Post-Dilnot, it’s time for a rethink on adult social care
If its aim was to create a burning platform for adult social care services, the Dilnot report, ‘Fairer Care Funding’, was a success, writes Keith Coleman
The report couldn’t have been more plain: “The adult social care funding system conceived in 1948 is not fit for purpose in the 21st century and is in urgent need of reform.”
Few among those who work in adult social care services would disagree. They are all too aware of the pressures the system faces, with rising demand competing with calls to cut costs. These pressures will only worsen with an ageing demographic and the rise in younger people accessing the services.
So recommendations on additional spending were welcome. But will they go far enough? Projections suggest demand for adult social care services will rise by 25 per cent in the next 10 years in many areas. So an additional £2bn, while welcome, will not solve the problem. Unless it is fixed, social care will drain local authorities dry.
Local authorities have several options for keeping costs down: they could raise barriers to entry, limiting demand. Or they could centralise and standardise – much like the NHS – to try to find economies of scale and eliminate personalisation (perhaps even under the cloak of doing away with the infamous ‘postcode lottery’). But neither of these unpalatable routes is likely to win the support of chief executives. The first puts protesters outside city hall. The second goes against the grain of localism and customer choice.
The most desirable option is to have a go at fixing the system, moving from the inherited, outmoded structure, culture and delivery system to one driven by customer demand and involving the wider stakeholder community. It involves a radical rethink of how services are commissioned and delivered, and pushes innovation across frontline services.
It also means fundamentally changing the nature of the ‘client’ relationship with adult social care services and shifting from a culture of dependency on state-provided solutions to one of prevention and self-service.
People have become so reliant on state provision that we’ve virtually forgotten how to look after ourselves. And the public sector has become so used to being the provider that it has forgotten how to lead communities into self-provision.
So it’s a question of how we can move to a more customer-driven delivery model where individuals and communities are active in directing their own care.
The ideas themselves are not complicated, but they call on everyone involved to think differently – not an easy ask.
But there are some simple points of change:
1. Self-guidance: empowering people to become experts in meeting their needs, working with local authorities to direct their own support and care and that of others in similar circumstances
2. Operational redesign including efficiency improvements in workforce, management, and case and demand management – 30 per cent productivity gains are possible
3. Rethinking the incentives in the system to be truly outcome-based, and changing commissioning.
Take prevention: why wait for a need to arise when experience demonstrates that there are some common triggers for adult social care services? We know what the triggers are: death of a spouse, hospitalisation, the onset of illness, a harsh winter. There’s an opportunity to actively manage demand, anticipating needs and working with community partners to provide the best early intervention before really expensive care is required.
Community provision, too, should become an integral part of the response to need. The question becomes not: what is the service must we provide; but how can we facilitate and finance a solution? Who will provide the care and support – whether on a professional basis or not?
Personalisation also becomes a priority, empowering people to direct their own care and support. That’s a big transition for the supply side, but buyers wouldn’t have to start alone – providing end-users with a supported personalisation budget would ultimately result in better commissioning.
Local authorities are already addressing operational inefficiencies to support more active client management – from the first point of contact through case assessment to follow up.
A fundamental issue remains: the economics of the adult social care system are complex and confusing, making it difficult for chief executives to understand the implications of the changes they are making. We are working with local authorities to put in place an economic model to enable them to start realising system efficiencies and identify value.
There are already examples of leading practice, but we need a holistic approach with the local authority as broker and leader.
One thing is certain: doing nothing is no longer an option. Dilnot took some of the financial uncertainty out. If it galvanises people to take more radical action, it will pay back the £2bn many times over.
Keith Coleman is global and UK head of public sector at Capgemini Consulting