Making prudent healthcare happen

Delivering excellence across the health and social care system through prudent healthcare

  • Sue Evans, Chief Officer, Social Care and Housing, Torfaen County Borough Council
  • Phil Evans, Director of Social Services, Vale of Glamorgan Council

Summary

The traditional approach to healthcare and social services has placed professionals in a position of power and control. Citizens become passive recipients of wisdom and resources. Neither professionals nor citizens are aware of the full cost of services and as a result services are over-subscribed and under-valued at the same time.

A prudent approach advocates greater partnership between professionals and citizens. This will include an understanding of the cost of treatments when making decisions, and awareness of the support networks and capability that individuals can access, which may allay the cost to the health service.

Image copyright: © Ollie-G

Context

Within social care and health economies, there are strong forces that encourage us to target resources and to seek best value, not least because this maximises opportunities to help as many people as possible.

However, there are countervailing influences. Health and social care professionals share a similar value-based motivation for working within the public sector. They are intent on providing effective help to people in need and this help can take many forms – advice, care, support and treatment. This motivation is commendable but, inadvertently, it can lead to a ‘gift’ relationship between professionals and people whereby professionals are encouraged to occupy a position of power and control and people become passive recipients of wisdom and resources. The urge to ‘do something for’ people in difficulties or distress is one factor underpinning increased dependency, over-medication or overly-intensive packages of care and support.

Front-line professionals and people, regarding the NHS as a free gift, may be resistant to information about the accumulative costs of clinical interventions. Many social care interventions are chargeable services but such charges rarely reflect the full cost of that support.

These factors undoubtedly contribute to a waste of resources, where the true cost of health and social care services is camouflaged and potentially not given proper weighting by recipients and professionals alike. The public are often surprised to find out that they need to make a financial contribution for some aspects of social care support, when most forms of healthcare are free of charge. However, this financial contribution helps people to make choices about how much state support they need and operational experience from the use of Direct Payments in Wales and evidence from England on personal budgets[1] demonstrates that people can be prudent in their approach.

The need for change: empowered people

With increasingly severe cuts to public sector budgets, we need to ensure that every pound spent is spent wisely, by becoming ‘prudent public servants’. In the face of demographic and technological changes, we must plan how people can be supported to take responsibility for and to improve their health and wellbeing. This will require a shift in the power relationship between providers and people, where risks are jointly assessed and shared.

However, at the same time, public expectations will have to be managed so that people make best use of their own resources, wherever possible. The state will be concerned with meeting residual need and at the least possible level of dependency. This is likely to mean moving away from an automatic right to service provision on the basis of age, diagnostic label or other historical criteria, so that professionally delivered services can be directed towards those with the highest needs.

From online and other data sources, people have easier access to evidence about effective support, treatments and interventions, as well as provider performance information. Skilled front-line professionals who are able to analyse evidence and co-produce solutions will be needed, so that people are empowered to use their own strengths and assets to meet their needs, whilst risks are effectively managed. This approach recognises that risks are faced by all of us every day and that the role of the state is to help the individual better manage that risk.

Co-production: a strengths based approach

The new Social Services and Well-being Act[2] will transform social care in Wales, if the policy aspirations are fully realised. In particular, we will be required to change the current approach to assessing needs and planning the care and support that will be available to meet those needs. People will become more empowered partners in both assessing and meeting their needs, with the expectation that there will be reduced reliance on state support. Under the new approach, it will be necessary to consider all the strengths and assets that people have (knowledge, family, networks, resources, skills) to meet their own needs. For some people, the provision of appropriate information and advice will be sufficient to meet their needs, following a self-assessment where control is retained by the individual. Fewer people will require a formal assessment by a social care professional, reducing waste and enabling these resources to be targeted towards those people with higher levels of need that cannot be managed without state intervention. Even when a professional assessment is necessary, the aim will be to provide care and support at the lowest level, so that risk is managed in partnership with people and their family or networks and independence is maximised.

Progress within the social care sector

In 2011, the Deputy Minister for Social Services announced a new strategic plan for putting social services on a sound footing in the face of significant changes in the social and financial context within which they are delivered. ‘Sustainable Social Services for Wales – A Framework for Action[3] sets out eight priorities for action that are introduced in support of renewal. In summary, the priorities are:

  • a strong national purpose and expectation; and clear accountability for delivery
  • a national outcomes framework
  • citizen centred services
  • integrated services
  • reducing complexity
  • a confident and competent workforce
  • safeguarding and promoting the wellbeing of citizens
  • a new improvement framework.

The 22 local authorities have been implementing this policy by reshaping our services in areas such as re-ablement and family support. Often these changes have been achieved through integration with health services and as part of the shift from acute hospital based care towards primary and community based solutions. The new Act will give increasing impetus to our collaboration.

Children

The role of social services in supporting vulnerable children is twofold. One primary aim is to protect children from harm, through effective safeguarding in partnership with families, communities and other public bodies. The other significant role for social care is in supporting children in need and their families, working with others to help children who may have a disability, poor physical or emotional health or have other welfare needs.

In the face of increasing demand and reducing resources, the prudent approach is to meet need at an early stage and to prevent escalation. This means:

  • supporting families to stay together and reducing the need for children to be looked after by ensuring a focus on early intervention and preventative action
  • managing risk confidently and providing increased support at the ‘edge of care’ to make sure that need is accurately assessed and that only the right children are formally accommodated at the right time. This includes supporting families to avoid children becoming accommodated by making private arrangements within their wider family networks
  • providing and commissioning a flexible and affordable mix of high quality placements that meet the diverse range of children’s needs
  • giving children and young people clearly planned journeys through care which remain focused on care plans, prevent drift, enable them to be reunited with family and friends where possible, have stable placements and exit the care system positively, to maximise their potential into adulthood.

Where these strategies have been adopted, there is evidence that the numbers of looked after children have been contained and that more of them are in local accommodation which is less expensive and more effective. For those children who cannot return home, a fostering placement or adoption often provides the best life chances. We are beginning to see increased recruitment of local foster carers and potential adopters, especially as more regional approaches become embedded. Court proceedings are being expedited, with good compliance in meeting the new 26-week target for reaching decisions on behalf of children.

We know that a prudent approach is to focus on prevention and early intervention and this is being pursued in partnership through programmes such as Flying Start,[4] Families First,[5] Intensive Family Support Services[6] and other national initiatives. A prudent approach requires that the same collaborative stance is applied to a wider range of educational, health (physical and mental), social care and housing needs, so that agencies can work well together and pool their resources, virtually or actually, to meet all needs, using a “Team around the Family” (TAF) [6] approach.

One of the key challenges for most social services departments is to support vulnerable children as they make the transition into adulthood. From operational experience, we know that many adults, who may have been previously labelled as ‘a very disabled child’ by the state or their own family, are now living full and active independent lives, with technology and suitable accommodation helping them to manage risks to their independence. This requires a strong professional role for front-line staff, who are negotiating changes to support and services with concerned parents and other stakeholders. There can be tensions between different professional groups, who will vary in their willingness to manage risk and in their commitment to a rights-based attitude to empowering children and young people. We need to push for an approach where ‘people know best’ and move away from ‘professionals know best’.”

Adults

For people with a learning disability or mental health problem, national strategies for Wales[7,8] published in the 1980s and 1990s provided the stimulus to close down long-stay hospitals and encourage patients to become residents, living in supported community settings. This has resulted in transformed lives, where independence is promoted through the use of assistive technologies and innovative provider responses to meet care and support needs.

The current pattern of support to adults with care and support needs has been further enhanced, through a programme of ‘promoting independence’ and ‘right-sizing’ which has seen front-line social care professionals taking up a strong leadership role in reducing formal packages of care and support, so that interventions are minimised and people have more control over their lives.

There are many examples of effective partnership working across social care and housing departments, where the needs of vulnerable people are now being met through considering accommodation needs and care needs on a multi-professional and multi-agency basis, where local authority housing departments and registered social landlords are working with health and social care professionals to find innovative solutions that avoid an institutional approach (e.g. Assistive Technologies, Extracare developments, young people hostels, supported accommodation units, with a real focus on maximising independence[9] ). This approach is helping to reduce separate assessments by different professionals, avoiding duplication and providing a seamless response to people whose needs may be complex. This prudent approach to multi-agency collaboration saves professional time, reduces waiting times for service delivery and provides tailored responses for individuals.

The use of Direct Payments[10] has been growing steadily across Wales, with some local authorities evidencing a significant growth in recent years. This method of providing care and support is the best way of evidencing how well people are fully empowered to find their own solutions to meet their eligible care and support needs.

Older adults

Evidence from John Bolton,[11] the King’s Fund[12] and others, has been used to transform social care support for older people, so that short-term rehabilitation programmes provide a prudent approach and replace expectations that care will be provided on an ongoing basis. There has been a significant reduction in the use of long-term residential care and nursing home provision, as more people are supported at home to maintain their independence. This is evidenced in the Welsh Local Government Data Unit annual performance reports.[13]

In most parts of Wales, there has been sustained improvement in the rate of delayed transfers of care (DTOC) .[13], despite the increased numbers of older people with complex needs, reflecting improved partnership working within health and social care communities. The focus now needs to shift from looking at the cause of DTOCs, towards one that considers which community based health and social care services are needed to prevent unplanned hospital admissions. There are many good examples.[14 of integrated and intermediate care services being jointly developed and commissioned. These include joint community equipment services in every region in Wales, community resource teams that support frail elderly and step up/down beds in a range of settings. However, more needs to be done to transfer resources from acute and residential service models to create more capacity to meet demand. It is recognised that a prudent approach means prevention and early intervention models are needed but the challenge is to create that capacity, whilst pressures on existing service models are still evident.

Carers

The burden of caring on individuals and families is well recognised and there is a need to support carers well (Carers UK[15]), through effective advice and support. Unpaid carers are estimated to save the public purse many millions of pounds. Supporting carers well is a prudent approach to reducing the impact on health and social care resources. It is essential to take a joint health and social care approach to help carers maintain and improve their own wellbeing, as this will prolong their caring role for as long as they are able. The Welsh Government Carer’s Measure[16] provides a useful framework for assessing and supporting the needs of carers, through an integrated approach to information, advice and practical support. There are many excellent examples of effective joint working in support of carers and these include support and services provided by the third sector, which plays a significant role in supporting vulnerable people and their carers in Wales

A recent study[17] of effective support to unpaid carers in the greater Gwent health and social care economy highlighted the benefits of joint training for new carers in understanding the impact of long-term conditions and how to improve and sustain their own health and wellbeing. This study highlighted the benefits of telecare and assisted technologies in providing practical support and also improving a sense of safety in the home, even when the needs of the vulnerable person being care for were quite high.

Effective commissioning

Social services departments in Wales are realising the benefits of developing a mixed provider economy, so that people can be supported to make choices in the type of service they will access to meet their assessed needs. For those people who may not be eligible for local authority funded or commissioned social care support, they are still able to access third sector and independent sector services that have been developed through the commissioning process. In some more affluent communities in Wales, the majority of care home placements are made privately. This helps to sustain provider capacity, with the potential for people to purchase their own care and support, if they have resources available. Some people would prefer to make their own arrangements for as long as they are able and this should be encouraged as a means of further enhancing independence and ensuring a prudent approach to statutory social care provision.

There is a national political commitment to encourage social enterprises and user-led support services to improve wellbeing, reflected in the new Social Services and Well-being Act.[2] These new forms of service delivery are desirable but difficult to achieve in communities that are facing the challenges of poverty, ill health and low capacity to create change. These are the same communities that currently rely on state interventions and it may take some time to redress Tudor Hart’s Inverse Care Law.[18]

We know from previous evidence, set out by Wanless,[19] Townsend[20] and others, that the balance of care needs to be shifted from acute healthcare (which is the most expensive part of the system) to community based health and social care support and to target resources towards those communities where need is highest. This will require professionals and politicians, nationally and locally, to prioritise resources to meet current health and social care needs, if we are serious about creating capacity to transform our approach towards prevention, self-help and early intervention.

A Strong Workforce

There is a nationally agreed career pathway for registered social work professionals in Wales, developed by the Care Council for Wales[21] in partnership with the social care workforce. A similar pathway is being developed for occupational therapists. This helps to ensure that work is delegated effectively, resources are used wisely and front-line professionals are empowered to maximise and develop their specialist skills. The use of generic care and support workers enhances flexible capacity within teams and also provides a stepping stone for those who want to pursue a professional career. The career pathway sets out clear expectations for case supervision and line management of operational teams, which creates the supportive culture that is essential in managing people-related risks.

The Association of Directors of Social Services, Cymru[22] (ADSSC) provides the professional leadership voice for social care in Wales. The ADSSC ensures that national policy is informed by and informs operational practice. It is supporting Welsh Government to develop the codes of practice and guidance that will underpin the new Social Services and Well-being Act.[2] This approach to policy development based on co-production has been led by the Deputy Minister and is welcomed. Co-production will help to provide assurance that the aspirations set out in the Act can be realised, notwithstanding very real demand and resource limitations.

Next steps for action on a prudent approach to social care

  1. Use the implementation programme for the new Social Services and Well-being Act to convey key prudent principles to front-line staff, managers, leaders and the public within each health and social care community (Local Health Board footprint).
  2. Provide better access to information and advice, to help people help themselves.
  3. Ensure front-line staff are responsible and accountable for resource use (time, expertise, cash and tangible assets).
  4. Move towards Outcome Based Care Plans and Contracts, where reduced activity and intervention is recognised and rewarded.
  5. Ensure front-line staff are empowered and supported to manage risks, with an emphasis on minimum intervention.
  6. Develop and use common templates for jointly assessing, recording and monitoring risk in each health and social care economy (e.g. the Joint Assessment Framework for Children,[5], the Integrated Assessment Tool for adults).[23]

References

  1. Bimpson L. QIPP and Personal Health Budgets. [Internet] [cited 2014 September 22]. Available at http://www.in-control.org.uk.
  2. Welsh Assembly Government. Social Services and Well-being Act. [Internet] [cited 2014 September 22]. Available at
  3.  http://www.senedd.assemblywales.org/mgIssueHistoryHome.aspx?IId=5664
  4. Welsh Assembly Government. Sustainable social services for Wales: a framework for action. 2011[Internet] [cited 2014 September 22]. Available at http://www.wales.nhs.uk/sitesplus/documents/829/WAG%20-%20Sustainable%20Social%20Services%20for%20Wales%202011.pdf
  5. Welsh Government Social Research. Flying Start Synthesis Report 2014. [Internet] [cited 2014 September 22]. Available at
  6. http://wales.gov.uk.statistics-and-research/national-evaluation-flying-start/?lang=en
  7. Families First Programme Guidance 2011. [Internet] [cited 2014 September 22]. Available at
  8. http://wales.gov.uk/topics/childrenyoungpeople/parenting/help/familiesfirst/publication-index/guidance/?lang=en. And Welsh Government Social Research. Evaluation of Families First Year 2 Report June 2014. [Internet] [cited 2014 September 22]. Available at
  9. http://wales.gov.uk/statistics-and-research/national-evaluation-families-first/?lang=en
  10. Welsh Government Social Research. Evaluation of the Integrated Family Support Service: year 3 Report February 2014. [Internet] [cited 2014 September 22]. Available at http://wales.gov.uk/statistics-and-research/evaluation-integrated-family-support-service/?lang=en
  11. Also ESVG Cost Savings Calculator for TAF interventions from LG Partnerships.
  12. Welsh Government. Sections 135 and 136 of the Mental Health Act 1983: Good Practice Guide. 2012. And: National Assembly for Wales. Mental Health (Wales) Measure 2010. And: Together for Mental Health – the Welsh Strategy and Delivery Plan 2012-16.
  13. All Wales Strategy for the Development of Services for Mentally Handicapped People, 1983. Also The Welsh Mental Handicap Strategy Guidance, 1994. Replaced by a new Statement on Policy and Practice for Adults with a Learning Disability, 2007, Welsh Government and subsequently, Together for Mental Health.
  14. SSIA. The impact of Assistive Technology within social care. August 201
  15. Bolton J. Help to live at home service: an outcome-based approach to social care. Institute of Public Care: Oxford Brookes University, April 2012.
  16. The King’s Fund. Making our health and care systems fit for an ageing population. 2012 [Internet] [cited 2014 September 22]. Available at http://www.kingsfund.org.uk/publications/making-our-health-and-care-systems-fit-ageing-population
  17. Welsh Local Government Data Unit Local Authority performance reports. [Internet] [cited 2014 September 22]. Available at www.mylocalcouncil.info
  18. National Effective Services for Vulnerable People Group. New service models and evidence from UK integrated systems. 2012.
  19. Carers UK. It could be you: a report on the chances of becoming a carer. London: Carers UK, 2001.
  20. Welsh Assembly Government. Carers Strategies (Wales) Measure. 2010 [Internet] [cited 2014 September 22]; Available at http://www.wales.nhs.uk/sitesplus/documents/829/FINAL_CARERS_STRATEGIES_WALES_GUIDANCE_2011_-_ENGLISH.pdf
  21. Yeandle S. Telecare: a crucial opportunity to help save our health and social care system. London: Bow Group and the University of Leeds; 2009.
  22. Hart JT. The Inverse Care Law. Lancet. 1971 297:7696, 405-412.
  23. Wanless D. Securing our future health: taking a long-term view. 2002 [Internet] [cited 2014 September 22]; Available at http://si.easp.es/derechosciudadania/wp-content/uploads/2009/10/4.Informe-Wanless.pdf
  24. Townsend P. Targeting Poor Health in Wales – Townsend Report, June 2001.
  25. Care Council for Wales. Continuing Professional Education and Learning Framework (CPEL) for Social Workers in Wales. [Internet] [cited 2014 September 22]. Available at http://www.ccwales.org.uk/continuing-professional-education-and-learning/
  26. Association of Directors of Social Services, Cymru. [Internet] [cited 2014 September 22]. Available at http://www.adsscymru.org.uk/home.php
  27. Welsh Government. A framework for delivering Integrated Health and Social Care for older people with complex needs. 2013. [Internet] [cited 2014 September 22]. Available at http://wales.gov.uk/topics/health/publications/socialcare/strategies/integration/?lang=en

Image copyright: © Ollie-G 


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Watch Sue Evans talk more about her article, click on the video.

More needs to be done to transfer resources from acute and residential service models to create more community capacity to meet demand. A prudent approach means prevention and early intervention models are needed, but the challenge will be to create capacity, whilst pressures on existing service models are still evident.”

Making it happen

  1. The urge to ‘do something for’ people in difficulties or distress is one factor underpinning increased dependency, over-medication or overly-intensive packages of care and support.
  2. From online and other data sources, people have easier access to evidence about effective support, treatments and interventions, as well as provider performance information. Skilled front-line professionals who are able to analyse evidence and co-produce solutions will be needed, so that people are empowered to use their own strengths and assets to meet their needs, whilst risks are effectively managed.
  3. For people with social care needs, we know that a prudent approach is to focus on prevention and early intervention and this is being pursued in partnership through several policy and practice programmes.
  4. We need to push for an approach where ‘people know best’ and move away from ‘professionals know best’.
  5. Social care professionals must take up a strong leadership role in reducing formal packages of care and support, so that interventions are minimised and people have more control over their lives.

Innovation is one of the key drivers for prudent Healthcare. #ConnectNHS

Prudent Healthcare - collaboration leads to increased sustainability in patient care. #ConnectNHS pic.twitter.com/C33lMtboqH