New modelling and old tricks for Birmingham adult social care

So this year's budget consultation for 2016-17 onwards started with language at the press launch about savings that appeared to be a Macguffin to make the overall numbers fit to present a balanced budget. Thankfully, once I heard Alan Lotinga (Service Director for Health and Wellbeing or whatever title he possesses this week) speak at last week's consultation event at Cannon Hill Park, the vagaries of the new Council Leader John Clancy and the consultation paperwork were dispelled.

In essence, the consultation papers present the savings to BCC adult social care budget. What it doesn't distinguish is the difference between a reduction in council costs with the expenditure of the department. In this case, £20m of the proposed £30m savings is made up of Better Care Fund monies replacing BCC spending with £10m of identified cuts making up the £30m. This is common practice across the country as the Better Care Fund is used to prop up social care (the Kings Fund estimate that the national 10% cuts to adult social care would be 17% without the BCF).

Now, given that John Clancy had only been in post for little more than a week, I can forgive him being misled by ill-defined consultation briefing papers and I suspect that his inherited cabinet member responsible Paulette Hamilton hasn't articulated this clearly enough either.

So last Friday, I experienced relief that it was only £10m of cuts (smaller than this year cuts). This is the reality of being involved with the last few years consultations, you get ground down into accepting big numbers like £10m. I made a point of thanking Alan afterwards as he had given real information.

That's not to say that there won't be funding choices within that £20m towards redesigning services as part of Birmingham's collaboration across care pathways with local NHS bodies. The nine workstreams set out in the local Better Care Plan and the pooling of budgets between BCC and the NHS are recognition that with all parties facing austerity (see the 5 year forward planning to deliver £20bn of efficiency savings in the NHS) that alternative ways of working have to be found to cope with these pressures.

However, if there is one thing designed to depress, its the claim for usage of methodology by Birmingham City Council which has been shown to be less than adept at generating the remodelling and cost savings claimed. Not only by other councils and academic studies but in practice by BCC itself.

I do find this particularly troubling. When I look at the workstreams of the BCF plan, I see the opportunity to develop genuine person-centred care and place-based care yet the language being used by politicians to describe remodelling is around personal budgets, direct payments and independent living. It is strange to see the city both ahead of the curve and a decade behind simultaneously.

Professor Martin Knapp of the London School of Economics and Political Science has done work on personal budgets and direct payments and found that although people may be happier with the decisions being made in their care, it doesn't reduce care costs but merely changes the delivery of those costs. The take home point here is simple - that meeting people's need requires money and changing how the money flows doesn't reduce that need. Also given that BCC recent survey of service users showed significant resistance to moving to a direct payments system, this appears to be a rather optimistic position to take.

As for independent living, the last couple of years experience should have disabused BCC of the idea that this is an area to claw significant savings in the timeframes being discussed. To explain, Birmingham is an outlier in terms of the percentage of service users in residential care for which the city bears all costs within its budget. With independent living, the housing costs can be drawn down from Whitehall in the form of the Housing Benefit grant. So officers compared BCC current position with that of the local authority with the highest percentage of independent living and then calculated the savings if BCC had the same percentage. There was nothing else to the methodology (I asked) and this 'saving' was presented to successive cabinet members as a way of contributing to the savings the city needed to make.

The reality of attempting this has been very different. The process has been run with integrity and found a large level of inertia. There isn't the market response to remodel existing service provision or move service users to new facilities. Perhaps most importantly, there isn't the willing to disrupt people's homes and their support. While numbers can be shifted on a spreadsheet, real people in real situations are very different.

Birmingham needs to face up to the fact that through its past actions, it has a legacy of residential care that will take a significant period of time to reduce. Its easy to make airy claims of moving from "dependence to independence" as Cllr Hamilton does but I've heard the same thing from her two immediate predecessors Steve Bedser and John Cotton. It is a weakness that this cabinet post has seen rapid turnover meaning that any learning disappears too quickly.

There also needs to be an acceptance that there are other factors of inertia that influence this dependence vs independence issue such as the fact that benefits use a deficit model of disability and award funding for what people cannot do. Even social care assessments undertaken by the council have strong deficit-modelling within them despite the best intentions for an 'asset-based' approach (like John Clancy, I dislike this term). With the pressures on finance and making the most of limited funding, the pressure is towards filling the deficits.

This contradiction between intention and practice also concerns me with the intention to only offer direct payments to young adults with disabilities transitioning from children's services to adult services. This isn't just crude in application but could be counter-productive when we consider that Better Care plan and pooled budgets. There is a difference between independent living (a technical definition) and independence of living (a philosophy). For example, young adults with learning difficulties could be in a semi-residential setting where they have access to pooled support enabling them to make choices throughout the day and evening whereas other young adults with learning difficulties could be living in 'independent living' yet be effectively curfewed due to lack of support available.

Not only does this policy not take into account costs on the health side (both immediate and longer-term) which the Better Care plan is meant to do, it ignores the first rule of independence which is the choice to choose their living arrangements. It, sadly, is part of that old Birmingham habit of doing things to people because it is good for them.

While the principle of maximising independence cannot be argued with, the city need to avoid changing one fixed pattern of behaviour with another. There are no easy paths to remodelling the needs of the city. Its a slow and continuous process which requires flexibility in approaches.

Likewise, I would urge caution as to the potential savings from the Better Care process. For example, while there are duplication of service provision in the NHS and BCC, it doesn't follow that there is double counting of need. My strong suspicion is that a proportion of the population is happy with drawing disability benefits and using the NHS while avoiding BCC and social workers altogether. The city has to be aware that a Better Care mapping exercise may present a larger cohort with identified needs to plan for and deliver services to in an integrated form.

This isn't an exhausive list of risks facing the city as it hopes to achieve £40m of savings in the next few years, I could mention the lowering of what qualifies as substantial need as a result of the 2014 Care Act compared with how the city currently operates or the expanded duties and requirements contained within the Care Act being enforced through judicial review. Its hard therefore to envisage the savings being delivered. So what can Birmingham do?

The first thing that the city could do is commit to using a significant proportion of John Clancy's 'bonds for housing' concept into generating activity in the adult social care marketplace. As I touched on earlier, there is sizeable inertia/lack of diversity in the market currently and there are numerous warnings of the market collapsing due to rising costs and a lack of purchasing power by local authorities. Offering partnership and patience financing would support the market and help towards achieving the savings required.

Related to that is around commissioning. The sense I get is that the city is more concerned with process rather than outcomes and struggles to move beyond rigid ideas (such as only offering direct payments for independent living above) which frustrates partners/potential partners in the private and 3rd sector. Without damaging certain controls, there needs to be an adoption of metrics that allow more art into commissioning services. Which brings me to the Better Care plan.

If the Better Care process is to facilitate real change then the city and its partners need to commit to its direction of travel, namely place-based care, explicitly. This is the recognition that approximately a fifth of healthcare outcomes result from clinical treatment with the majority of benefits come from lifestyle, environment, family and social networks. This is also the direction of travel that is explicit with the wellness agenda within the 2014 Care Act.

Rather than make bland statements about "remodelling adult social care" or "doing things differently" which are intangible and unmeasureable, this city needs to make a statement as to what it wants to achieve. Modelling adult social care along place-based principles would enable the development of milestones that can be measured and agreed with both service users and the wider electorate. It also offers a scope to expand and support other city objectives when we eventually move beyond austerity (one day...).

It also fits into the Better Care process in that local authorities and the NHS need to develop common metrics that allow both parties to measure success and savings on both sides. Such metrics should feed into commissioning especially where pooled budgets are concerned. I'm not yet convinced that enough thought has gone into this.

There are other thoughts I have about the consultation with regards to adult social care, let alone other parts of the consultation. For this part of the consultation, my plea is for greater recognition of the risks and a commitment to thinking beyond the narrow options proposed to achive remodelling as they won't. This city needs to be a lot smarter and creative in how it tackles this incredibly difficult situation.

Note: this is the product of late-night blogging. Links and labels will be added later.

Mazars and the Parliamentary Urgent Question

This morning, the Secretary of State for Health Jeremy Hunt responded to an urgent question from his shadow opposite Heidi Alexander on the leaking of the Mazars Report into unexpected deaths between 2011 and 2014 under the care of Southern Health Mental Health Trust.

I don't want to discuss the substance of the report here as it is ably being discussed elsewhere. Rather I wanted to focus on the 30 minutes in the House of Commons.

Because of the current unpublished status of the report, even with Parliamentary privilege, MPs were rightfully careful of their language. Yet the manner of Jeremy Hunt's statement should leave no doubt as to the status held of it by the Government and NHS England. 

Jeremy Hunt's Statement

The whole House will be profoundly shocked by this morning’s allegations of a failure by Southern Health NHS Foundation Trust to investigate over 1,000 unexpected deaths. Following the tragic death of 18-year-old Connor Sparrowhawk at Southern’s short-term assessment and treatment unit in Oxfordshire in July 2013, NHS England commissioned a report from audit providers Mazars on unexpected deaths between April 2011 and March 2015.

The draft report, submitted to NHS England in September, found a lack of leadership, focus and sufficient time spent in the trust on carefully reporting and investigating unexpected deaths of mental health and learning disability service users. Of 1,454 deaths reported, only 272 were investigated as critical incidents, and only 195 of those were reported as serious incidents requiring investigation. The report found that there had been no effective, systematic management and oversight of the reporting of deaths and the investigations that follow.

Prior to publication, or indeed showing the report to me, NHS England rightly asked the trust for its comments. It accepted failures in its reporting and investigations into unexpected deaths, but challenged the methodology, in particular pointing out that a number of the deaths were of out-patients for whom it was not the primary care provider. However, NHS England has assured me this morning that the report will be published before Christmas, and it is our intention to accept the vast majority, if not all, of the recommendations it makes.

Our hearts go out to the families of those affected. More than anything, they want to know that the NHS learns from tragedies such as what happened to Connor Sparrowhawk, and that is something we patently fail to do on too many occasions at the moment. Nor should we pretend that this is a result of the wrong culture at just one NHS trust. There is an urgent need to improve the investigation of, and learning from, the estimated 200 avoidable deaths we have every week across the system.

I will give the House more details about the report and recommendations when I have had a chance to read the final version and understand its recommendations, but I can tell the House about three important steps that will help to create the change in culture that we need. First, it is totally and utterly unacceptable that, according to the leaked report, only 1% of the unexpected deaths of patients with learning disabilities were investigated, so from next June, we will publish independently assured, Ofsted-style ratings of the quality of care offered to people with learning disabilities for all 209 clinical commissioning group areas. That will ensure that we shine a spotlight on the variations in care, allowing rapid action to be taken when standards fall short.

Secondly, NHS England has commissioned the University of Bristol to do an independent study of the mortality rates of people with learning disabilities in NHS care. This is a very important moment at which to step back and consider the way in which we look after that particular highly vulnerable group.

Thirdly, I have previously given the House a commitment to publishing the number of avoidable deaths, broken down by NHS trust, next year. Professor Sir Bruce Keogh has worked hard to develop a methodology to do this. He will write to medical directors at all trusts in the next week explaining how it works, and asking them to supply estimated figures that can be published in the spring. Central to that will be establishing a no-blame reporting culture across the NHS, with people being rewarded, not penalised, for speaking openly and transparently about mistakes.

Finally, I pay tribute to Connor’s mother, Sarah Ryan, who has campaigned tirelessly to get to the bottom of these issues. Her determination to make sure the right lessons are learned from Connor’s unexpected and wholly preventable, tragic death is an inspiration to us all. Today, I would like to offer her and all other families affected by similar tragedies a heartfelt apology on behalf of the Government and the NHS.

No-one reading that should take credibly the claims in the HSJ article this morning which ran with the counter claims of a tame academic appointed by Southern Health and having a partial extract of the report shown to them. Still its another example of the desparate lengths the Trust are prepared to go that is in the public arena. NHS England take note.

This was a shocked chamber that listened to and responded to Hunt's statement. There were two questions that reoccurred that need highlighting. 

The first question was when did the Secretary of State know about the concerns over Southern Health. The answer was early 2014. The issue about repeating this question is that there has been a delegation of power from the Department of Health to NHS England through the 2012 reforms. The Secretary of State cannot be hands on as previous secretaries of state were. 

As a result of repeated marketisation reforms, the NHS banner contains numerous separate legal entities. The ability to act has to be lawful and consistent. It is, in my opinion, this space that has allowed Southern Health to make 300 challenges which will have been legally argued as required. Here its worth noting Jeremy Hunt's response to Andrew Turner:

The commitment I have from NHS England is that it will be published before Christmas. I am confident that, whenever it is published, it will generate huge media interest, rightly so and partly thanks to the shadow Health Secretary’s urgent question. When the draft report was sent to the trust, it came back with 300 individual items of concern, and it was right for NHS England, in the interests of accuracy and justice, to consider fully all those concerns. It has given me an assurance, however, that, whether or not it can reach an agreement with the trust about its contents, the report will be published before Christmas.

An agreement with the Trust. Yet also note what Hunt said to Heidi Alexander that [w]e will not allow any further arguments about methodologies to stand in the way of the report being published before Christmas. I would suggest that any goodwill within Whitehall towards Southern Health has been burnt up.

The second question was around families not having access to legal aid to challenge NHS bodies. This placed Jeremy Hunt in a difficult position because it isn't his turf but that of the Lord Chancellor Michael Gove and the members asking the question knew that. Hence the line that with a properly accountable NHS with full family involvement that there wouldn't need to be litigation. A sentiment that I would like to see fulfilled as it would be an extraordinary achievement. Until that perfect world, the Ministry of Justice needs to be lobbied in order that the scales of justice are balanced. 

This 30 minutes merely sets the context for future events. Once the report is published then a full debate will follow. This is where the House of Commons can give direction to the Secretary of State and that then empowers NHS England. Publication shifts power balances and serious reports require serious actions.

I would want to see Southern Health broken up, the earth salted and its ashes scattered to the winds. Its board and senior management were too remote and separate from the actual practice of care. Its size and empire (property) building are emblematic of an unfit culture. I believe, based on experience, in rooting management in the community so that values are shared and mutually understood. This sector of the NHS appears aloof and outside of those processes. When the debate occurs, I hope consideration is made on that point.