Fundamental reset for social care?

with not either!

Luckygirl3

This for instance .....

The Scandinavian model

Denmark is often regarded as the gold standard.

Older people are supported at home for as long as possible. Municipalities are responsible for:

home care
personal care
rehabilitation
nursing care
equipment
housing adaptations

District nurses, therapists and care workers work together as one local service. The municipality receives tax funding to provide both health-related community services and social care, so there is much less argument over "whose budget" something belongs to.

I would have thought Andy Burnham might be interested in the way Denmark does this. It sits well either his ideas on devolution. Thanks for the research Luckygirl.

Luckgirl "I do need to disabuse people if the seemingly intractable idea that to get CHC funding you have to be "practically at death's door." This is not so".

I completely endorse this.

Yes, that’s what I am used to in terms of registration as well Lemonjam, but I’ve never come across a dual registered home with nursing beds that was run by a LA, only privately owned establishments where that happens.

Definitely time for a new era.
The current system has been tried and found very much wanting.

I do need to disabuse people if the seemingly intractable idea that to get CHC funding you have to be "practically at death's door." This is not so ... you simply have to fulfill a number of criteria over different needs to qualify. I have obtained it for young disabled people ... predominantly with brain injuries ... whose life expectancy is normal.

LA care homes in my area traditionally were either dual registered for both Nursing Beds and Residential Care (as would now be known as Social Care now) beds.

Or registered as a Nursing home or a Residential Care Home. That is there was a mix. Nursing Homes were equipped and still should be today, to care for patients with complicit care needs.

Nursing Homes or dual registered homes with nursing beds would have to have a Registered Nurse, on site/duty at all times to gain registration. Residential homes need not necessarily have RNs on site and depend on NHS ancillary nursing services to come in- e.g District Nurse, Continence Nurse, Tissue Viability Nurse, Diabetic Specialist Nurse, Parkinson's Nurse etc.

The 1960s and 1970s was known as the Residential Era a heavily paternalistic care environment. There were many so called Geriatric Beds in the NHS delivering free care. My Gran used to work at Salford Royal Infirmary as a care assistant on a Geriatric ward and I remember going to see her at the end of shifting to walk back to her house together in school holidays.

Rising costs and the desire for a better quality, less institutionalised care model led to the Community Care Era in the 1980s/1990s. Governments heavily invested in domiciliary support and home care and there was a strategic push to help older people age in place. Our Primary care Trust had a Strategic Care for Older People (SCOP) plan. There was a big push to close down all the older care hospital wards and get all the patients out into care homes. This coincided with many, many private care providers coming into the care home market to accommodate this shift. All the staff on those wards had to be interviewed for jobs in the remaining complex care/rehabilitation ward beds but many went to work on care homes opening up or other settings.

The NHS CHC National Framework legislation emerged to determine care needs, ie whether predominantly health or social care. The rest followed as in posts to date.

Time for another new Era?

I’ve been thinking a bit more about the role of Local Authority managed care homes. My recollection is that the ones in my area at least, were residential homes, with no medical input other than through GP visits, and nursing input only for individual people through the district nurses. It would require a huge model shift for LAs to take on people with more complex needs. Residential care is no longer the preferred model for older people, who are now supported in the community for as long as possible, so if the an LA managed residential homes model was re instituted, presumably it would need to be very different to previously.

62Granny

Continuing Health Care, has always had a very strict criteria and you practically had to be on deaths door to get it. I know nurses who were assessors
and filled out the paperwork for it and even they said the criteria was too strict.
My personal thoughts are:
1)Paid carers need to be properly trained and regulated. Travel time between calls should be paid time and allowed for.
2) Unpaid carers need to be heard and their health ( mental & Physical )checked up on regularly( 6 months?)
3) Respite care for those that want should be re-introduced , day centres and longer.
You hear so many horror stories about paid carers practically running in and out of calls, being aggressive to clients , when you are infirm , young or old you can't be rushed. But also some clients will also be aggressive to the carers too unfortunately.

You make some excellent points 62 Granny.
1) The Care Quality Commission as regulator does inspect and regulate all care homes . It is mandatory for private care homes to ensure that their carers are properly trained. Every care home is rated by the CQC- see their ratings on the care home website.
2) All family carers are entitled to their own carer holistic assessment- ask GP and/or DN.
3) Respite care is available for self funders in some care homes if they have bed capacity, ie an empty bed attracts no payment. Free availability is very patchy plus private care homes don't want empty beds ie keeping a respite bed free in case someone requests respite. It's expensive- who pays? Needs to be considered in new model.

Yes, patients with dementia can be both verbally and physically aggressive to carers. Patient should have a behavioural risk assessment completed and the carers should receive training in how to care for patients with dementia. Ongoing Community MH engagement might be necessary and behavioural modification medication can be requested. and prescribed by GP.

Travel time between domiciliary calls, particularly in rural areas or city centre areas with heavy traffic and parking restrictions- is a key issue.

MaizieD

^Also LA staff are paid at a standard rate, get increments, annual leave, sick pay, etc, so it costs more to staff an LA run facility^

Well, I think that's a mindset we have to dispense with. I don't care for private providers skimping on staff costs to enhance their profits.

I agree, but there is no doubt at all that it costs more. The other cost to LAs that I forgot to mention is the capital and maintenance costs of buildings, which are kept to a higher standard than in the private sector. It’s not that that isn’t what we should want, it’s that it comes with a price tag, and the public need to understand the full implications of the options.

Continuing Health Care, has always had a very strict criteria and you practically had to be on deaths door to get it. I know nurses who were assessors
and filled out the paperwork for it and even they said the criteria was too strict.
My personal thoughts are:
1)Paid carers need to be properly trained and regulated. Travel time between calls should be paid time and allowed for.
2) Unpaid carers need to be heard and their health ( mental & Physical )checked up on regularly( 6 months?)
3) Respite care for those that want should be re-introduced , day centres and longer.
You hear so many horror stories about paid carers practically running in and out of calls, being aggressive to clients , when you are infirm , young or old you can't be rushed. But also some clients will also be aggressive to the carers too unfortunately.

With you all the way Maizie ... one of the reasons that the LA homes were so good was because of the properly paid, trained and supported staff with decent working conditions. Happy staff give a better service.
I don't mind us paying for good care and staff conditions ... I do mind paying shareholders for poor care.
We cannot base our services on the lowest common denominator.

Care workers in care homes also get increments, annual leave, sick pay etc and compete to attract staff- equivalence.

LA do not seek to make a profit, private providers absolutely do.

Also LA staff are paid at a standard rate, get increments, annual leave, sick pay, etc, so it costs more to staff an LA run facility

Well, I think that's a mindset we have to dispense with. I don't care for private providers skimping on staff costs to enhance their profits.

Maybe not inherently Luckygirl13, but in practice it costs the LA more to run a home than it does a private contractor. Partly because everybody gets charged the same, which isn’t the case in privately owned care homes. Also LA staff are paid at a standard rate, get increments, annual leave, sick pay, etc, so it costs more to staff an LA run facility - that’s one of the main reasons most LAs stopped providing in house care. The other limitation is around the range of clients in different care need groups in each LA area, they could not feasibly look after the full range of needs in area. It’s not simple to see the wood for the trees.

I am unconvinced that in house LA run residential homes are more expensive as they had no profit motive or shareholders to appease. I found them excellent because they had secure training and good staff conditions and monitoring. The contact between the homes and the placing social workers was speedy and efficient and as a SW I was able to keep an eye on what was going on and get speedy changes where needed.

It goes beyond that too, because there have always been private nursing and care homes, including for people with lifelong conditions and mental health conditions. A lot of charities operate facilities too. I don’t think bringing all care into the statutory sector would necessarily provide a better service for all groups, and it would be less cost effective. Not saying I have any answers, it’s a very multi layered situation.

MazieD- it is the case that very few Local Authorities still own and manage adult care homes. Instead they commission and fund placements ( at a capped fee) in private run care home- many of which have been taken over by larger organisations- for those that have asserts below the £23k+ threshold.

These care homes are fundamentally profit driven and subsidised by self funding patients whose assets are above the LA threshold.

The same principle applies to children's care albeit LAs have a statutory duty to fund children's social care as I posted earlier. We've read stores in then papers of how private companies extort the LA who access is limited.

In that context a right wing party less likely to put forward state funded social and health care service model that changes the current profit driven private social care service provision models?

I think AB has some ideas re a state funded UK H and SC organisation- I await detail with interest.

The question and challenge in the UK is political and contentious. That is - how to raise this additional money? Which party puts forward a plan to raise this money? Will other parties support this plan to raise this money? Is the electorate prepared to pay higher taxes (or an alternative payment) to raise this additional pot of money?

Well, you know just what I would say. The government should spend the money first and tax some of it back as it is spent.

A problem that I see with this is that a significant amount of our social care is privatised. Take children in care for example. When some providers charge up to 60,000per week for a single child placement you wonder just what is going on.

Clearly some of this excessive cost is reclaimed via income tax (though with poorly paid care workers this tax take must be minimal) and indirect taxation of the goods and services needed to run and maintain the homes but corporate profits are taxed at a lower rate than income tax, as are profits taken in the form of dividends.

While the government must always run a deficit to ensure that there is sufficient money circulating in the economy it would seem to me to be reasonable to to either increase taxation on profits or to take care back into public ownership in order to cut the costs. I do realise that this second option is difficult and would take time.

I haven't looked a adult social care costs but I suspect they are of a similar magnitude.

Asking the general public to pay more in tax to fund private company profits (and fund care which is not always of a satisfactory standard) seems wrong to me.

Is it the duty of a government to care for its citizens or is it to fund the excessive acquisition of wealth?

There is not universally integrated domiciliary health and social care funding across the EU. The EU commission shows that there are divergent funding models and most member states currently spilt responsibilities horizontally between health (medical) and social (daily living) assistance.

Predominantly Health is funded usually by a tax funded or statutory health insurance model that funds nursing, medical treatments and rehabilitation. Social care is often decentralised to local municipalities or regional authorities funded through local taxes and subject to means testing for daily assistance as currently in the UK.

Full financial integration remains a challenge across much of the EU. Ireland and Portugal align H and SC budgets for example at national and regional level.

Some countries have hybrid and. localised models like France where there is means testing but heavily subsidised by the state,

Decentralised models like Italy and Spain fund services regionally which causes disparity in integrated access. .

To combat this fragmentation the EU is increasingly partially supporting models of integrated domiciliary care through the European Social Fund (ESF+) and targeted research programmes like the Value Care Project

Denmark, an effective welfare, criminal justice and other public services. Sensibly the Danish people recognise this means higher taxes but a stronger society

If the state provides the overall funding to the municipalities in Scandinavia there is not reason why that cant be done in the UK as long as there is a bigger pot of money.

The question and challenge in the UK is political and contentious. That is - how to raise this additional money? Which party puts forward a plan to raise this money? Will other parties support this plan to raise this money? Is the electorate prepared to pay higher taxes (or an alternative payment) to raise this additional pot of money?

Luckygirl3

This for instance .....

The Scandinavian model

Denmark is often regarded as the gold standard.

Older people are supported at home for as long as possible. Municipalities are responsible for:

home care
personal care
rehabilitation
nursing care
equipment
housing adaptations

District nurses, therapists and care workers work together as one local service. The municipality receives tax funding to provide both health-related community services and social care, so there is much less argument over "whose budget" something belongs to.

There you go- that sounds more like a Health and Social care model for older people to stay at home as long as possible.

You say municipalities fund this model rather than the state. How are the municipalities funded? Could that work in the UK?

We dod have locality enablement teams on a similar basis in the UK working in 'partnership". Some also are gold standard. the only difference is that the District Nursing care and professional expertise rehabilitation in the UK is funded by the NHS and home adaptations, personal and social care assistants are funded by LA and means tested

Thus the home care enablement service provision is not fundamentally different its the funding model that differs

Luckygirl3

As to the question of how care should be both funded and organised, the basic problem, apart from the intrinsic complexity, is that any government who picks up this poisoned chalice is going to get clobbered at the ballot box, because there will be winners and losers and likely more tax. They know this - which is why it gets kicked down the road all the time!

I think it is important that the false distinction between health and social care should go somehow, both on a practical and a financial level.

As long as there are competing financial interests between the health authorities and the local authority social services departments this chaos will continue.

It seems to me that if for instance someone at home needs help then the relevant people should be sent in whether they are wearing a health or a social care hat and that the means of paying for this should be uniform. Ditto if in residential or nursing care.

The dialogue (a nice neutral word!) between these two is responsible for a great deal of bed blocking as setting up care can get delayed.

There is often a very fine line between what is social care and what is medical - at the extremes it is obvious, but in the main there is a mixture of both and in the end that should not matter or be a consideration in providing what is needed. These crazy minutely-detailed assessments that take up time and money (and generate canny lawyers' involvement as they see a chance to make some dosh!) need to go.

The truth is that at present however hard people try to create foolproof assessment criteria there is still an element of interpretation and the iniquitous postcode lottery holds good.

Good professional assessment of needs by both health and SSD should be done for each person for the purpose of ensuring that their needs are met, rather than to decide who pays.

If there were an overarching payment system for all this then the costly and time-consuming layer of assessment could go.

Currently in the UK we have the National Health Service, free at the.point of delivery for health care.

We have Local Authorities that means test and assess for Social Care and only fund below a certain threshold of assets.

Therefore, in the absence of a Health and Social Care state model/organisation there is a need for the distinction between the 2 and assessment- it is not currently a false distinction it is a necessary distinction therefore

As you rightly highlight there are competing finical interests between the NHS and LA currently. There are laws in place that the NHS only funds healthcare and does not have a remit or legal responsibility to fund Social Care .

This distinction can only be relinquished if the state sets up a Health and Social Care model with an overarching funding capacity to universally fund continuing care needs regardless of whether they are predominantly SC needs or Health Needs.

Thats is DAR's question- what would the model look like and where would the funding come from?

Your comment Good professional assessment of needs by both health and SSD should be done for each person for the purpose of ensuring that their needs are met, rather than to decide who pays is key in the current assessment process. The aim of the current assessment process is entirely about determining care needs as set out in my earlier post regarding mobility domain- there is absolutely no mention of finances throughout the assessment and it is NOT a financial assessment . The quality of the DST assessment which I must review is to determine that it was professional and good and adhered. the NHS CHC Framework.

The outcome of the assessment is a decision the person's care needs. Currently it. determines whther the person's care needs are Social or healthcare to match the current funding model and Laws. The state funding models determine what that means for the family not the DST assessment or the assessors or the IRP .

This for instance .....

The Scandinavian model

Denmark is often regarded as the gold standard.

Older people are supported at home for as long as possible. Municipalities are responsible for:

home care
personal care
rehabilitation
nursing care
equipment
housing adaptations

District nurses, therapists and care workers work together as one local service. The municipality receives tax funding to provide both health-related community services and social care, so there is much less argument over "whose budget" something belongs to.

I asked Chatgpt about whether funding is more integrated in Europe and this is what they came up with ....

The short answer is yes, in many European countries health and social care are funded or commissioned jointly to a much greater extent than in England, although the exact model varies enormously. England is actually something of an outlier in having such a sharp divide between NHS healthcare (free) and means-tested social care.

They went on to provide more detail which I can paste if people are interested.

Let us hope that Casey is looking at examples from other nations.