The Tory answer to the question “who pays for social care?”: You!

Image via WikiHow

Two excellent responses to the Conservatives’ social care manifesto proposal: Torsten Bell at the Resolution Foundation and, of course, The King’s Fund.

It took me quite a long time to figure out the main implications of the proposals (I’m not sure I understand them even now).

We can summarise them as:

  • If you have assets under £100,000, you’re a winner
  • If you have assets over £100,000, you’re not a winner

In essence, the Tory answer to the question “who pays for social care?” is “you, not us”.

Coupled with the proposal to scrap the universall Winter Fuel Allowance, one argument is that the Conseratives’ proposals are progressive, redistributive mechanisms that will benefit people from lower incomes, or working-age people who have been reliant on social care for their adult lives (and are less likely to have built up assets).

The counter argument – including when comparing the proposals against the Dilnot Commission’s proposals – is that these proposals create a further breakdown in the inherent universalism and sharing of risk that only government can provide (see also: the NHS).

These proposals may provide a financial solution to the social care crisis*, but they certainly don’t shore up the idea that “we’re all in this together”.

*Though deferred payments from housing still requires large short- and medium-term injections of cash, and we don’t know how inheritance law and behaviour will respond to these announcements.

People in power don’t think they have power


Most people who are thought to have power don’t think themselves they have power.

Let’s look at those thought of as traditionally having power[1].

In the world of health, we hear about the “power” of the clinician over the “patient”; in care the “power” of the social worker over the “service user”. In the world of services the commissioner is the most powerful, and in the civil service we think that power resides with (Prime) Ministers or Permanent Secretaries.

Inevitably, the person at the top of any organisation is often thought to be the most powerful: the higher you go the more powerful the people get.

And, to some extent, this is true: their decisions affect larger and larger numbers, whatever those numbers happen to represent (people, staff, money).

So how can it be that the person thought of as the most powerful in the world can lament his own lack of power?

It goes back to my opening: if you ask those people listed above who are traditionally thought to hold power, I doubt very many of them would feel anywhere near as powerful as they are perceived to be by other people.

Take a social worker: from the point of view of someone who uses care services the social worker is incredibly powerful: they potentially determine what money you do/don’t get and what types of services you can access. But if we ask the social worker about their power they will talk about the pressure of their caseload, the policies they have to implement, the limited number of providers that exist on their patch, the pressure from their manager, and several other factors that all act to curtail their power to act.

Ask the social worker’s manager if they are powerful. They’ll probably laugh at you and say they have a team of social workers completely under the kosh who don’t fill out paperwork in the way they should do. They’ll be harangued by management for implementing lovely sounding changes there is actually little resource or appetite to put into practice. They’ll be getting phone calls from providers at all times about placements that are breaking down, and they’ll be pestered to complete monitoring data they’ll never see again by people they’ve possibly never met.

Commissioners in the same area will be thought of as having the power because they hold the purse strings. When they look up from reading the scant information about the latest priority they have to reflect in commissioning intentions with no new money, alongside the 78 other priorities they’ve been given, they’ll tell you that big providers call most of the shots, or that health commissioners are in the driving seat now. For what it’s worth, the supposedly powerful providers will tell you they’re being asked to do more and more for rates that are decreasing rapidly whilst under greater regulatory scrutiny.

At the top of the care staffing pyramid, the director of social care will tell you about the unrelenting pressure of upward demand, downward resources, their obligations under the Care Act, the threat of judicial review from any one of tens of families who have been treated poorly by their department, a recalcitrant workforce working in a culture that can’t be shifted, and the waffling politics of their portfolio holder and the local health and wellbeing board. They want to do good stuff in and for their local area, but the politics (big ‘P’ and little ‘p’) significantly curtails them.

And on and on it goes: “powerful” people for whom power is little more than juggling clouds.

What to do? The only reflection I can give is to try to recognise:

  • The person you think has power probably doesn’t think themselves they have power
  • Helping them in their relatively powerless position will probably help you as well
  • To someone somewhere in the system, you are the person with power.

[1] – There is, of course, a vast literature on all types of power in a variety of different settings. I’ve not gone into that at all here, but a useful starting point for the interested reader is Chapter 10 of Fred Luthans’s Organizational Behavior (pdf).

A mathematician’s view on integration in health and social care

Though the answer may be integration, we don’t always know what the question is.

Similarly, though we often say “integration”, it’s not always clear what type of integration we mean. There are at least four interpretations of what we meant when we talk about “integration”:

  • Integration across any of primary, secondary and tertiary healthcare
  • Integration across health and social care (and education and housing and etc.) boundaries
  • Integration of resources and processes
  • Integration at the level of the individual.

As a mathematician by training, integration has another particular meaning to me. I thought it would be useful to reflect on what integration means from a mathematician’s perspective and so what we might learn from this in the context of health and social care.IntegrationMathematically, integration is the reverse process of differentiation. Differentiation is all about rates of change across different variables in a system. Differentiation is a way of thinking about the world as a result of combining infinitesimally small changes at particular points in time or space.

Integration, on the other hand, gives you a bigger sense of the whole. It tells you not just about rates of change but the overall picture you have: the sum total of what exists in time or space.

Differentiation is easier. It’s exciting (think Mick Jagger swaggering around a stage) and has no room for anything but the most important stuff. If there are any ‘spare’ numbers floating around then the process of differentiation gets rids of them – they disappear.

Integration, as any mathematician will tell you, is far harder. It’s a slower, altogether more considered process that requires more sophistication (think Bjork). There are some tricks you can use to make it slightly easier – such as integration by parts – but the challenge of integration remains.

And because integration is the reverse of differentiation it adds in an unknown factor: the arbitrary constant (from which this blog takes its name). Where differentiation has no space or time for the arbitrary constant, integration very deliberately includes it and recognises it. This unknown factor – an unidentified ingredient – is a vital component of integration.

(Interestingly, the only time the added, unknown ingredient of the arbitrary constant doesn’t play a part in integration is if you explicitly define the boundaries within which integration happens. By specifying these limits so exactly the arbitrary constant is cancelled out.)

If we were therefore to try and summarise what we know about integration from a mathematical point of view we’d say something like this:

  • Integration is harder than differentiation – though there are limited tricks to make it easier
  • It gives a bigger picture across a wider area than a specific view of just one point in time or space
  • It has a secret ingredient – the arbitrary constant – which his fundamental to capturing this bigger picture
  • This secret ingredient disappears only if you define exactly the boundaries of what integration is trying to achieve
  • Integration is a subtle, complex process that takes time and understanding to do.

Thus, though you wouldn’t immediately think it, the mathematical conception of integration tells us everything we need to know about successful integration in public services, especially across health and social care and beyond.

It’s person-centred, Jim – but not as we know it

We all have our favourite “I can’t believe that actually happened” stories in social care.

Mine relates to care and support planning: whilst observing a panel process (error number 1), a Head of Social Care instructed a social worker (error number 2) to change a support plan so that all sentences were “I” statements (error number 3) from the point of view of the patient [sic] (error number 4), without going back to the person themselves (error number 5).

It would be funny if it weren’t so normal.

But we hear variations of this all the time, summarised in the line:

Of course what I do is person-centred care – it always has been

If we are honest, relatively little of what currently happens in the care and support system is person-centred (though we’re definitely moving in the right direction).

This being the case, we should ask ourselves: if it isn’t person-centred, then what is it? I think there are at least four alternatives:

  1. Money-centred care: where what people get is what commissioners can either afford, currently buy, or have always bought
  2. Provider-centred care: where the primary objective is to ensure the ongoing feasibility of an organisation rather than the people it serves
  3. Process-driven care: where filling out the paperwork or keeping the IT system happy is the main driver
  4. Professionally-driven care: where the professional knows best and tends to think of the person in front of them as another one of their caseload or a walking set of conditions

Thinking of it in this way shows why the drive to person-centred care has been so difficult: it requires significant change on a number of major fronts – the flows of money, the role of providers, the supremacy and comfort of process, and the culture of professionals.

It’s why I’m personally so excited about person-centred care and what it means for the future. It isn’t just an optional variation of what we’ve always done; it flips public services as we know them on their head. To make this happen, though, we need to be clearer on the alternatives that being person-centred is replacing.

Social care council tax precept: the beginnings of an opportunity?

social care precept
The distribution of revenue raised for each council per head by the social care precept (Source: Richard Humphries at the King’s Fund)

First, some facts on where we are with local government and social care spending:

  • Local government saw a 37% real-terms cut in government funding between 2010/11 and 2015/16 (NAO (pdf), executive summary)
  • Adult social care expenditure fell by 8.7% in real terms between 2010/11 and 2014/15 (NAO (pdf), para 1.15)
  • There has been a corresponding fall in social care activity in all areas of social care: homecare, day care, nursing care and residential care (between 2008/09 and 2013/14 – when data is available) (NAO (pdf), figure 4)
  • Net local government spending per person (excluding public health, education, police and fire services) has been reduced by 23.4% between 2009/10 to 2014/15 (IFS (pdf), table 2.1)

Second, the effects of the social care precept. (Recall that the council tax precept for social care was introduced in the 2015 Spending Review, and is the ability of local government to raise council tax by up to 2%, as long as it is spent on social care.)

  • LGA analysis suggests the council tax precept for social care would raise £400million in 2016/17, but only if all 152 local authorities used the precept in full
  • The average Band D taxpayer would see an average rise of £24 in their council tax bill if the precept were used in full in 2016/17 (LGA)
  • (The LGA has previously estimated that the social care funding gap would grow by at least £700 million in 2016/17. The introduction of the National Living Wage will cost councils at least £340 million in 2016/17 on top of this gap)
  • Though the Treasury thinks the social care precept will raise £2billion by 2019/20, the King’s Fund notes the precept will (a) widen the gap in provision between richer and poorer areas, and (b) raise at most only £800m a year.

It’s hardly grounds for optimism is it?

And yet, I find myself wondering if there are reasons for hope in the social care precept? I suggest this for two reasons:

  1. By saying that social care costs can be met by a centrally-enabled (general) tax, it feels to me that the government has set a precedent for funding social care through general taxation. This has not been an option government has realistically considered before, though there are plenty of ways general taxes can be levied and used (see, for example, pp.31-37 of the final report of the Barker Commission (pdf))
  2. People will notice if their council tax bills rise. They’ll probably not appreciate it, and will want to know why their bills have gone up by an average of £24 for social care alone. We know that the general public has very little awareness of how social care is funded (see Chapter 2 of Ipsos Mori’s research for the Dilnot Commission (pdf)), so this therefore represents a communications opportunity that could begin to put social care (and how it is funded) on a par with the NHS in terms of public awareness.

It’s not much to go on, but the ability to make the case for adequate and sustainable funding for social care needs all the help it can get. The social care precept itself is neither adequate nor sustainable; but it might be the beginnings of an opportunity.

Another cross-party commission on health and social care?

Andy Cowper is most probably right that there won’t be another cross-party commission on health and social care:

A cross-party funding commission on health and social care might get traction if funding issues represented an imminent and significant political challenge to the Government.

Thanks to The Fixed Term Parliaments Act and the tacit, uncivil war within the Labour Party, this does not seem likely.

Andy also makes another vital point: the Treasury doesn’t think there is an NHS financial crisis, let alone one that can be fixed by investing more in social care.

(As an aside, can someone explain to me why ex-Ministers seem to be more proactive in a policy area than they were when actually Minister for the relevant portfolio? This, of course, is a rhetorical question, but doesn’t make the situation any less frustrating.)



IPCMy current work is on the Integrated Personal Commissioning (IPC) programme, working for Think Local Act Personal and closely with NHS England.

A natural question to ask is “What’s that?”, and it’s a very good question.

Before answering that, though, I think there are questions we should ask before, such as:

  • “What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
  • “What difference do each make?”

This is the third of three posts looking at each topic individually (see the introduction to this short series and the posts on ‘integrated’ and ‘personal’). It’s a very quick way into the issue of commissioning, sharing information that I’ve found useful in my own learning. It’s not intended in any way to be comprehensive! Thus, if there are things you think should be added feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.

What do we mean by ‘commissioning’?

Put bluntly, the core role of commissioners has been to buy services for their populations, although it has always been more than this.

This is from Health Select Committee’s report on Commissioning in the NHS (pdf) – a report which notes (rightly) that the vast majority of the public don’t know what commissioning is despite its central importance to the running of health and social care.
Commissioning models in the NHSThere are endless reports, chapters and even books on the topic of commissioning. Below, therefore, is a very brief summary of some of the key developments in commissioning relevant to health and social care.

Commissioning in the NHS began in earnest with the ‘purchaser-provider’ split of 1991 and has
been maintained since then (though in various guises – see Box 1 to the right). The “more” than buying services for populations that commissioning is has best been captured by the commissioning cycle. There are hundreds of versions of the commissioning cycle, but each is essentially a variation of the following:

IPC_commissioning_cycleAs with integration, commissioning can happen at a variety of different levels. This is most obvious in health:

Commissioning levelsCommissioning in social care also emerged at the same time as the purchaser-provider split in the NHS. It took a slightly different form, however, with more emphasis put on the role of care management – where social workers were central to assessing need, arranging packages of care and managing and negotiating resources. This new approach was reflected in the Caring for People White Paper (1989).

Commissioning has come a long way since then, at least in the number of commissioners. The Barker Commission highlighted particular the problem of increasing fragmentation of commissioning responsibilities between different organisations within the NHS and local government – estimating there to be over 400 organisations with responsibility for commissioning. The main response to this has been “joint” or “integrated” commissioning across health and social care.

The development of personalisation in adult social care was a focus of attention in commissioning, especially focusing on the role of market shaping, market facilitation and market development. This was a new role for local government, best captured in the work of the National Market Development Forum (pdf).

Finally, an alternative to top-down commissioning is bottom-up commissioning, or more nicely what we might call people- or community-led commissioning. At the individual level this is essentially what Direct Payments are (and what we are seeing in the extension to Personal Health Budgets; see the post on Personal for more information on what this is and its effects). At a collective level it is best represented by the idea of co-production in commissioning or people-powered health.

(It’s worth noting that relatively little attention has been paid to decommissioning. Two honourable exceptions are this paper from IPC (pdf) and this decommissioning toolkit from the National Audit Office.)

Here is a selection of what I’ve found to be the most useful documents on commissioning:

What difference does commissioning make?

[It is] clear that there are few examples of robust evaluations of commissioning in the academic literature. Moreover, the grey and practitioner literature tends to focus on commissioning in single government departments, local initiatives or single services/client groups. It has been noted that the efficiency, effectiveness and efficacy of commissioning and strategic commissioning is typically taken for granted rather than demonstrated… The evidence base on the outcomes of commissioning remains under-developed and such evidence as exists is equivocal – Williams et al. (pdf)

Asking whether commissioning makes a difference is a very interesting question. One of the issues with it is knowing exactly whether what is happening in practice is actually good commissioning. Mark Britnell, who led the development of World Class Commissioning within the NHS, commented:

It might strike you as slightly odd—it did me coming into the department—that no-one had defined what good commissioning was in 20 or 30 years. (para 137) (pdf)

Having thus defined what good commissioning looked like, an assurance framework to quantify how good commissioners were showed that most commissioning wasn’t very good: in only one of ten competencies did people achieve better than half marks in their ranking:

Source: King's Fund
Source: King’s Fund (pdf)

If knowing what was happening in practice was actually commissioning was one problem, the other major issue was in understanding the difference commissioning makes is. The main issue here was the lack of a counterfactual: if commissioning is the only option, there’s nothing to compare it against.

Against this backdrop, we therefore shouldn’t be surprised to read that nearly all flavours of commissioning attempted in the NHS have not had much impact against a variety of themes, including efficiency, equity, changing patterns of service delivery, quality and partnership working.

The best of what we do have is therefore as follows:

Overall the research suggests that examples of fully integrated commissioning are limited, and that this approach is typically confined to a small number of service areas. It follows that research into the nature and, in particular, the effectiveness of joint commissioning is also relatively limited… The evidence that is available suggests that the nature and success of integrated commissioning arrangements varies significantly between local areas and between services.

Commissioning evidence of impact

In social care there is a similar issue. Only recently has the University of Birmingham attempted to create a comprehensive framework of what good commissioning in social care is. Even then, there is no requirement to use this framework or measure commissioner performance against it. Much of what we know about the effectiveness of commissioning in social care comes from the literature mentioned above.

People-led commissioning is an emerging area; as such, the literature is nowhere as well developed. There are some bits of evidence, however, most notably the findings of the People-Powered Health initiative (pdf). Other evidence is available from particular sites, such as work in the Isle of Wight done by the Health Foundation.