Thursday 17 December 2015

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.

Thursday 10 December 2015

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.

Monday 19 October 2015

Black Swans, Pink Flamingos and Southern Health NHSFT

Sometimes a concept serendipitously appears that helps shape my thoughts and today I came across Dr Frank Hoffman's Black Swans and Pink Flamingos article which does exactly that. Hoffman uses the concepts in relation to defence planning but they have wider utility. Since the inquest verdict into the death of Connor Sparrowhawk on Friday, I've been reflecting on its meaning.

The Black Swan concept has been popularised by the writings of Nassim Nicholas Taleb who used it in relation to financial events. As Hoffman describes “[a] black swan is an event or situation which is unpredictable and for which the consequences could not be measured”. You cannot plan for black swans but only cope with their aftermath.

A Black Swan event is exactly what two of my closest friends experienced when their youngest child contracted and died of neuroblastoma. The thing about neuroblastoma is that it is a childhood cancer which has no known genetic or environmental markers. It is a random cruelty that visit children under the age of ten.

It still pains me to remember their hurt, grief, dignity and bravery when their child died. The funeral is still fresh in the memory. That no-one witnessing that cruelty would be anything but heart-broken by it. It was a profound event for me and has been one of my motivations for my involvement with #JusticeforLB and #LBBill. The unconscionable behaviour that Southern Health NHSFT display towards Connor's family has been untempered by any empathy or sense of responsibility.

That sense of outrage remains after the considered, comprehensive and damning jury verdict. A verdict which fits Hoffman's Pink Flamingo concept. To quote Hoffman:

Thinking historically about the future means dealing openly with those things we want to avoid or are in denial about. These are what I call our pink flamingoes. A pink flamingo is a predictable event that is ignored due to cognitive biases of a senior leader or a group of leaders trapped by powerful institutional forces. These are the cases which are “known knowns,” often brightly lit, but remaining studiously ignored by policymakers.

Having read the timeline for @LBInquest (as tweeted over the fortnight by the phenomenal George Julian) and then the written verdict of the jury, I find Hoffman's concept resonates powerfully. The jury found that Connor's epilepsy was a known known, brightly lit by his family, and was studiously ignored.

Here 'policymakers' refers to both the clinical practice team at STATT and the corporate structures within Southern Health. Many of the criticisms of the jury should have been picked up by due diligence in Southern Health's takeover of Ridgeway which previously operated STATT. I thoroughly recommend Chris Hatton's blog Diligence My Arse for those wanting a more detailed analysis.

The take home point for the corporates in Southern Health NHSFT is that the jury has pointed accountability at you. Mouthing platitudes to the media and sacking a low level grunt doesn't absolve you of your responsibilities. However there is some useful advice in Frank Hoffman's article which you might reflect upon especially this: “[a] crash in the real world is not subject to “no fault” rules; there truly are consequences to complacency and to faulty strategy”.

In this case, the devastation inflicted on a family.

The jury agreed that multiple 'very serious failings' occurred under the watch of Southern Health NHSFT leading to a preventable death. Fault occur at all levels. It wasn't an unpredictable event.

To be honest, I'm still struggling with that. I can't imagine how Sara, Rich and their family can reconcile those facts. Life can be randomly cruel, it really doesn't need so-called caring organisations to inflict further cruelties. Yet Southern Health actions, especially post July 4th 2013, have done exactly that.

As the media reports have given Katrina Percy the last word, I shall direct my final comments to her: kindly shut up, take some responsibility and resign.

Wednesday 29 July 2015

Rose Tint My World a message for Labour leadership candidates

It was great when it all began
I was a regular Tony fan
But it was over when he had the plan
To invade Iraq and Aghanistan...

Ian Dunt has today written an article on stategy, cynicism and idealism which resonates with a twitter discussion I had yesterday with a fellow Labour Party member on using themes such as Tax Justice to make the Party more electable. To quote Ian's salient point:

Labour seems to have split into three factions: The beige, the red and the white. The beige – represented by Andy Burnham and Yvette Cooper - are mechanical, seemingly without political values, poor to middling media performers and change according to the prevailing political weather. Burnham, for instance, was a Blairite under Blair, a Brownite under Brown and a Milibandite under Miliband. Under none of those personalities did he appear to be a winner. The whites, representing the white flag contingent and currently led by Kendall, have only one tactic: surrender. They are Blairites without any of the intellectual underpinnings. The reds, under Corbyn, are singing from the same socialist hymn sheet as ever, with absolutely no changes, either ideologically or tactically, since the 1970s.

Is it so much to ask that we could ignore the beige, but have a little bit of red and white together? It is possible to get a genuine leftist into Downing Street, but it requires giving up on some of the political purity which seems to motivate Corbyn's supporters.
Ian Dunt ends his article by stating that Jeremy Corbyn and Liz Kendall have a lot to learn from each other if they sat down and listened to each other. I agree with this sentiment.

What I found interesting about the theme of Tax Justice was that Jeremy and Liz were approaching the subject from opposite ends but both were developing the theme: e.g. Liz's request of Margaret Hodge to look at the world of corporate welfare and Jeremy adopting the arguments of Richard Murphy that HMRC should calculate tax revenues using GDP (tax gap in excess of £100bn) rather than their own tax returns (tax gap of £35bn).

The ideas of how we collect taxes and where we spend them are two sides of the same coin.

So my proposal to my comrade was a mixture of cynicism and idealism. I proposed that part of the increased revenues from an aggressive HMRC operating on Tax Justice principles be used to reduce income tax on middle earners up to £100k to 35p in the pound.

We know that the wealthy through various accountancy-inspired schemes pay around 35% of income. The middle classes therefore pay a higher proportion of income. So reducing the percentage paid in tax by this cohort has some notional fairness to it.

I also think we shouldn't forget the lesson of the 1992 election when John Smith's tax proposals scared those who were struggling particularly in the over-heated South-East despite having what seemed reasonable salaries. The same conditions exist today so the Party needs to avoid scaring people with headlines about high taxation.. So by having a policy that supports the 'middle-classes' as defined by the Daily Mail would park the tanks on traditional Tory ground.

Given the increasingly blunt tool that is Income Tax for collecting from high earners, being creative in alternative tax devices to capture from the wealthy would be sensible and show some learning from George Osborne. This would mean giving up the symbolic 50p threshold that defines the Party as being anti-hard-working-families types (pass the sick bucket vicar). Less symbolism, more practical policies please.

Tax Justice with ensuring that the majority benefit from it would cause the Tories some difficulties and present problems to right-wing newspapers as well. It is a policy that is both cynical and idealistic.

So my message to the four leadership candidates is to rose-tint our world with smart polices. Don't dream it, be it...


Monday 22 June 2015

Beyond the Valley of the DoLS

A quick post on why Deprivation of Liberty Safeguards (DoLS) are a shared problem.

It is perhaps the most depressing part of recent social media comments I've read that describe DoLS as an industry within social care. This fails to recognise that Local Authorities (LAs) are responding to the 2014 Chester West & Chester Council v P judgment which found that LAs were applying DoLS (part of the 2005 Mental Capacity Act) incorrectly.

The response to this judgment is that councils up and down the country have had to scramble reassessments to ensure that their placements were within the law. Figures gathered by Andy McNicol show that 110 councils have identified almost 18,000 cases.

The essential problem is that judicial oversight is required because people's liberties have been compromised. Despite the attempts of Justice Mostyn to rule for a more 'common sense' approach to DoLS, that has been overruled by a higher court. Given where we are, the current consensus is that judicial oversight is better than the alternatives.

The difficulties that LAs have is that this additional cost comes out of current budgets and resources. There is no unlimited Whitehall pot to draw down funding for the assessments and the court costs. A one-off  £25m has been found but this is inadequate given the scale of the problem. The time and the majority of the expense has to be found internally. This at a time when LAs grants are being squeezed considerably. Half a million people have stopped receiving social care support as a result of austerity in local government. Diverting money to resolve the DoLS crisis adds to that number.

There is no benefit to LAs for this situation as it creates a beggar my neighbour approach in deciding budget expenditure. To call it an industry ignores other service users who are seeing their services reduced or cut and it also ignores that LAs have had this additional workload thrust upon them.

The lack of court applications shown by Andy McNicol (286 applications out of 17,829 identified cases) is further evidence of this crisis. There is simply not the resources available to cope. An industry? LAs are being criticised for not making applications as Steve Broach does in his recent blog on the subject.

The author of the "industry" quote, Mark Neary, has an interesting blog on how DoLS assessments are being extended to assess supported living arrangements such as his son Steven by Hillingdon Council. This extends the provisions into the area that Lucy Series has argued should have been the case since 2005. My suspicion is that the broad concept of 'Wellbeing' in the 2014 Care Act has informed Hillingdon's decision here.

If you talk to everyone involved with DoLS, they'll tell you that we need to find a better way of protecting people's rights without the level of cost or legal requirements currently involved. Everyone will be in favour of a Goldilocks solution. Getting agreement on that Goldilocks solution however feels a long way away. How do you enforce a framework without recourse to the law? What happens if judicial oversight is re-enforced by a further Supreme Court judgment (a back to square one scenario)? What if you cannot separate DoLS from judicial oversight as trust in LAs are non-existent (see Mark Neary)?

 This is a shared problem between service users, carers, local authorities and the legal system. If everyone acts in opposition to each other then hope for a reformed DoLS working will be pie in the sky. There is no magic framework that the Law Commission can provide or an unlimited cheque from Whitehall to fund judicial oversight or increase social care budgets to resolve this issue. The first step is to accept it is a shared problem. Only then can we move towards resolving it.

Tuesday 3 March 2015

A clash of ambitions

Today (Tuesday 3rd March) has been an interesting day for the contrast between my morning spent in London discussing the 2nd draft of the Laughing Boy Bill (LBBill), a movement to see enacted in law changes that will improve the lives of people with learning difficulties and/or autism, and this afternoon/evening spent following the debate to set the 2015-16 budget for Birmingham City Council (BCC) where the Labour administration is having to enact £85m of cuts for the next financial year alone.

Now I have considerable sympathy for the position that Sir Albert Bore et al find themselves in. This is unprecedented in terms of scale. Yet some of this has been self-inflicted by successive administrations to favour the city centre development over citywide responsibilities. So in my area of interest, adult social care, Birmingham City Council is underspending comparatively with other metropolitan areas by 2.5% of budget or £39million in cash terms. That is an outlier that is significant by any stretch of the imagination.

It cannot be said with confidence that the budget that will be set today will meet the statutory requirements on the city as the 2014 Care Act comes into effect from April. Its an difficult juxaposition where Whitehall expectations are increased while the grants for BCC are decreased. If the consultation, budget or any service provision were tested legally, BCC would probably have more difficulties than the contingency fund would allow.

Against this, the 2nd draft of the LBBill sits as a statement of intent. In particular, clause 4.4 of the 2nd draft which asserts duties above financial resources. As a principle, this is absolutely right. In practise, if this culture of austerity for local authorities continues, it will inflict more pain on the functioning of any authority. It makes me uncomfortable because I know that 2015-16 isn't the worst point for Birmingham City Council. 2016-17 and 2017-18 will be harder still as the cuts drive deeper. Its against this background that I and others hope that Sir Albert, John Cotton etc will start working with us and others interested parties from May 8th to help the city mitigate the worse aspects of 2016-17 onwards and close that gap with comparable cities. Its a hard road ahead.

Against that, the 2014 Care Act does reduce the ability of local authorities to use financial considerations as a basis for setting who qualifies as having statutory needs. The imposition of national standards does challenge the 1997 Gloucestershire Judgement that local authorities have used to tighten qualification of substantial or critical needs. So clause 4.4 can be said to work with the 2014 Care Act. This will be tested in court soon I suspect.

So the optimism I felt this morning at Monckton Chambers with the diverse and knowledgeable individuals and organisations around the table, both in person and the disembodied voices on speakerphone, has been tempered by the ugly reality that is occurring in Birmingham's Council House.

Yet the ambitions of LBBill has to happen. We cannot compromise on the principle that underpins LBBill that is everyone has the right to live their lives however messy that may be. That it may make local government's life more messy is something we'll have to live with.

Monday 16 February 2015

Evaluating Simon Stevens Dowry

After over a year's wait for a blog, two come along inside a week...

After Tuesday's blog describing the discombobulation of NHS England's Simon Stevens when asked  to consider the concept of fairness, I have found myself continuing to think about the dowry proposal made prior to that moment. It needs to be unpacked as a concept because I think it tells us a lot about the thinking that is happening and thinking that is not happening currently.

If we look at the exchange as transcribed here:


Q63 Austin Mitchell: I just want to pursue the financial imperative. The targets were overambitious for financial reasons: the fact that the money did not follow the patient created local resistance to having the patients. Paragraph 2.24 says, “Meeting the needs of people in the community, who NHS England previously funded in hospital, is a material cost to local commissioners. This can affect their ability to provide appropriate and sustainable care packages. Hospitals subsequently experience significant delays in discharging patients while complex negotiations continue”. This must mean that you can speed up the process through a fairer, better financial arrangement with the CCGs and local providers.

Simon Stevens: What makes this complex is that you have two sets of things going on there. One is that there are a group of people who have been in institutional care for a very long time. When you talk about moving them, as we will be when we are closing some of these facilities, you need to take the old mental health model—we talk about dowries and funding endowments that move with people, and those might be partly with the local authority and partly with the local CCG. If you look at the fact that a fifth of people in in-patient settings have been there for more than five years, those are the sort of folks for whom you are talking about dowries. But for people who have been in an in-patient setting funded by specialist care for three or six months, that is not so much about their ongoing support for ever; that is a moment in time when they are getting something. Distinguishing between those two categories is what we have to do. Some of this will have to be dowry-type arrangements; some will just have to be about a recognition that, actually, this is the CCG’s or the local authority’s funding responsibility, and they will have to step up to the plate.


On a superficial reading, the response made by Simon Stevens could be read as though some thought had occurred before sitting in front of the Select Committee. However there are some jarring inconsistencies of thought occurring that are troubling if we are to take the rhetoric seriously.


The first point of contention comes with the notion of the dowry itself. What exactly will NHS England be funding with this dowry? If the care plans are accurately assessed then the needs of the individual receiving the care package have to be statutorily met. So will any such dowries be providing additional non-statutory needs or is this an implicit admission that the funding streams of CCGs/LAs are not sufficient to provide statutory needs? Is this about the needs of the service user or the needs of service funders?

Then there is the usage of years institutionalised to determine whether the individual requires a dowry as oppose to those expected to be pick-up by CCG/LA spending. How exactly will NHS England determine the qualification for this dowry? Will it focus on enablement? A problem with this is that there doesn't appear to be any evidence for that particular cohort being any more requiring of deinstitutionalisation than those who are there for six months or three years. This isn't person-centred policy based on needs but rather an arbitrary qualification of time that seems to have been plucked out of the air. I can't help but think of Mark Neary's excellent blog and that one of the consequences of his son Steven having spent a year in an ATU has been the need to permission-seek for actions such as going to the toilet as a result of his previous institutionisation.

These questions are particularly important in terms of the concept pursued by the members of the Select Committee of "the money following the patient" (NB for the Select Committee - they are people who aren't ill just because they have LD/ASD). In this context, the dowry concept seems less about facilitating this concept as blocking it. My cynicism would suggest that Simon and his colleagues should be viewing this issue as an efficiency opportunity for NHS England. That isn't a bad motivator in itself as it is more likely to see some change forced through. But for that motivator to work, the incentive needs to be that NHS England retains a sizeable proportion of the spending or in other words ensuring the money doesn't follow the individual. The dowry concept with its years incarcerated qualifier would allow NHS England to retain 80% of its spending. But as I said, I'm cynical.

Indeed with the challenge that Simon Stevens has set NHS England of finding £20bn of efficiency savings and our current cohort of politicians indulging in magical thinking as to bringing together two underfunded services (Health and Social Care) and expecting them to find that their deficit funding disappears, its no wonder that throwing a bone such as dowries occurs.

So I have questions for the Select Committee - what exactly are you attempting to achieve by this notion of "the money following the patient"? What exactly are you funding with it and for what purpose? What does fairness look like to you in this context?

Perhaps I'm being unreasonable to the Public Accounts Committee here but there doesn't appear to be much awareness of how the funding creates action or resistence. Simon Stevens is clearly telling the Select Committee in the answer quoted above that he needs to retain a significant proportion or there isn't the incentive to create change. Hence the discombobulation when Austin Mitchell followed up with the "so you think the funding is fair?" question. Fairness to the individual was the last thing on Simon's mind.

Yet I think Simon has a reasonable argument here given the financial pressures NHS England are under and that if keeping a significant proportion of the spend to allocate elsewhere sees the majority of ATUs shut down then that is a compromise worth making.

What I would advise Margaret Hodge and her colleagues on the PAC is to focus on a more holistic approach to achieving the goals of reducing institutionalisation. Abandon the money following the individual approach and instead split the money being spent on this cohort in three ways: a transitional fund to help CCGs/LAs budgets when any individual moves into the community (this can be graduated for need); developing more community-based specialist mental health services; allowing NHS England to redistribute the remaining savings. The precise proportionality can be debated but lets create incentives to move people into the community and support them when they are there.

The statutory responsibilities on CCGs and LAs to provide care and support  need to be funded properly in themselves. This is where the direction of travel re merging health and social care provision needs to be discussed with honesty rather than magical thinking. Just grabbing part of NHS England's budget as Margaret Hodge suggested to Simon Stevens is also counter-productive as it creates resistence and most likely perverse outcomes. The environment of health and social care post May 7th will be a very contested space regardless of what sort of government emerges.

The need for more thinking about what outcomes you want to achieve and less glib statements that sound good is necessary more than ever. Trouble is I think it will be a long long time before it happens. Perhaps that why this song is in my head this morning.


Tuesday 10 February 2015

Simon Stevens Failure is not an Option

Another in a very occasional series of blogs.

Yesterday (Monday 9th February 2015) in the Boothroyd Room of Portcullis House, the House of Commons' Public Accounts Committee chaired by Margaret Hodge met to receive evidence for their inquiry into Care for people with learning disabilities.

As noted on Twitter by Chris Hatton, there was a real disconnect between the mood of the Select Committee and those witnesses appearing in the second half of the hearing. 

Those witnesses were: Una O'Brien, Permanent Secretary, and Jon Rouse, Director General, Social Care, Local Government and Care Partnerships, Department of Health, and Simon Stevens, Chief Executive, and Jane Cummings, Chief Nursing Officer, NHS England.

There was a feisty attitude to the committee members questioning as to why the stated target to move approximately 3,000 Learning Disabled (LD) and/or Autistic Spectrum Disorder (ASD) people out of units following the outrage of Winterbourne View by June 2014 failed.

This was a target that had little bearing on the reality of how commissioning and supply works for LD/ASD people and although traction for the target wasn't helped by the 2012 health reforms, the cultural issues surrounding responsibility and accountability extend further back. It is therefore with a raised quizical eyebrow and copious amounts of salt that I took Simon Stevens commitment to "substantial transition" in the next eighteen months.

This isn't to disbelieve the sincerity of Simon when he states that they "cannot defend the indefensible" but rather that the siren voices of caveats and funding will lure his attempts onto the rocks.

The most significant exchange for me starts at 16:37:30 when Austin Mitchell, whose questioning style is generally languid, starts discussing the failure of the money to follow the LD/ASD individual and that there are disincentives in local authority funding to facilitate the transfer into the community.

This point re local authority funding is vitally important to grasp. To explain, lets use another NHS and local authority cooperation - the transfer of elderly people with care needs out of hospital and into community facilities. This is a constant dialogue between the NHS and LAs with peak demand for flow happening in the winter. To meet the peak demand requires a market response to provide the community spaces and support required and markets respond to funding signals. Yet the funding flow from NHS to LAs operates as if the market capacity responds to a 'just in time' signal. Such an approach is fine if you have automated assembly lines but less so when the largest resource is people. If you are not prepared to pay for excess capacity then time lags will occur and any additional monies thrown at the problem as Jeremy Hunt has done is asking people to retrofit capacity.

So funding flow is important and consistency of funding is important to developing the market capacity required to enable the stated ambitions of Simon Stevens here. Austin Mitchell touches on this when finishing his question by suggesting that the process of transfer could be speeded up by a "fairer" funding settlement.

Simon Stevens response to this is to separate those trapped in the system for a long time (more than five years) and suggests using the dowry model that facilitated the closing of mental institutions in the 1980s with those who been in the system for three to six months where the CCGs or LAs will have to pick up the tab. Note that those who been in the system for 1-4 years aren't being considered in this response.

Austin Mitchell then asks the killer question at 16:39:40: "so you think the funding is fair?"

To use cricketing metaphors, this was the equivalent of a medium paced mid-70s mph trundler bowling a 90+ mph throat-high bouncer that Mitchell Johnson would have been proud of. Watching Simon Stevens body language disintegrate faster than an English batsman facing Mitchell Johnson was quite amusing.

Simon then pulls himself together with the cop-out phrase "its an accident of history". Ladies and gentlemen - welcome to the bullshit zone.

I have to thank Austin Mitchell for asking the right question here as it exposed the thinking here as being limited to "Houston, we have a problem". I don't knock the acknowledgement as the journey has to start with this step but its clear that the stated aspirations as reported by David Brindle haven't remotely been thought through.

This is why two and a half years down the line, work around pooled budgets remains at the starting gate when discussed at the PAC yesterday. A fair settlement starts with what it means to live as a LD/ASD person in their community and to live life to the full. Not as Jane Cummings suggests "as normal as possible" but to live a messy life of their choosing. Any funding settlement needs to follow and facilitate those principles. Its why campaigns such as the LBBill are so important - these need to be legal rights. Those committee members agreeing with a rights-based approach should take note.

My lasting impression of yesterday was that any thinking around this was couched in terms of the conflict of funding streams between health and social care rather than cooperation. The contested space that is the Better Care Fund which is being used more to retain existing LA services than developing new cooperative working as the NHS resents the top-slicing occurring as they experience real terms cuts to their budget. Against this background, it felt as though costs were expected to be pushed from one part of the system to another. Any idea of "fairness" in funding was therefore a shocking concept.

The top-down instruction to get people out of ATUs isn't a bad thing but we need to pool our intelligence to design the mechanisms properly else we'll Heath Robinson the process and create problems down the line. So thinking of Apollo 13 again, this scene resonates somewhat...