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.
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