Cinderella Service In An Alice In Wonderland World
As our elderly population grows and care resources are put under increasing pressure we need a national debate to focus on the quality of life in later years, says Janet Sillett
For too long, adult social care and services for older people have been the poor relation of health and children’s services. Now they seem to be rising rapidly up the political agenda. The impressive response to the inquiry by the All Party Parliamentary Local Government Group into services for older people clearly reflected their increasing political importance and the urgency of tackling the current problems.
Adult social care is in crisis – care costs are escalating; we have a rapidly ageing population and declining public resources. Each year more councils are forced to restrict services – three- quarters of local authorities now only provide care for older people with critical or substantial needs. The system is hugely dependent on private and informal care.
This is an Alice in Wonderland world and everyone knows it: services that prevent or delay illness and disability are much less expensive than acute services. But, as we cannot even cope with the rising costs of services for those in crisis now, investing in a longer term preventative agenda is very hard to achieve.
There is no shortage of policy or aspiration on improving older people’s services – the reality is, however, very different for many people.
The evidence to the inquiry was not all depressing. There was much that was innovative; submissions showed the passion people felt for improving services. There were numerous examples of health and social care working together, including councils’ promotion of a positive agenda around personalisation and the genuine engagement by older people in policy planning and service delivery. The involvement of older people as carers and volunteers, as advocates and campaigners, shone through.
The first strong message from the inquiry was that this is not only, or even primarily, about health and social care. The inquiry report, Never Too Late for Living, underlines that “if the rhetoric around choice, control, dignity and independence is to be translated into reality, policy reform will need to address a wider agenda than social care and health, such as housing, leisure, planning and transport”.
What was critical for the panel was not an exact definition of the outcomes that define quality of life, but the principles that should underpin it – there must be consistency nationally; there must be flexibility locally, and the lives of older people must be seen in the round. Easy to say but harder to deliver.
Never Too Late for Living suggests a national debate on the quality of life in later years. The outcomes will not be surprising – the point is to engage the public and to achieve consensus by government. If outcomes are public and recognised, local areas must set out how they will be delivered in a way that makes sense. If central government has succeeded in setting expectations nationally, local areas will face expectations from citizens to deliver – this is the best performance management there can be.
Working more closely together across departments, agencies and services is a persistent mantra. Despite the many good examples, the evidence highlighted numerous barriers to progress, particularly between health and social care.
Different legal and financial systems and cultures impede integration; information requirements and systems are not compatible; there are issues around privacy and sharing information. The frequent structural changes in the NHS have meant it has been hard to build up relationships.
Increasing fragmentation of delivery in the NHS can make joint working harder to achieve. Central government is not always very joined-up. Above all, much greater strategic level service integration is difficult without addressing the differences between health care being free at the point of delivery and social care increasingly subject to means-testing.
The inquiry was from a local government perspective and could not cover the big funding issues in detail, but the panel did recommend some steps to greater integration. They wanted to see a staged process of integration starting with pooled funding through the local area agreement (LAA), with health money being increasingly channelled through LAAs to focus on prevention. This would be followed with a piloting of merged commissioning for health and social care, led by the local authority.
Such a change in the system requires a smarter approach to addressing the complexities of the relationships between agencies and services. In the introduction to the inquiry report, Local Government Information Unit (LGiU) chief executive Andy Sawford insists reform will mean: “reshaping delivery and access to increase efficiency in the system, to maximise the use of public funding as a whole, and to ensure genuine engagement by communities and older people themselves”. He says it will need to be more explicit about what is cost effective and what are entitlements, as well as ensure there is clarity and consensus over what is funded and by whom. “It will require an urgent examination of the boundaries between health and social care responsibilities and accountabilities,” he concludes.
The parliamentary inquiry is an important contribution to what should be a lively, contentious and public debate about how society can respond positively to demographic change. It may be a difficult challenge, but it should be a major opportunity to increase well-being and the quality of life for all of us.
Janet Sillett is the author of the All Party Parliamentary Group report on older people and a policy analyst at the LGiU