construction and development partners to the care sector · 1.6–2.0 18–23 system reforms •...

My Journey

Fulbourn Hospital circa 1983 Images of Care 2010

So where are we now?

The case for change is as compelling as ever:

Three commissioning challenges:

Population demand

Costs and funding

Customer expectations

Arranging the right service for each individual

Getting the right mix of services and capacity in each locality

Working together on things that are too big for individual customers, providers or commissioners

Demand for care and support is increasing amongst all age groups

There will be a significant increase of those aged over 65..

..and, the number of disabled adults will also increase

Numbers of over 65s in England with care need

Numbers of working age adult in England with care need

The cost of meeting this demand is unsustainable

The projected cost of personal social services will rise…

…leading to a funding gap of £6bn in twenty years’ time

Projected cost of personal social services Personal social services funding gap

Expectations are rising for older people and younger disabled people….

“There are now 17 million baby boomers marching towards retirement with a

high set of demands and a clear expectation of what they want in retirement…”

(Age Concern 2004)

•  Attitudes and expectations of public services of older people now are very different to those held by people who will reach old age over the next 35 years

•  Disabled People’s movement has also emphasised the need to ensure that people can take control of their own lives

…and there are concerns over the fairness, equity and transparency

Local variation and inequalities between self-funders and State-funded people exist

It is difficult for people to anticipate and plan for the costs of care

•  In a poll, 1 in 5 people were unable to describe what they understood social care to mean

• Majority of people believe that social care is provided for free by the NHS

• Local variation and the lack of a single source of advice causes difficulties

• Local discretion means that some local authorities will fund people with moderate needs, whereas others will fund only those with critical needs. This can be perceived as unfair

• People find the current means testing system unfair

Objectives For Today

• To hear about the journey ahead. • To ask questions about post election national policies and priorities.

• To contribute to the discussion. • To exchange information. • To consider what it all means for us all?

William Greenwood Director and Senior Consultant, Hope Street Centre [email protected] Tel: 0151 709 0012

Hope Street Centre for Health and Social Care Development

Challenges in Social Care •  Budget pressures - acute pressures on local authority budgets arising from

demographic changes; •  Fragmented funding - with direct and indirect funding spread across local

government, DH, DCLG and DWP, through benefits and allowances; •  Fragmented commissioning - 150 local authorities / 152 PCTs and increasingly

individual budgets; •  Fragmented supply side and lack of scale and investment capacity - inability of •  Small traditional providers to integrate new technology (such as “assistive

technology”) or home adaptations, case finding and call centre monitoring to their service offerings.

•  Absence of diversity of service offering - little real choice in terms of quality and innovation;

•  Lack of fit for purpose “home” or “near home” accommodation - inadequate supply of appropriate tenanted/owner-occupier accommodation and inadequate supply of service or support into tenanted/ owner-occupier environments (home care, telecare, day centres, respite and rehabilitation).

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Challenges in Social Care – Another View?

Predicting the Future can be Dangerous - A Health Warning!

•  "Radio has no future." •  "Heavier than air flying machines are impossible." •  "X-rays will prove to be a hoax.”

(Predictions of Lord Kelvin, president of the Royal Society, 1890-95 )

What is Happening in the Health and Social Care System?

•  Commission on Social Care. •  The economic climate and public sector. •  Constant demand pressures on the local care

systems. •  Health and Social Care system reforms –

including GP based commissioning. •  Innovations such as Total Place.

Ones to watch.........

Policy and System Drivers

• Delivery of personalisation and increased choice and control for the citizen and user of services

• A more integrated approach across all public services with a focus on achieving ‘sustainable communities’.

• Strategic planning and performance assessment driven by outcomes.

Policy and System Drivers

• Achieving cost efficiencies and savings to the public purse with a relentless pursuit of value for money, maximising the benefits from investment.

• Ongoing innovation and improvement in a highly risk averse climate.

• A huge cultural shift in service design and delivery, leading to transformation in housing, health and social care services.

Planning: The English Context

Performance framework for LAs and their partners

NHS performance framework

Overarching principles

Delivery priorities (performance indicators )

Delivery mechanisms

Local Government White Paper

NHS Operating Framework

PCT Operational

Plans

Local Area Agreements LA Business

Plans

National Indicator

Set

NHS Vital Signs

Public Service Agreements

PSA/DSO Indicators

Departmental Strategic

Objectives

Central Government performance framework

The Economic Climate

Demand Pressures/ QIPP

% % of current revenue limit

x Spend gap, £b

Trajectory

Flat spend scenario

Growth history

Trajectory based on range derived from 5.5–7% average annual growth seen in previous years

EoE SHA area revenue limits, £bn

2010–11 data – based on commissioning framework as of January 2010

06/11/10 06/11/10 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14

0.5–0.6

6–7

1.0–1.3

11–14

1.6–2.0

18–23

System Reforms

• The Department of Health has introduced the ambition for World Class Commissioning.

• The commissioning framework for health and wellbeing sets out how services should be shaped including:

• Moving services to be more personal and sensitive to individual needs, and supporting independence and dignity;

System Reforms

•  Re-orientating services to promote health and wellbeing, investing to save (in prevention etc to reduce future ill health costs); and

•  Focusing more strongly on commissioning services that will achieve better health, across health and local government, working together to promote inclusion and tackle health inequalities.

Total Place

• Whole area approach to commissioning/ delivery of public services.

• 13 national pilot sites. • 63 LAs; 34 PCTs; 12 Fire & 12 Police Authorities + Social Sector.

• Covers older people/ children/ addictions/ housing/ worklessness/ asset management/ offender services etc.

Opportunities

• Keeping people out of hospital. • Enabling people to remain “independent”. • “New” technologies. • Working with primary care (GPs/pharmacy). • Rehabilitation services – Stroke etc. • Prevention and life style?

•  A common failing is making predictions rather than attaching probabilities to possibilities!

•  Regeneration medicine will become a major component of healthcare. –  Predictive modelling of biological behaviour. –  Wearable computers & intelligent clothing. –  Digital “butlers” i.e. home smart sensors. –  Electronic circuitry connected to nerves and tissues.

Probabilities in the Future – 2020+

Conclusions

• The future is highly unpredictable. • Nevertheless, it is important to think about the future; those who do prosper.

• A good way to think about the future is to imagine different futures/different partnerships.

• In health - care systems will increasingly be concerned with chronic disease and prevention not acute disease.

Hope Street Centre for Health and Social Care Development -

Thank You.

Nursing started in Chaos

Nursing Indicators; Future Challenge

  676,547 nurses on register

  17.15% 55 yrs & over

  13.89% 50-54 years

  34.38% 40-49%

  12,000 reduction in overseas nurses 2004-2008

Realities Nursing faces

  Revalidation NMC

  Changes in Immigration

  Economic downturn

  Ageing population & global impact

  Recruitment to profession

Care Homes; a good career choice?

 30-35% Sector staff turnover

 40% leave within a year

 60% leave within 2 years

Is this where Nurses want to be ?

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The Stark Reality

  Europe 2005 2050

  Age 20-34 28% 18%   Age 60+ 27% 44%   USA   Age 20-34 29% 26%   Age 60+ 23% 34%   Japan   Age 20-34 25% 15%   Age 60+ 33% 52%   East Asia   Age 20-34 35% 20%   Age 60+ 16% 40%   Latin America   Age 20-34 41% 29%   Age 60+ 15% 30% Source UN 2007

The Nursing Challenge

  Ageing populations > long term conditions

  Reduction in labour market

  Reduction in available revenue

  Less family care support

  Cultural challenges migration

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Future Challenges   Demographic impact

  Costs of care

  Grey vote

  Loss of tax revenue

  Intergenerational tension

  Reduction in global Migration care workers

  Global migration of Care provision

  Need shared solution

Opportunities New Realities

  New ways of working

  Greater plurality of provision

  Personal Health Budgets

  New Healthcare worker ? Registration

  National Minimum of training HCA workforce


  Develop leaders as specialists in Long Term Facility Care

  Coherent Sector Voice influencing national scene

  Engage in Research Agendas not just leave to the academics

  Develop career paths which bring specialism to forefront of nursing agenda


  Responsive flexible services

  Out reach from Care Home hubs

  Flexible respite and short term rehabilitation

  Flexible careers matrix across voluntary, social care, independent and NHS

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The world in 2050

  Chronic disease overtake communicable disease as global challenge

  Less family carers

  More older woman poor, widowed, single living alone

  Labour shortage

Nursing in 2050

  New hybrid of Practitioner Support

  Fewer Advanced practitioners

  Flexible consultants / Freelance

  Flexible Careers Portfolio careers across sectors

  Highly educated

  Partnering patients

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How does the money flow?

What do citizens want?

What are the service pressures?

Developing, testing, and

refining a series of

propositions

Total Place

•  greater collaboration;

•  a deeper engagement with citizens; and

•  a genuine focus on place?

How can we get improved outcomes at less cost through:

How providers might prosper in a Time of

Adversity

The gathering storm Or

The new hope A conflicted presentation

Three hot topics

•  5 minute SWOT analysis of the Coalition programme for government

•  How we are going to reduce public expenditure

•  Re-orientating your business to thrive in big society

5 minute SWOT analysis of the

Coalition programme for government

Qualifications •  Not all 400 commitments •  Just the ones that seem relevant to providers of

health and social care

The strengths •  Devolution of financial control and authority coupled

with ‘general power of competence’ to local government could create opportunities for innovation

•  Guarantee to increase spend on the NHS in real terms and a softer approach to cuts means more money maintained in the system

•  Easily accessible local data will enable improved planning by providers

•  More proportionate approach to vetting and barring could save money

The weaknesses •  Localisation of planning at a neighbourhood level

could make controversial development more difficult •  Relying on more GP led commissioning could be a

mistake – difficult to get local agenda properly aligned with ‘small business’ priorities

•  Further delay in deciding how to fund long term care

The opportunities •  Re-focused, better funded Sure Start for areas of

higher deprivation allied with payment by results •  Open up, simplify and make cheaper government

procurement •  Patient choice within the NHS will stimulate a

market for non-statutory providers •  Greater priority for preventative health care in areas

of higher deprivation •  General focus on payment by results is good news

for effective providers

The opportunities •  Extending the roll out of personal budgets creates a

new market of customers •  Voluntary insurance and partnering schemes for

funding long term care will create a new generation of customers with different purchasing power and expectations

The threats •  Shake up of benefits system is likely to challenge

people with intermittent but enduring conditions •  The transformation of Monitor into an economic

regulator of the NHS – will want to prove its rigour early

The threats •  Shake up of benefits system is likely to challenge

people with intermittent but enduring conditions •  The transformation of Monitor into an economic

regulator of the NHS – will want to prove its rigour early

How do you save lots of public

money?

Act like Canadians •  Canadian budget deficit of 9%+ in 1994 turned into

a surplus by 1997 •  Cuts of 20% in public expenditure aligned with

modest tax increases •  Possibly an easier strategy for a nation half the size

of the UK •  Did result in longer waiting times for hospital

admission and higher infection rates (due to over crowding)

UK Public Spending

UK Public Spending

UK Public Spending

UK Public Spending

Departmental contributions in 2010-11 Value Department for Education £670m Department for Transport £683m Communities and Local Government £780m CLG Local Government £405m Business Innovation and Skills £836m Home Office £367m Ministry of Justice £325m Law Officers’ Departments £18m Foreign and Commonwealth Office £55m Department for Energy and Climate Change £85m Department for Environment Food and Rural Affairs £162m Department for Culture Media and Sport £88m Department for Work and Pensions £535m Chancellor’s Departments £451m

Start with the first £6billion

£320 million from Child Trust Funds

Some observations on cuts

•  Pre election, the Conservative party identified £2billion in IT efficiency targets which could be easily realised

•  In reality this turned into £95million i.e. a 95% overestimate

•  Efficiency is much harder than expected •  This first wave of cuts will impact on large numbers of

interim managers in government departments •  Subsequent waves will need to reduce permanent

employee numbers elsewhere in public services

Some observations on cuts

•  Local government was the biggest loser – 19% of this first £6.2billion is coming from this area

•  Around £311m from education, £309m from transport and over £500million individual grants

•  Abolition of ring fencing around £1.7billion of central government grants from 2010/11

•  At this stage no reduction in the £29billion of formula grant

The timetable

•  May 25th £6.2billion cuts announced •  Emergency Budget taking place next week on 24th

June 2010 will set the big picture or general direction

•  Comprehensive public spending review in October will identify more precisely specific areas of cost reduction, and the means by which some will be achieved

•  In between all of this we – the public – will be chipping in our ideas for how to save money

How much is going to go?

•  The public number is 20% over either 3 years or the life time of the parliament.

•  20% over three years equates to year on year reductions of around 7%.

•  20% over five years equates to year on year reductions of around 4.5%

•  Cost of part nationalisation of Lloyds and RBS and full nationalisation of Northern Rock around £45.8billion – money recovered on sale and debt re-payment.

The spending review

•  45 days (including weekend working) is a very short time to work out how to reduce public expenditure by 20% in 3/5 years.

•  The spending review in October is probably the more significant event and will contain much of the detail of how reductions are to be achieved.

•  Cuts are a bit like quality – we measure them in terms of the detail of their impact.

The spending review

‘The forthcoming Spending Review will involve more than the allocation of resources. While it will rightly focus on reducing Britain’s record deficit and restoring sound public finances, it will also provide a platform to consider new and radical approaches to public service provision’

The spending review


There are two agendas here.

Reduce the public spending deficit – cuts in expenditure and sale of bank

assets

Reduce public expenditure forever - fundamental change in expectation of

what government does, establish a ‘lower tax’ economy

The spending review


There are two agendas here.

Reduce the public spending deficit – cuts in expenditure and sale of bank

assets

Reduce public expenditure forever - fundamental change in expectation of

what government does, establish a ‘lower tax’ economy

Your challenge is to:

Ride out the first a well as possible

Adapt your offer to succeed in the second

The spending review

•  Challenge departments, local government and delivery partners to consider fundamental changes to the way they provide vital services: –  better targeting of interventions –  greater range of service providers –  challenge state monopolies –  exploit the synergies between delivery bodies –  promote responsibility by shifting power, funding and

accountability into the hands of individuals and frontline professionals

The spending review



Means testing of universal benefits

such as child benefit, only delivering

Sure Start services to people in

deprivation

The spending review



Positive and negative incentives to

increase the role for the private

sector, and voluntary sector – with a

public preference for small voluntary

organisations

The spending review



A return to non-compulsory

Compulsory Competitive Tendering?

The spending review



Consolidate housing benefit and

other welfare payments?

The spending review



Self Help

Community Sprit

Lower expectations of the state

The spending review

•  Set out its plans to reform the welfare system •  Restrain the costs of public sector pay and pensions •  The more that can be achieved in these areas, the

more the Government will be able to do to protect jobs and spending on frontline public services

The spending review



Reduce the cost of welfare – limit access to

incapacity benefit, very strict application of

all benefits relating to unemployment

The spending review



Combination of de-facto salary/T&C caps

and more aggressive outsourcing

The spending review



Offering to trade lower salaries, and poorer

terms for job security

The spending review

•  9 big questions •  Depending on the answers it could fundamentally

change the role and nature of the state •  Feeds into key theme of localisation – local

services, commissioned locally, reflecting local priorities and ethos

•  A smaller state but bigger citizen driven activity

The spending review

•  9 big questions •  Depending on the answers it could fundamentally

change the role and nature of the state •  Feeds into key theme of localisation – local

services, commissioned locally, reflecting local priorities and ethos

•  A smaller state but bigger citizen driven activity

•  Is the activity essential to meet Government priorities? •  Does the Government need to fund this activity? •  Does the activity provide substantial economic value? •  Can the activity be targeted to those most in need? •  How can the activity be provided at lower cost? •  How can the activity be provided more effectively? •  Can the activity be provided by a non-state provider or by

citizens, wholly or in partnership? •  Can non-state providers be paid to carry out the activity

according to the results they achieve? •  Can local bodies as opposed to central government provide

the activity?

Adapting to the big society


•  10 ideas for how adaptation could be achieved.


•  10 ideas for how adaptation could be achieved. Seek to build alliances and

partnerships with smaller local/ community groups and

organisations – so that they become part of your delivery

offer

The spending review


Look to develop formal partnerships with GPs to assist them in expanding the range of

their local offer – reablement, GP supervised step down etc

The spending review


Develop support offers which formally utilise family members

at low or nil cost

The spending review


Develop housing solutions which hardwire in technology

and actively promote a sense of individuality and independence whilst increasing client density

The spending review

•  10 ideas for how adaptation could be achieved. Seek to be a partner with local authority provision and NHS provider functions which are

emerging into social enterprise status – they do not have to be

competitors

The spending review


Proactively seek merger partners which add expertise and

credibility as well as scale

The spending review


Have fully worked up strategies of community engagement –

‘people power’ is the new doctrine

The spending review


Apply effective measurement of services outcomes and quantify in terms of cashable efficiency

The spending review


Develop service offers which work for individual procurement

which are based on a mixed funding stream (private

resources and state resources)

The spending review


Work on the basis that local is the new regional but …..

customers will still expect you to price like a national

30 minutes – 3 tasks

•  Identify the top six barriers to successful complementary/joint working with the NHS

• What changes could the new government make to overcome them?

• What are the two most significant and specific contributions that social care services can make to the effective running of the NHS?

30 minutes – 3 tasks

• Decide who is feeding back

• Be ready to present your thoughts in a maximum of 5 minutes

• Critique from the expert panel and your colleagues

construction and development partners to the care sector · 1.6–2.0 18–23 system reforms •...

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