional care costs for an average of nine months longer than those without telecare, saving the council over £700 net per person per annum.

These golden threads are intertwined and the focus on prevention should flow into the commissioning, contract award and payment process.

Commissioners should develop requirements that prioritise building independence and set out how this will be measured. When they take new requirements to market, the desired outcomes should be made central to the contract process, for example by including a payment by results mechanism and ensuring the bid evaluation regime gives due weight to lifetime value, not just input costs.

This focus on prevention and commissioning for outcomes cannot bridge the whole adult social care funding gap, but these practical steps should make a real difference in helping councils to cope with the shortfall.